NUR 100 EXAM

Nur 100 Exam #2 Chapter 3,4,5,6 Chapter 3: Assessment  Assessment: first phase of the nursing process  Nurses use data to o Identify health problems o Plan nursing care o Evaluate patient outcomes  Collect data o Interview o Observation o Physical examination  Validate data o Compare subjective and objective data o Validate conflicting data  Organize and record data **Nursing assessment focuses on patient responses – unlike medical assessment, which focuses on disease process and pathology**  Patient outcomes – ability to self-care – what recover will be like  Assessment overlaps with implementation (pg. 68)  Critical Thinking in assessment o Apply principles and theories about basic human needs, anatomy and physiology, disease process, human growth and development, human behavior, socioeconomic patterns and trends, and carious cultures and religions  Reflective practice o Who is this person? o What is this person’s story? o How is this person feeling? o Who and what are this person’s support?  Collecting data o Data collection: gathering information about client, family, or community – health status.  Client data: BP reading, urine color, lab test results  Family data: genogram, family income, home safety  Community data: environment (air, water), morbidity and mortality rate  Standards of reasoning o Clarify – statement must be clear in order to know whether it is accurate or relevant  Are the data recorded clearly? o Accuracy – a statement can be clear but not accurate  Are my measurements correct?  Is there reason to believe that the patient gave me incorrect information? o Precision – a statement can be both clear and accurate but not precise  Would someone know exactly what I mean by this? o Relevance – a statement can be clear, accurate, and precise, but not relevant to the issue.  Do I have data that relate to this nursing diagnosis or problem? o Depth – a statement can be clear, accurate, precise, and releveant – but superficial.  Did I cover all areas on the assessment form? o Breadth – a line of reasoning can meet all other standards, but one-sided.  Did I get data about patient and family concerns, as well as my own? o Logic – reason brings various thoughts together in some kind of order. When the thoughts make sense in combination, thinking is logical  Do these data make sense? o Significane – related to relevance  What is most important? o Subjective data are NOT measurable or observable  Obtasined from what the client tells you  Clients thoughts, beliefs, feelings, sensation, and perception of self and health  Objective data is taken by observing and examinging the client o Pulse, skin color, urine output, results of diagnostic test/radiograph  Primary Data: the client  Secondary data: obtained from sources other than the client  Types of assessment o Initial assessment – made during the first nurse-client encounter, usually comprehensive – consisting of subjective and objective data o Admission assessment – intial assessment performed at health care agency o Ongoing assessment – consists of data gathered after the database is completed o Comprehensive assessment – provides overall picture of the client’s health status nurse obtains data about all the clients body systems and functional abilities without having a problem in mind o Focused assessment – gathers information about a specific condition: an actual, potential, or possible problem that has been identified ***Nursing observations must be systematic so that no significant data are missed***  Data collection methods o Observations, conscious use of physical senses to gather information/data from the patient and environment  As you enter the room, observe for patients sign of distress  Scan for safety hazards  Look at equipment. Is it working? IV running?  Scan room. Who is there? How do those people interact with the patient?  Observe patient for more data – skin temp, breath sounds, drainage odors, conditions of dressings, need for repositioning  Data from the initial examination serves as a baseline o After providing nursing and medical interventions, the nurse can compare that data with the baseline data to assess the client’s responses to nursing and medical interventions.  