NR 226 Nursing Process Questions and Answers

NR 226 Nursing Process Questions and Answers ASSESSMENT the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns Includes 2 steps: -Collection of information from a primary source (the patient) and secondary sources (e.g., family members, health professionals, and medical record) -The interpretation and validation of data to ensure a complete database Purpose of assessment is to: establish a database about the patient's perceived needs, health problems, and responses to these problems. Cue information that you obtain through use of the senses Inference your judgment or interpretation of these cues Subjective data -patients' verbal descriptions of their health problems -only patients provide subjective data Objective data -observations or measurements of a patient's health status. -ex: inspecting the condition of a surgical incision or wound, describing an observed behavior, measuring blood pressure Initial patient center interview (1) setting the stage (2) gathering information about the patient's chief concerns or problems and setting an agenda (3) collecting the assessment or a nursing health history (4) terminating the interview. Concomitant symptoms Does the patient experience other symptoms along with the primary symptom? For example, does nausea accompany pain? DIAGNOSIS clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat Collaborative problem an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's statu Data cluster set of signs or symptoms gathered during assessment that you group together in a logical way Risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. These diagnoses do not have related factors or defining characteristics because they have not occurred yet Health Promotion nursing diagnosis clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise Diagnostic label describes the patient's response to a health condition in as few words as possible Related factors -The reason the patient is displaying the nursing diagnosis. -It is not cause and effect. -Indicates etiology that contributes to the diagnosis. A related factor is: a condition, historical factor, or causative event that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis PES format P= Problem, use NANDA-I label E= Etiology or related factor S= Symptoms or defining characteristics PLANNING involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions Establishing priorities helps nurses anticipate and sequence nursing interventions Classification of priorities High—Emergent Intermediate Low—Affect patients' future well-being Goal broad statement that describes the desired change in a patient's condition or behavior Expected outcome measurable criteria to evaluate goal achievement Patient-centered goal specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function Short term goal an objective behavior or response expected within hours to a week Long term goal an objective behavior or response expected within days, weeks, or months Nursing-sensitive patient outcome measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions Critical pathways patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially Purpose of critical pathways: deliver timely care at each phase of the care process for a specific type of patient Delegation transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. It results in quality patient care, improved efficiency and empowered staff IMPLEMENTATION fourth step of the nursing process, formally begins after the nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, the nurse initiates interventions that are designed to achieve the goals and expected outcomes needed to support or improve the patient's health status Nursing intervention any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes Standing orders preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems NIC interventions offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes. If nurses uses NIC nurses learn common interventions recommended for NANDA nursing diagnosis. Implementation process: 1. Reassess the patient 2. Revise the nursing care plan 3. Gather resources 4. Anticipate and prevent complications 5. Implementation skills Implementation skills: -Cognitive skills -Interpersonal skills -Psychomotor skills EVALUATION final step of the nursing process, is crucial to determine whether, after application of the nursing process, the patient's condition or well-being improves. You apply all that you know about a patient and his or her condition and your experiences with previous patients to evaluate whether nursing care was effective Involves 2 components: 1. Examination of a condition 2. Judgment if a change has occurred