Solving Clinical Problems in Nursing Practice

Question 1

steps of nursing process?

Answer 1

1. assessment & diagnosis
2. planning
3. implementation
4. evaluation

Question 2

Data Collection methods?

Answer 2

Interview
Basic tool of communication

Physical Examination
Inspection
Palpation
Percussion
Auscultation

Review of the chart

Question 3

Cluster Data?

Answer 3

Clustering the data into meaningful patterns involves:

Recognizing cues and making inferences

Collecting/identifying data that supports your preliminary conclusion.

Generating an Action Demand.

Question 4

Identification of Self-Care Deficits?

Answer 4

No self-care deficit:
Self-care ability = action demand
Self-care ability > action demand

Self-care Deficit with need for nursing intervention:
Self-care ability < action demand

Question 5

Components of a SCD Statement?

Answer 5

State the actual or potential inability to meet the specific self-care demand.

State the specific limitations of your patient

“Inability to ACTION DEMAND STATEMENT related to limitations in POWER COMPONENTS.”

Question 6

10 Power components: knowledge-skills-motivation?

Answer 6

1. Required knowledge or ability to acquire knowledge re: actions/steps
2. Motivation for each actions/steps
3. Attention span for each action/step
4. Physical energy for each action/step
5. Control of the body position for each action/step
6. Ability to reason for each action/step
7. Ability to make best decisions for each action/step
8. Repertoire of skills to be able to perform actions/steps
9. Ability to adjust self-care priorities to include actions/steps
10. Consistently perform steps/actions to integrate in one’s life

Question 7

Example of SCD statement?

Answer 7

inability to reduce falls in a 60 y.o. male who has colon cancer and is undergoing chemotherapy, had diarrhea and vomiting due to a limitation :

lacks knowledge
inability to make best decisions for himself
inability to control body position

Question 8

phases of planning?

Answer 8

1. Establish priorities among the SCDs
2. Determine desired outcomes based on the SCD statement.
3. Plan interventions (orders) to achieve these outcomes.
4. Communicate the plan of care.

Question 9

Guidelines for Establishing Priorities?

Answer 9

Maslow’s Hierarchy of needs:

• Those essential for the maintenance of all life processes.
• Those that prevent personal harm or injury.
• Those that maintain health.
• Those that contribute to the state of human well-being.

Question 10

Nursing outcomes or goals of nursing need to be?

Answer 10

Measurable and time-limited

Question 11

types of goals?

Answer 11

Client goal

Short-term goal

Long-term goal

Question 12

client goal?

Answer 12

A specific, measurable behaviour or response reflecting client’s highest possible wellness level and independence of function

Question 13

Short term goal?

Answer 13

An objective client behaviour or response expected within hours to a week

Question 14

Long term goal?

Answer 14

An objective client behaviour or response expected within days, weeks, or months

Question 15

Sample long term goal for M. counts?

Answer 15

regain initial wt of — kg in 4 weeks as evidenced by:

pt will reduce # of bm to 2/day

Question 16

Determine Desired Patient Goals?

Answer 16

Broad overall statement that describes an expected conclusion to a patient problem.

Should be clearly connected to the SCD you have identified.

Will be similar to your action demand statement but more specific because you can make reference to your client’s self-care ability or limitations thereof.

Should start with the words “patient will” as the goal should be patient centered.

Question 17

Expected outcomes for goals?

Answer 17

Specific, measurable changes in a client’s status
Provide focus or direction
Determine when a specific client-centered goal has been met

Question 18

types of outcomes for goals?

Answer 18

Cognitive outcomes
Psychomotor outcomes
Affective outcomes
Physiological outcomes

Question 19

cognitive outcome?

Answer 19

describe increased patient knowledge or intellectual behaviours.

EX: GOAL: Patient will develop basic knowledge of healthy weight loss diet as evidenced by:

Correctly lists at least 5 high sugar content foods to avoid by discharge.
Correctly identifies high fat content foods in his diet by discharge.

Question 20

psychomotor outcomes?