Assessment techniques: inspection, palpation, auscultation, percussion  Nursing interview o Purposeful structured communication in which the nurse questions a patient to obtain subjective data  Focused and planned  During ongoing interview may be informal or brief o The nursing history contains data about the effects of illness on the patients daily functioning ability to cope  Types of interviews o Directive interview: highly structured; nurse controls the subject matter and asks questions in order to obtain specific information o Nondirective interview: nurse allows the patient to control the purpose, subject matter, and pacing  Uses open ended questions  Can result in a great deal of irrelevant data **Closed questions are especially effective in emergency situation or highly stressed patient**  Behaviors of active listening o S – sit or stand facing the patient to indicate you are interested o O – open posture; arms/legs uncrossed o L – lean forward toward patient o E – establish and maintain eye contact o R – relax to convey a sense of connection with patient  Interviewing older adults o Proceed slowly o Check for sensory deficits o Don’t assume all elderly people are deaf o Be aware that appropriate affect and articulate speech do not always go together o Rely on body language o Be alert for intermittent confusion o When possible try to get data  Validation – act of double checking or verifying data o Critical thinkers validate data  Ensure assessment info is complete, accurate, and factual  Eliminate own errors, biases, and misperceptions  Avoid jumping to faulty conclusions  Nursing model (theoretical framework) – set of interrelated concepts that represents a particular way of thinking about nurses, clients, health and environment o Gordons functional health pattern – directs nurses to collect data about common patterns or behaviors that contribute to health/quality of life, etc. o Orem’s self-care model – focuses on patients’ ability to perform self-care to maintain life, health and well-being. o Roy’s adaption model – describes patients as biopsychosocial beings, constantly adapting to external and internal demands o NANDA International Taxonomy II provides a framework for assessing and diagnosing  Non-nursing models o Maslow Hierarchy of needs – organizes data according to basic human needs that are common to all people o Body systems model – useful for identifying data that may indicate a medical problem ***Maslow’s Hierarchy provides a holistic approach that enables the nurse to identify both medical and nursing problems***  Recording data o Cues – what the client tells you and what you see, hear, feel, smell, and measure o Inferences – your judgment/interpretation of what the cues mean  WHEN RECORDING AVOID GENERALITIES SUCH AS “GOOD, NORMAL, ADEQUATE, or TOLERATED WELL.”  Cultural assessment o Cultural competence – requires knowledge of the values, beliefs, and practices of various cultures along with an attitude of awareness, openness, and sensitivity  PULSES – Physical Condition, Upper limb function, Lower limb function, Sensory component, Excretory function, Support factors  Ethnicity includes race but is not the same as race  Spiritual assessment (pg 104) o A holistic assessment includes information about the client’s spiritual well-being. o Used at the end of an interview  Wellness Assessment o Health promotion  Activities undertaken for the purpose of improving well-being and achieving a higher level of health  Active listening and dialogue o Components of wellness assessment (pg 106)  Risk factor o Anything that increases a person’s chance of acquiring a specific disease such as cancer  Ex) exposure to the sun is a risk factor for skin cancer o May be categorized according to age, genetic factors, biological characteristics, personal health habits, lifestyle and environment  Ethical and legal considerations o Veracity – (honesty) holds that we should tell the truth and not lie  When introducing yourself to the patient, tell them what to expect from the interview and how the information will be used o Autonomy – moral principle – holds that a person has the right to be independent and to decide for himself what is to happen to him o Treat assessment data as confidential – failure to do so robs the patient of his autonomy – removes control of how data is used and shared.  Malpractice suits o Monitoring is frequent and ongoing assessment often done at specific intervals Chapter 4: Diagnostic Reasoning  Diagnosis o Phase of nursing process o Is a reasoning process that nurses use to interpret patient data o End product of reasoning process is statement of health status called diagnosis. o Nurses refer to standardized list of terms called nursing diagnosis o Second phase of the nursing process  Use diagnostic reasoning to analyze data and draw conclusions about client health status  Verify conclusions with client and select standardized labels and record in plan of care  DIAGNOSIS IS PIVOTAL o Affects planning, implementation, and evaluation o EMERGENCY SITUATION – nursing may act (implementation) identifying the rest of the problems before assessing the patient o During evaluation the nurse determines whether the patients’ health status has changed Nursing diagnosis first appeared in the 1950s to describe the functions of a professional nurse (McManus 1951). Fry (1953) stated that nursing diagnoses is based on clients’ needs for nursing, rather than medical care.  