Nursing Process/CJM Flashcards
Compare Medical Diagnosis vs Nursing Diagnosis/Pt problem
(Include what it focuses on, time, and provide and example)
Medical diagnoses: focus on diseases
- Long-term/permanent
-> Right ankle fracture (confirmed via X-ray).
Nursing diagnoses/patient problems: focus on unhealthy responses to health and illness - symptoms
- Can change overtime
-> Acute pain R/T tissue injury AEB patient rating pain 8/10, grimacing, and guarding the right ankle.
Nursing Process
systematic method that directs the nurse to provide care utilize 5 phases: Assessing, Diagnosing/Analysis, Planning, Implementation, Evaluation
Nurse-initiated (Independent Intervention)
actions performed by a nurse without a physician’s order
Physician-initiated (Dependent Intervention)
actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
Collaborative Interventions
treatments initiated by other providers and carried out by a nurse
The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client, which step of the nursing process does this address?
implementation
The nurse has multiple client assignments on the surgical unit. At the beginning of the shift, the nurse needs to determine which post-operative client should be seen first. Of the following, the nurse should go to see the client who:
A) Has a documented blood pressure of 90/50
B) Was medicated for back pain 10 minutes ago
C) Has an order to be out of bed and ambulated
D) Requires instructions for wound care before discharge
A) has a documented blood pressure of 90/50
Which of the following is the best example of a nurses use of reflection?
A)The nurse places a client experiencing respiratory difficulties in the high Fowler’s position
B) The nurse calls the provider when the client reports feeling chilled and achy while having an oral temperature of 100.2
C) While caring for a client with a history of asthma, the nurse assesses the clients pulse-ox reading when he doesn’t sound right
D) A nurse tells a client “When you refuse to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time”
D) A nurse tells a client “When you refuse to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time”
Which of the following nursing actions is the best example of problem solving?
A) Requesting an IV team to start an antibiotic drip on the client with a history of being a difficult stick
B) Offering to call the kitchen to provide an alternate breakfast for a client who does not like cook cereal
C) Trying several different wound dressings to determine which one the client can apply the most effectively
D) Calling for another pain medication order when the current drug results in the client experiencing nausea
C) Trying several different wound dressings to determine which one the client can apply the most effectively
Which of the following nursing interventions is the best example of the implementation step of the nursing process?
A) Determining the clients ankle edema is worse after he ambulates
B) Asking the client to rate his ankle pain after receiving oral pain medication
C) Arranging for the client to receive pain medication 30 minutes before his ordered ambulation
D) Crushing the clients pain medication to facilitate easier swallowing and thus minimizing the risk for choking
D) Crushing the clients pain medication to facilitate easier swallowing and thus minimizing the risk for choking
A nurse reviews a patient’s vital signs, listens to lung sounds, and asks the patient about their pain level. The nurse also examines the patient’s chart for lab results and recent medication history
Assessment
Nurse identifies that the patient has ineffective airway clearance due to excessive mucus production, as evidenced by a productive cough, crackles in the lungs, and an SpO2 of 92% on room air
Diagnosis/Analyze
“The patient will ambulate 50 feet with assistance within 24 hours to prevent complications from immobility.” The nurse also determines interventions such as administering pain medication before activity and assisting the patient with walking.
Planning
The nurse assists a patient in repositioning every two hours, administers prescribed pain medication, and provides breathing exercises to help prevent pneumonia.
Implementation
The nurse assesses whether the patient’s pain level has decreased from 8/10 to 4/10 as planned and determines whether additional interventions are necessary.
Evaluation
Patient goals must be _________, which stands for…
SMART:
- Specific
- Measurable
- Achieveable
- Realistic
- Time bound
Describe each letter of SMART goals
Specific: specific health problem
Measurable: quantifiable indicators
Achievable: consider patient’s condition
Realistic: align with available resources
Time bound: set a clear timeframe
Do AS MANY practice questions regarding the nursing process (Be able to identify which nursing actions are a part of Assessment, Identify Problems, Planning, Implementation, and Evaluation)
Liste the 5 characteristics of the nursing process. Describe each
- Systematic: part of an ordered sequence of activites
- Dynamic: interation and overlapping among the steps
- Interpersonal: promotes the dignity and respect of pt & establish caring relationships
- Outcome Orientated: nurse and pts work together to identify & reach outcomes
- Universally Applicable: framework for all nursing activities
What are the 6 steps to the Clinical Judgement Model?