Answer 20

describe the patient’s achievement of a new skill.

EX: GOAL: Patient will develop adequate skills in order to be able to carry out the prescribed insulin treatment as evidenced by:

Demonstrates proper technique for accurate drawing of insulin into the syringe by discharge.
Demonstrates correct technique for insulin injection at the end of the teaching session.

Question 21

affective outcomes?

Answer 21

describe changes in the patient’s values, beliefs and/or attitudes.

EX: GOAL: Patient will verbalize valuing the health sufficiently to change nutritional plan for weight loss as evidenced by:

Verbalizes the benefits of low fat diet by the end of the course
Verbalizes the need for maintaining lifetime dietary changes by the end of Novemeber.

Question 22

physiological outcomes?

Answer 22

describe changes in patient’s physical state

EX: GOAL: Pt will regain baseline defecation pattern as evidenced by:

Soft stool q day by the end of the week
No pain on defecation by the end of the week

Question 23

Guidelines for Writing Expected Outcomes?

Answer 23

Client-centered 
Singular 
Observable 
Measurable 
Time-limited 
Mutual 
Realistic

Question 24

Setting a Goal and Expected Outcomes for Mr Counts

Answer 24

Goal:
Patient will use strategies to prevent falls during hospitalization
as evidenced by:

Expected outcomes:
Getting out of bed slowly with assistance by Nov.20
Returning to a supine position when dizzy by Nov.20
Transferring from bed to commode by pivoting by Nov.20
Walking only when supervised until strength improves by Dec. 5th.

Question 25

Other examples of goals and expected outcomes

Answer 25

Student will successfully pass nursing 180-111 as evidenced by:
Obtaining 60% total on all tests (CT1, CT2 and final) at the end of the semester
Obtaining 60% on Q0 questions on final exam
Obtaining “Meets expectations” for all performance criteria on clinical evaluation tool at the end of the semester

Patient will maintain adequate ventilation as evidenced by:
RR 12-20 bpm by …(date)
O2 sat of 95% or higher on room air by…(date)
Effortless breathing by….(date)

Question 26

Planning Interventions?

Answer 26

A nursing intervention is any treatment that a nurse performs to enhance the patient’s condition.

Question 27

Knowledge required by the nurse to determine the nursing actions includes?

Answer 27

Knowledge of the patient.
His/her abilities and limitations for self-care.
Theoretical knowledge of what is required.
Based on research and understanding of:
The courses of action required to resolve the SCD(s).
How these actions work (scientific rationale)

Question 28

Types of Interventions?

Answer 28

Nurse-initiated
Independent
Physician-initiated
Dependent
Collaborative 
Interdependent

Question 29

Nurse-Initiated Interventions?

Answer 29

Action based on scientific rationale that a nurse executes.

Actions are performed to:

Monitor health status
Reduce risks
Resolve, prevent or manage a problem
Facilitate independence or assist with ADL
Promote optimal sense of physical, psychological and spiritual wellbeing
Do not require a physician’s (or other team member’s) order.

Question 30

Nurse-Initiated Interventions?

Answer 30

RESOLVE OR MANAGE A PROBLEM
REDUCE RISKS
MONITOR HEALTH STATUS
ASSIST WITH ADL’S

Question 31

Physician-Initiated Interventions?

Answer 31

An intervention carried out by a nurse in response to a doctor’s order (delegated act)

Nurse will start, monitor and maintain IV fluids in response to a medical order.

Question 32

Collaborative Interventions?

Answer 32

Interventions initiated by other members of the team that require the knowledge, skills and/or judgement of the nurse to carry out.

Nurse administers pain medication that is ordered PRN based on her assessment of pain.

Question 33

Guidelines for Selecting Nursing Interventions?

Answer 33

Nursing interventions should be:

• Related to the nursing diagnosis and goal of care.
• Based on evidence from research (scientific rationale)
• Realistic (abilities, time and resources available)
• Compatible with the patients values, beliefs and culture
• Valued by the patient and family.
• Compatible with other planned therapies.