QUESTIONS AND SOLUTIONS
◉ Guidelines for reducing error. Answer: 1. Identify a patients
response, not the medical diagnosis
2. Identify a NANDA-I diagnostic statement, not the symptom
3. Identify a treatable related factor or risk rather then a clinical sign
or chronic problem
4. Identify a problem caused by the treatment or diagnostic study
rather than the treatment or study itself
5. Identify the patients response to the equipment rather than the
equipment itself
6. Identify the patients problems rather than our problems with
nursing care
7. Identify a patients problem rather than a nursing intervention
8. Identify a patients problem rather than the goal of care
9. Make professional rather than prejudicial judgements
10. Avoid legally inadvisable statements
11. Identify the problem and etiology to avoid a circular statement
12. Identify only one patient problem in the diagnostic statement
◉ Documentation and Informatics. Answer: edOnce you identify a
patient's nursing diagnoses, enter them either on the written plan of
,care or in the electronic health information record (EHR) of the
agency.
- Computer helps organize data into clusters
- Enhances ability to select accurate diagnoses
When initiating an original care plan, place the highest-priority
nursing diagnosis first.
◉ NANDA-I terminology. Answer: -diagnoses have a broad literature
base, with many -diagnoses being evidence based. Patient safety
requires accurate documentation of health problems
-classifications are the most comprehensive
- diagnoses are under continual refinement and development by
professional nurses
◉ Nursing Diagnoses: Application to Care Planning. Answer:
Diagnoses direct the planning process and the selection of nursing
interventions to achieve desired outcomes for patients
-By making accurate these, your subsequent care plan
communicates a patients health care problems to other
professionals and ensures that you select relevant and appropriate
nursing interventions
◉ Third Step of the Nursing Process. Answer: planning
,◉ Planning. Answer: the nurse collaborates with a patient and
family and the rest of the health care team to determine the urgency
of the identified problems and prioritize patient needs
◉ Plan of care. Answer: Dynamic and changes as a patient's
individualized needs change
◉ Establishing Priorities. Answer: Ordering of nursing diagnoses or
patient problems uses determinations of urgency and/or
importance to establish a preferential order for nursing actions.
Helps nurses anticipate and sequence nursing interventions.
-Symptom pattern recognition
◉ High (emergent) Priority. Answer: nursing diagnoses that, if
untreated, result in harm to a patient or others
-ex. those related to airway status
-circulations
-safety and pain
◉ Three levels of Priorities. Answer: high
intermediate
low
, ◉ Intermediate (non-life threatening) Priority. Answer: involve non-
emergent, nonlinear- threatening needs of a patient
◉ low priority. Answer: not always directly related to a specific
illness or prognosis but affect a patient's future well-being.
-ex. patients long term health care needs
◉ Priorities in Practice. Answer: Many factors within the healthcare
environment affect your ability to set priorities
-the same factors that influence your minute- by-minute ability to
prioritize nursing actions affect the ability to prioritize nursing
diagnosis and plan care for groups of patients
-When ethical issues make prioritizes less clear, it is important to
have an open discussion with the patient, family, and other health
care providers
◉ Steps in Plan of Care (POC)- Priorities. Answer: Assess patient
identify problems
prioritize problems
identify desired outcomes
identify interventions for achieving outcomes
prioritize interventions
deliver patient care
evaluate interventions