ANA standards 2: Diagnosis o Competencies  The registered nurse:  Derives diagnoses or issues based on assessment data  Validates the diagnoses or issues with the patient, family, and other health care providers when possible and appropriate  Documents diagnoses or issues in a manner that facilitates the determination of the expected outcome and plans  Identifies actual or potential risks to the patients’ health and safety or barriers to health which may include but are not limited to interpersonal, systematic, or environment circumstances  Use standardized classification systems in naming diagnoses  Importance of nursing diagnosis o Facilitates individualized care  Healthcare organizations emphasize standardized care as a way to promote efficiency and decrease cost o Nursing diagnoses promote professional and accountability and autonomy by defining and describing the independent area of nursing practice  Nursing diagnosis language makes it clear that nurses do far more than simply carry out orders for medical treatment o Nursing diagnoses provide an effective vehicle for communication among nurses and other healthcare professionals  Provide short hand means of communicating client status o Nursing diagnoses help determine assessment parameter  Human responses – reactions to an event or stressor such as disease or injury o Occur in several dimensions  Can be biological, psychological, interpersonal/social, or spiritual o Occur at different levels  Can be cellular, systemic, organic, or whole person (organismic)  Responses to stressors can be helpful as well as harmful  Health problem (maladaptive or harmful response) o Is a human response to a life process, event, or stressor o Is a health related condition that both the patient and the nurse wish to change o Requires intervention in order to prevent or resolve illness or to facilitate coping o Results in ineffective coping, adaptation, or daily living that is unsatisfying to the patient o Undesirable state *Misunderstanding problems (pg 124) *  Strengths – areas of normal healthy functioning that will help the patient to achieve higher levels of wellness, or to prevent, control, or resolve problems o Physical – good nutritional status o Psychological – good coping and problem-solving skills o Psychosocial – strong family support system o Spiritual – strong personal values  Other examples include: sense of humor, motivation to change, supportive extended family, good knowledge of disease process, history of successful coping, etc. ***A nursing diagnosis is a statement about the patient’s present health status. It describes an actual, potential (risk), or possible problem***  Nursing Diagnosis: example - activity intolerance related to decreased cardiac output o Description – describe human responses to disease process or stressors o Problem status – actual, potential, or possible o Duration – can change frequently – not associated with medical diagnosis o Orientation – oriented to the individual o Focus – to treat and prevent o Treatment orders – nurses can order most interventions to prevent and treat o Classification system – are developed and being used but not universally accepted (NANDA-!)  Wellness Diagnosis  Describe areas in which a healthy client is functioning normally – no problem – person wishes to achieve higher level of wellness  A statement reflecting a client’s healthy responses in areas where the nurse can intervene to promote growth or maintenance of the healthy response o NANDA-I defines wellness as “quality or state of being healthy” and a wellness diagnosis as “human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. o Wellness Diagnosis include:  Effective therapeutic regimen maintenance  Readiness for enhanced nutrition, sleep, parenting, community coping  Actual Nursing Diagnosis o Problem that is actually present at the time you make assessment o Recognized by presence of associated signs and symptoms (defining characteristics)  examples:  anxiety related to change in health status and situational crisis  body image disturbance related to temporary presence of visible drain/tube  Potential (Risk) Nursing Diagnosis o Develops if the nurse does not intervene o Diagnosed by the presence of risk factors that predispose patient to developing problem  Example: Risk for compromised family coping related to limited support system and lack of knowledge o Risk nursing diagnosis describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community o Should only be used for patients who have a higher than normal risk for developing problem Actual Nursing Diagnosis Potential (Risk) Nursing Diagnosis Possible Nursing Diagnosis  Problem present  Signs and symptoms present  Problems may develop  Risk factors present  Unsure if problem is present  Some signs and symptoms present but not definitive  Data incomplete  Possible Nursing Diagnosis o Similar to physicians’ rule of out diagnosis – is one that you believe to exist o Enough data to suspect a problem but not enough to be sure o Using possible problems can help avoid:  Omitting an important diagnosis  Making an incorrect diagnosis because of insufficient data  Collaborative Problems o Predictable physiological complications of medical diagnoses or treatments that nurses manage by using both physician – prescribed and nursing prescribed interventions o The following will help predict and detect potential complications:  Look up patient’s medical diagnosis  Look up patient’s medications  Look up most common complications associated with the patient’s surgery, treatment, or tests  Know the signs and symptoms of potential complications so you will know what assessments are needed  Computer-assisted diagnosis o Expert (knowledge-based) systems  Artificial intelligence that uses reasoning to infer conclusions from stored facts o Many organizations use a system called managed care to standardize care for medical diagnoses they treat most often o Critical pathway – pre-printed standardized plan of care often associated with a medical diagnosis.  A variance occurs when the patient does not achieve a goal in time predicted by the critical pathway  Diagnostic reasoning can be divided into 3 broad stages o Interpreting the data o Verifying the diagnosis o Labeling and recording the diagnosis  Use of nursing models o Roy’s Model (1984) – recognize a problem as a failure to adapt o Gordon Model (1994) – recognize patient problems as a dysfunctional health pattern (i.e group of related cues that do not meet expected norms  Overview of Diagnostic Reasoning o Level 1: identify significant cues o Level 2: Cluster cues and identify data gap o Level 3: Draw conclusions about present health status o Level 4: determine etiologies and categorize problems  Criteria for validating diagnoses o Database is complete and accurate o Data analysis is based off a nursing framework o Cue clusters demonstrate the existence of a pattern o Cues are truly characteristic of the problems hypothesized o There are enough cues present to demonstrate the existence of a problem o The tentative cause and effect relationship are based on scientific nursing knowledge and clinical experience ***WHEN DIAGNOSING, YOU WILL USE CRITICAL THINKING TO ANALYZE AND SYNTHESIZE DATA, APPLY KNOWLEDGE, RECOGNIZE PATTERNS, AND DRAW CONCLUSIONS***  Common Diagnostic Errors o Using only the label definition without comparing patient data with defining characteristics for the diagnosis o Missing etiological or related factors o Inferring beyond the data – drawing conclusions not supported by the assessed data o Misinterpreting a patient’s realistic worry (e.g. identifying it as Anxiety or Ineffective coping) o Reading data or diagnostic criteria inaccurately o Missing cues because of lack of knowledge and experience  Avoid Diagnostic errors by: o Being aware of sources of error o Keeping an open mind o Ensuring data are complete o Supporting diagnostic conclusions with data o Validating diagnosis with the patient  Don’t jump to conclusions based on a few cues  Suspend judgment when data are imcomplete  Build gppd knowledge base and acquire clicical experience  Examine your beliefs and values o Bias, stereotypes, prejudice  Keep your mind open to all possible explanations of the data clusters o Forming premature conclusions based on context o Relying too much on past experience  Validate all diagnoses with data, don’t rely on intuition alone  Develop cultural sensitivity Chapter 5: Diagnostic Language  A classification system (taxonomy) identifies and classifies ideas or objects on the basis of their similarities  The need for uniform nursing language o Expanding nursing knowledge o Supporting computerized records o Defining and communicating unique nursing knowledge o Improving nursing care quality o Influencing health policy decisions  Choosing a problem label o The NANDA-I diagnostic labels provide a common language for nurss to use to describe health problems for any type of client and in all healthcare settings  Each NANDA-I diagnosis has 4 components: label, definition, defining characteristics, and related or risk factors  Label – (title or name) is a concise word or phrase describing the client’s health. Most labels include qualifying terms such as actual, risk, ineffective, impaired, or increased.  The definition expresses clearly and concisely the essential nature of the diagnostic label, it differentiates the label from all others.  Defining characteristics o Cues – (subjective and objective data) that indicate the presence of the diagnostic label.  For actual diagnosis, the defining characteristics are the patient’s signs and symptoms; for risk diagnosis, they are the risk factors.  