- Recognizing Cues
- Analyzing
- Prioritize Hypotheses
- Generate Solutions
- Take Action
- Evaluate Outcomes
Describe the following step to the Clinical Judgment Model:
Recognizing Cues
(What does it mean?, How does it relate to the Nursing Process)
What does it mean?
- Which cues matter most?
How does it relate to the Nursing Process?
- Assessment
Describe the following step to the Clinical Judgment Model:
Analyzing Cues
(What does it mean?, How does it relate to the Nursing Process)
What does it mean?
- What do the cues mean?
How does it relate to the Nursing Process?
- Diagnosis/Analyze
Describe the following step to the Clinical Judgment Model:
Prioritze Hypotheses
(What does it mean?, How does it relate to the Nursing Process?)
What does it mean?
- Where do I start?
How does it relate to the Nursing Process?
- Diagnosis/Analyze
Describe the following step to the Clinical Judgment Model:
Generate Solutions
(What does it mean?, How does it relate to the Nursing Process?)
What does it mean?
- What can I do?
How does it relate to the Nursing Process?
- Planning
Describe the following step to the Clinical Judgment Model:
Take Action
(What does it mean?, How does it relate to the Nursing Process?)
What does it mean?
- What will I do?
How does it relate to the Nursing Process?
- Implement
Describe the following step to the Clinical Judgment Model:
Evaluate Outcomes
(What does it mean?, How does it relate to the Nursing Process?)
What does it mean?
- Did it help?
How does it relate to the Nursing Process?
- Evaluation
Cognitive Competencies
use critical thinking
Technical Competencies
mastering manual skills (manipulating equipment skillfully)
Interpersonal Competencies
promote dignity/respect of patients and stablish caring relationships
Ethical/Legal Compentencies
establish personal moral code and professional role responsibilites
When formulating a patient problem statement, it must include ________, _________, and ___________.
Problem, Etilogy, Signs & Symptoms (defining characteristics)
PES!
Describe each step of a three part statement.
- Problem: indentify pt actual problem
-
Etiology: Identify factors causing/maintaining the actual weakness
-> Related to (r/t) -
Defining Characteristics: subjective/objective data
-> As evidenced by (AEB)
A three part state CANNOT include a _____________.
Medical diagnosis
dx is only by doctor!
Evaluative statements in the care plan comminucate that nursing care is not complete until …
the patient outcomes have been evaluated
Seperate the following statements into Subjective and Objective data:
- I feel nauseous after eating
- Blood pressure is 150/90 mmHg
- Patient’s skin is cool, pale, and diaphoretic
- My chest feels tight when I breathe
- Lung sounds reveal wheezing in both lower lobes
- I’m so dizzy when I stand up
- I have a sharp pain in my lower back
- Patient’s gait is unsteady, requiring assistance to walk
- Abdominal palpation reveals distension and tenderness
- I feel anxious and can’t sleep at night
Subjective Data:
1, 4, 6, 7, 10
Objective Date:
2, 3, 5, 8, 9
Seperate the following statements into Subjective and Objective data:
- I have a constant headache that won’t go away
- Patient’s temperature is 102°F (38.9°C)
- Respiratory rate is 28 breaths per minute
- My stomach cramps get worse after I eat
- Patient has 3+ pitting edema in both lower extremities.
- I feel like my heart is racing all the time
- I have this burning sensation when I urinate
- I feel so tired even after sleeping all night
- Skin is jaundiced with yellowing of sclera
- Blood glucose level is 250 mg/dL
- My joints ache, especially in the morning
- Wound on left foot is red, warm to touch, and has purulent drainage
- I keep forgetting things, and it’s getting worse
- I get short of breath after walking just a few steps
- Patient’s gait is wide-based and unsteady, requires assistance.
- Urine output is 150 mL in 8 hours, dark amber in color
- Patient’s speech is slurred, and right side of the face is drooping
- I feel really down and don’t want to do anything
- My feet tingle all the time, and it’s hard to feel them
- Heart rate is irregular at 110 bpm
Subjective Data:
1, 4, 6, 7, 8, 11, 13, 14, 18, 19
Objective Date:
2, 3, 5, 9, 10, 12, 15, 16, 17, 20
starting from bottom to top:
List the levels of Maslow’s hierarchy of needs:
- Physiological Needs
- Safety Needs
- Love & Belonging Needs
- Esteem Needs
- Self Actualization
Which level of Maslow’s hierarchy of needs is the priority in this case?
A 70-year-old homeless man is brought to the emergency department with signs of dehydration and malnutrition. He is weak, disoriented, and states he hasn’t eaten in two days.
Physiological Needs:
The patient’s most urgent needs are food and water for survival.
