W4: Nursing Process + Integ. System

Question 1

Critical thinking

Answer 1

Process nurses use to evaluate and interpret client data. Nurses learn to assess and modifty before acting. Evidence informed assessment is also vital to assessment.

Question 2

Nursing Process

Answer 2

Systematic way to provide organize a care plan for clients. Organized through phases that creates a holsitic view and ensures pt focused personalized planning.
ADPIE
Assessment: collecting objective / subjective data
Diagnosis: analyze, interpret data
Planning: priotize issues and needs , interventions
Intervention: reassess pt, implement , document
Evaluation: collect data outcomes, see if interventions were sucess, reassess , modfiy , reflect plan.

Question 3

Creating Nursing Diagosis Steps

Answer 3

1. NADA Section I
2. Section II: Match clients symptoms with medical diagosis, suggestions
3. Section III- care plans listed based on Diagosis

Question 4

1. Nursing Assessment

Answer 4

1. Acessment assess the data gathered from the client including pt symptoms , mental and physical state.
   - Gathering Subjective data: primary source (paitent) and secondary sources ( medical records, family, care providers)
   - Interview client
   Gather objective data: General survey, physcial examination, vitals assess. Note info prior to next step

Question 5

2. Nursing Diagosis

Answer 5

Under section II, match the symptoms of client with the symptoms listed.
- Probelm Focused , risk for, health promotion
- Review data gathered, make a list of symptoms and match to nursing diagosis.

Question 6

Analyzing Concerns

Answer 6

• Review data, is the data healthy
• Cluster simiarl symptoms
• Selected NADA diagosis and cluster such as ( ABC approach, Gordon patterns, system assessment)

Question 7

How to write a nursing diagosis ?

Answer 7

Written in three portions: probelm , etiology, and symptoms PES
1. NANADA part of diagosis / problem + section I ( Over-weight)
2. Etiology/cause written as r/t ( related to) statement
3. Symptoms and signs: aeb ( r/t excessive intake aeb weight 20% over ideal “ as evidence by”
Three parts:
Clinical judgement regarding health issues at time: Over-weight related to excessive intake in related to (rt)
metabolic needs, concerning food intake at the end of the day as evidenced by (aeb) weight 20% over ideal for
height and frame (three-part nursing dx)

Question 8

3. Plan Interventions

Answer 8

Nursing interventions: guides care and sec III provides list

Question 9

Setting Priorities

Answer 9

Priorities are the signs and symptoms reportd that can wait, and determinng what must be treated. If situation is life threatning, is data abnromal it must have priority.

Question 10

Health Priority Settings

Answer 10

First level Issues: emergent, life threatning immediate ABC’s , must be addressed.
Second Level: urgent, prompting intervetions such as acute pain, lab results, risk for safety
Third: imporant only after more urgent issues are addressed. Stable.

Question 11

Measuring Client Outcomes

Answer 11

• Measuring degree of pt changes is the response to expect. May be favorable or not so.
• Section III may provide client outcomes
• Use nurse outcome or client outcomes
• SMART goals
• Short term: outcomes achieved within a week, more immeidate , hours , a shift
• Long Term: outcomes achieved within weeks to months, used with more chornic health concerns.

Question 12

Short / Long Temr Goals

Answer 12

Short Term: achieved SMART within a day or shift. Such as walk to end of hall by day 3.
Long Term take weeks to achieve, more for chronic related issues. Report releif from urinary incontiniuence within one month.

Question 13

4. Interventions

Answer 13

Section III
- Review data and select the intervention that best matches needs. Evidence based rationales , provide care following intervention. Whe choosing interventions, consider the diagosis, goals and outcomes, evidece, own competence.

Question 14

Direct / Indirect Care

Answer 14

Direct care–> life saving meausres, ADL’s, teaching
Indirect–> communicating interventions, evaluate others work.

Question 15

Types of Interventions

Answer 15

Nurse initated: interventions that don’t require direct orders
Physcian initaed; dependent on nursing interventions
Collab/interdependent: interventions require combined knowlege

Question 16

Difference between intervention and outcome

Answer 16

Interventions: nurse actions to help pt achieve their goals , initaed by nurse in response to the diganosis. Such as client will be repoistioned, observe skin throughout. ( Conducted by the nurse to help achieve outcomes)
Outcomes: The clients goal , the measureable change in status response to care.