Related or risk factors o The conditions or situations that are associated with the problem in some way  They are conditions that precede, influence, cause, or contribute to the problem  Can be biological, psychological, social, developmental, treatmentrelated, situational o Related factors are often but not always used as the causes of a diagnostic statement Chapter 6: Planning: Overview and Outcomes  In the planning phases (planning outcomes, planning interventions), the nurse, with patient and family input, derives desire outcomes from the diagnostic statements and identifies nursing interventions to achieve goals. o Purpose and product of two planning phases is a holistic plan of care tailored toward the patient’s problems. o A plan is NOT always a written, individualized care plan.  In the planning phase the nurse engages in: o Deciding which problems need individually developed plans and which can be addressed by critical pathways, standards of care, policies and procedures, and other forms of preplanned standardized care. o Choosing and adapting standardized, preprinted interventions and plans of care where appropriate. o Choosing and writing individualized outcomes and nursing orders for problems that require nursing attention beyond preplanned, routine care.  Formal planning o Conscious, deliberate activity involving decision making, critical thinking, and creativity  Informal planning o Phases overlap when performing informal planning while carrying out the activities in other steps  While listening to a patients lungs sounds (assessment), the nurse may be making a mental note (planning) to notify a primary care provider of findings  Time-Sequenced planning o Used when planning a patient’s care for a shift or for a 24-hour period  Timing and order of nursing activities for a patient must often be planned (giving pain meds before changing surgical dressing)  Nurses must coordinate timing of nursing care with the actions of other healthcare members, visits from family and friends, and circadian rhythm  Nurses must plan a daily work schedule  Initial planning o Begins with the first patient contact and continues until the nurse-patient relationship is ended  Ongoing planning o Can be performed by any nurse who works with the client o Carried out as new info is obtained and as the client’s responses are evaluated o Will use ongoing assessment data to:  Determine whether the client’s health status has changed  Set the days priorities for the client’s care  Decide which problem to focus on during shift  Coordinate activities to address more than one problem at each client contact  Discharge planning o Proves of preparing the patient to leave the healthcare agency o MODEL  M- make a written plan  O – offer resources  D – devise ways to increase compliance  E – evaluate your teaching with immediate feedback  L – legal implications – document  Two types of care plans o Comprehensive nursing plans of care o Multidisciplinary (collaborative) plan of care  Standardized pre-planned and preprinted  Individualized to fit the unique needs of individual patient o Provides community of care  Comprehensive nursing plan of care o Made up of several different documents that integrate, dependent, interdependent, and independent nursing functions o Provides central source of patient information to guide care o Nursing diagnosis care plan  Section of the comprehensive plan that prescribes the outcomes and interventions for the patient’s nursing diagnoses and collaborative problems.  Rationale – consists of principles or scientific reasons for selecting a specific nursing action o Critical pathway – standardized, multidisciplinary plan of care that sequences patient care based on diagnosis or case type  Outlines assessments, interventions, and expected outcomes  Variance  Occurs when an outcome is not met  Occurs when an intervention is not completed on time o Nursing-sensitive outcome  Achieved by nursing interventions o Goals  Long term  Goals for actual nursing diagnosis  Focus on restoring healthy responses and preventing further complications  Goals for risk nursing diagnoses  Focus on preventing the problem  Goals for possible nursing diagnosis  That the presence of the diagnosis will be confirmed or ruled out o Outcomes  Short term  Patients plan of care o Comprehensive nursing plan o Multidisciplinary plan of care o Require by The Joint Comission  Electronic care planning o Standardized o Individualized o Easy to review and update  Students plans of care o Nursing diagnoses o Predicted outcomes o Nursing orders o Rationale o Evaluation  Teaching objectives: patient outcomes that describe what the patient is to learn or how he will demonstrate learning  Cognitive learning: involves perception, understanding, and the storing and recall of new information  Psychomotor skills: involve physical skills  Affective learning: involves changes in feelings, attitudes, and values