Which level of Maslow’s hierarchy of needs is the priority in this case?
A 35-year-old woman is admitted to the hospital after a domestic violence incident. She expresses fear that her abuser will find her. She refuses to give her home address and frequently looks over her shoulder.
Safety Needs
The patient’s most urgent need is ensuring physical safety.
Which level of Maslow’s hierarchy of needs is the priority in this case?
A 55-year-old man recovering from a stroke has limited mobility and is feeling isolated. He frequently talks about missing his family and expresses sadness that he doesn’t have visitors.
Love & Belonging Needs
The patient is struggling with emotional connection and loneliness.
Which level of Maslow’s hierarchy of needs is the priority in this case?
A 40-year-old woman with an amputation feels useless because she can no longer work as she used to. She states, “I feel like I have no purpose anymore.”
Esteem Needs
The patient is struggling with self worth and independence.
Which level of Maslow’s hierarchy of needs is the priority in this case?
A 28-year-old patient who recently recovered from cancer decides to start a nonprofit organization to support others undergoing treatment. He expresses fulfillment in helping others and dedicated his life to helping those who are also going through cancer.
Self-Actualization Needs
The patient achieved personal growth and is now dedicated to helping others.
A nurse is reviewing a set of nursing diagnoses written by a student nurse. Which of the following nursing diagnoses are correctly written, following guidelines for avoiding common errors? (Select all that apply)
A) Impaired Skin Integrity related to prolonged immobility and pressure on bony prominences.
B) Risk for Infection related to presence of an indwelling urinary catheter.
C) Anxiety related to a need for emotional support.
D) Ineffective Airway Clearance related to accumulation of secretions in the lungs.
E) Self-Care Deficit related to cerebrovascular accident (CVA).
F) Imbalanced Nutrition: Less than Body Requirements related to inadequate dietary intake.
A, B, D, F
A nurse is formulating a nursing diagnosis for a patient experiencing impaired mobility due to a recent stroke. Which of the following nursing diagnoses is correctly written while avoiding common errors?
A) Impaired Physical Mobility related to left-sided weakness and cerebrovascular accident (CVA).
B) Need for assistance with ambulation related to left-sided weakness.
C) Impaired Physical Mobility related to decreased muscle strength and coordination.
D) Impaired Physical Mobility related to inability to walk and muscle atrophy.
C
A nurse is caring for a patient diagnosed with pneumonia who has impaired gas exchange as the priority physiological problem. Which nursing interventions should the nurse include in the individualized care plan? (Select all that apply.)
A. Administer oxygen therapy as prescribed.
B. Encourage deep breathing and coughing exercises.
C. Monitor oxygen saturation and respiratory rate closely.
D. Limit fluid intake to prevent fluid overload.
E. Position the patient in high Fowler’s position.
F. Teach the patient to avoid ambulation to conserve energy.
A, B, C, E
A nurse is developing an individualized nursing care plan for a patient with Type 2 Diabetes Mellitus who has uncontrolled blood glucose levels as the priority physiological problem. Which nursing intervention is the most important to include in the care plan?
A. Educate the patient on the importance of proper foot care.
B. Monitor blood glucose levels regularly and administer insulin as prescribed.
C. Encourage the patient to limit all carbohydrates from the diet.
D. Advise the patient to avoid physical activity to prevent hypoglycemia.
B
What are the 5 rights of delagation?
-
Right task
-> Task falls within delegates job description -
Right circumstance
-> Pt health condition is stable - Right person
-
Right directions/communication
-> Licensed nurse communicates specifiic intstruciton and delegatee asks clarifying questions -
Right supervision and evaluation
-> Licenses nurse responsible for:
–> monitoring the delegated activity
–> following up with delegatee
–> evaluating pt outcomes
Describe the Nursing Intervention Classification (NIC):
(What is it?, Why is it important?, What does it include?)
What is it?
- comprehensive list of treatments/actions that nurses perform
Why is it important?
- helps to standardize nursing knowledge, improve communication, and show impact of nursing care
What does it includes?
- includes actions for treating illnesses, preventing problems, and promoting health
-> Covers both direct and indirect care
-> Actions can be directed toward individuals, families, or entire communities
As an RN, you can not delegate what you can T.A.P.E.. What does each letter mean?
Teach
Assess
Plan
Evaluation
What is the purpose of the evaluation phase in the nursing process?