Question 17

5. Evaluation: Are goals met?

Answer 17

Determine effectiveness of the nursing interventions and client outcomes
- The clients goal is to be evaluated not the nurses intervention
- Compare actual outcomes with the exepcted ones
-Ongoing
- Analysis of client respones to nurse interventions
- if outcomes met, resolve plan, changes in diagosis, outcomes, interventions should be made.

Question 18

Integumentary Skin Hair Nails Assessment ( IPPA)

Answer 18

Vital Signs + General survey, this part of head toe assessment involves inspection and papatation of the area.

Question 19

What is the Subjective data ?

Answer 19

• Refers to assesment of the risk factors that affects the skin, hair, and nails
  Questions asked regarding the following topics:
  1. General health
  2. Family History of skin condition
  3. Past History
  4. Medications and treatments
  5. Allergies and nutrition
  6. Lifestyle
  7. Previous history of skin conditons
  8. Mole changes ( color, size, shape)
  9. Pigmentation
  10. Dryness / moisture / itching (Puritis) / Rash or lesions
  11. Bruising ( ecchymosis)
  12. Sunbruns
  13. Skin breakdown ( frinction, mositure)

Question 20

How to prepare for a physcial examination?

Answer 20

• Wash hands, privacy, explain procedures, wear gloves
• Lighting
• Small ruler, penlight, gloves

Question 21

What is the objective data?

Answer 21

Objective assessment: Inspection and palptation
General Assessment: Involves inspection and palptation of areas.
1. Nails: is nail pink bed, firm base, smooth nail angle 160, cap refill 2 sec, any nail clubbing , trimmed (IP). Non tender nail folds
2. Hair: Color, Texture, Distrubution ( IP)
3. Skin: understand baseline color, texture
- Color: obssereve color tone in all areas, freckles , sunspots. Note any jandice or cyanosis (blue) of area
- Temperature: using dorsal side of hand palpate skin bilaterally. Warm ( hypo/hyperthermia)
- Moisture: face, axilla, check for dehydration of mucos areas,
- Texture: should be smooth, thicker calluses ( edema is the buildup of fluid in the skin leaving indents.
- Mobility: Assess for elasticty of skin , check for dehydration by pinching. Tudor ( skin returns to place)
- Edema ( pressure indents)
- Lesions: palptate ligh brushes, Asymmetry, Boarders, color, diameter, evolution ABCDE

Question 22

Objective data for Lesions

Answer 22

Lesions are to be oberved using ABCDE rules
- Color, elevation, pattern, size (6mm), location and distrubution
Promote self care and teach self skin exam using ABCDE (Assymetry, Boarder ireh=gular, color, diameter, elevation

Question 23

Nurses role in Assessment ?

Answer 23

• To monitor skin integrity, prevent skin breakdown, healing
• General survey and physical examination of inspection and palpation

Question 24

Edema

Answer 24

Skin that retains pressure indent
Various ways to quanitify +1, +2 +3 +4

Question 25

Color assessment

Answer 25

- Black, yellow, mixed, red granulation - Skin pigmentation: pallor , erythermia, cyanosis, jaudice

Question 26

Pressure Points

Answer 26

Hips, knees, back of head etc - Stage 1 Skin in intact , red - Stage 2 Loss of Dermis - Stage 3 Full pressure injury: extend to fat - Stage 4 exposed to bone and muscle

Question 27

Branden Scale

Answer 27

Tool used to predict pressure sores , find factors that lead to skin breakdown. Composed of sensory perception, moisture, activity, mobility, friction, nuirtion. Low score = high

Question 28

Assessment of Moles

Answer 28

Begin normal: symmetrical, even boarders, one shade, smaller than 1/4 . Note color, shape, size, location - Maligant: assyemitcal, uneven, shades, larger

Question 29

Older adults

Answer 29

Skin color liver spots, hyperpig Dryness, loss of collagen, thin dermis, increased risk for skin, hair, distribution, loss of sweat , thin skin and fat loss.

Question 30

Documentation of Integumentary System

Answer 30

Includes subjetive data gathered from asking questions to client to get health ( hsitory of diease, change in pig, pruitis(itchy), burisesing, rashes, lesions, medications) What the client is telling Objective: Inspection and palpation: Skin ( color, pigmentaion, texture, mositure, mobility) Hair ( distrbution, color, texture) Nails ( shape, color, cap refill, clubbing)