The evaluation phase determines whether patient outcomes have been:
- Met: continue or discontinue interventions
- Partially met: modify interventions as needed
- Not met: Reassess, revise the care plan
In revising/modifying a care plan, why is it imporant to collect new assessment data?
to have the most accurate and updated information about a patients condition
In revising/modifying a care plan, why is it imporant to rewrite outcomes?
rewrite outcomes to make them more realistic/achievable for the patient
In revising/modifying a care plan, why is it imporant to change nurse order?
revise interventions to be more effective and patient centered
In revising/modifying a care plan, why is it imporant to increase evaluation frequency?
monitor patient’s progress more closely and make timely adjustments
In revising/modifying a care plan, why is it imporant to adjust time criteria?
assess if the patient needs more time
Evidence-Based Practice (EBP)
integrate current evidence with clinical expertise, and patient/family preferences to deliver optimal health care
Evidence Based Practice
What are variables to consider when constructing nursing interventions?
- Appropriate for the pt problem
-> (include etiology/pathophysiology, assessment data) - Consistent with research findings
- Realistic for pt and nurse
- Compatible with pt’s values and other components of care
- Specificity: frequency, time and method
A 72-year-old patient recovering from hip surgery is experiencing difficulty walking, requiring assistance with a walker. The patient reports muscle weakness and expresses fear of falling when attempting to move independently.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Impaired physical mobility
Etiology:
- Muscle weakness
- Post-op pain
Symptoms:
- Difficulty walking
- requiring a walker
- fear of falling
A 58-year-old patient with chronic bronchitis has persistent coughing, labored breathing, and increased mucus production. The nurse observes wheezing on auscultation and notes the patient has difficulty clearing secretions.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Impaired airway clearance
Etiology:
- Increased mucus production
- Chronic bronchitis
Symptoms:
- Persistent coughing
- Wheezing
- Difficulty clearing secretion
A 35-year-old patient with Crohn’s disease reports poor appetite, weight loss, and fatigue over the past month. The nurse notes pale skin, dry mucous membranes, and a BMI of 17. Lab results indicate low albumin levels.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Imbalanced Nutrition
Etiology:
- Poor appetite
- Crohn’s disease
Symptoms:
- Weight loss
- Fatigue
- Pale skin
- Dry mucus membranes
- Low albumin levels
A 45-year-old patient recovering from abdominal surgery reports severe pain (8/10) at the incision site, guarding the area when moving. The nurse observes shallow breathing and facial grimacing.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Acute pain
Etiology:
- surgical incision
Symptoms:
- Pain rated 8/10
- Guarding behavior
- Shallow breathing
- Facial grimacing
A 76-year-old bedbound patient has developed a Stage II pressure ulcer on their sacrum. The nurse observes red, open skin with drainage and notes that the patient has been unable to reposition themselves due to severe weakness and immobility.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Impaired skin integrity
Etiology:
- Prolonged immobility
- Pressure on bony prominences
Symptoms:
- Stage II pressure ulcer on sacrum
- Open skin with drainage
- Inability to reposition self
A 65-year-old patient with prolonged vomiting and diarrhea is weak, lightheaded, and unable to stand without assistance. The nurse notes dry mucous membranes, decreased urine output, and a blood pressure of 88/56 mmHg.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Deficient fluid volume
Etiology:
- Excessive fluid loss from vommiting and diarrhea
Symptoms:
- Weakness
- Lightheaddedness
- Dry mucous membranes
- Decreased urine output
- Hypotension (88/56)
A 45-year-old hospitalized patient reports having difficulty falling and staying asleep due to frequent hospital noises, stress about their condition, and discomfort from their IV line. The patient appears fatigued and irritable during morning rounds.
Create a three part statement including:
Problem: What is the patient’s main issue?
Etiology: What is causing the problem?
Symptoms: What are the signs/symptoms that support this diagnosis?
Problem:
- Disrupted sleep pattern
Etiology:
- Frequent hospital noises
- Stress about condition
- Discomfort from IV line
Symptoms:
- difficulty falling and staying asleep
- Fatigued
- Irritable
What is a Care Plan?
personalized document outlining specific interventions & goals for a pt
The nursing process is a _______, while the care plan is the _____________________________
Nursing process = framework
Care plan = result of applying framework to a specific pt
Compare Direct vs Indirect Care
-
Direct care: treatments performed through interaction with pt
-> Elevating pt right foot -
Indirect care: treatments performed away from the pt
-> Contacting physical therapy
Compare the different types of priority (High, Medium, Low)
High Priority: greatest threat to pt well-being
Medium priority: non threatening problems
Low priority: problem not specifically related to current health problems
Describe this type of assessment: Patient-Centered Assessment Methods (What does it use/entail?)
use of interviews, observations, and physical exams that capture subjective and objective data
