NURS1016 - Final Exam Study Guide
What are the steps in the nursing process? (handout) - Answer 1) Organization of data
2) Interpretation of data
3) Clustering data
4) Data gaps
5) Nursing diagnosis
6) Planning
7) Evaluation
How do you organize data in the nursing process? - Answer *1. Utilize an assessment
tool*
- Gordon's Function Health Patterns
*2. Identify type of data*
- Subjective: client's perceptions about their health; obtained from the client or family
- Objective: observations or measurements made by the nurse and/or obtained by the
nurse; includes history, physical exams, health records
- Kardex/Chart
How do you interpret data in the nursing process? - Answer *1) Interpret in terms of:*
- normal values
- principles & theories
*2) Reference appropriately*
- if intuition, state as such
*3) Identify each piece of data as:*
- strength
- weakness
How do you cluster data during the nursing process? - Answer 1. cluster (group) data
according to patterns, themes in data
2. refer to nursing diagnostic categories
3. cluster should include data from more than one category
,4. clustering of data will determine the relatedness of facts & highlight patterns in facts
5. clustering data involves:
- nurses judgement & interpretation of facts
- search in nurse's memory for previous learned meaningful groups of clinical data
6. clustering assists in judging whether or not and what type of problem exists
What is involved in identifying data gaps? - Answer 1. identify gaps from the cluster
(data may be completely missing or incomplete)
2. Identify inconsistencies
- ex. discrepancies between verbal and nonverbal data
What are the three parts of the nursing diagnosis? - Answer *X1* = NANDX Dx
*X2* = individualization of client problems (signs and symptoms)
- "as evidenced by"
*Y* = contributing factors or probable causes
- "related to"
X1 + X2 r/t Y
Ex. Constipation (no BM x 8 days) r/t immobility, decreased fluids intake
What is included as part of the planning stage? - Answer - Prioritizing Nsg Dx
- Identifying goals
- Expected outcomes
- Strategies and interventions
How do you prioritize Nsg Dx? - Answer // part of planning stage //
Rank as high, intermediate, or low based on:
- urgency
- client perspective
- Maslow's hierarchy of needs
*High priority*
- prompt resolution prevents further physiological/emotional status
,*Intermediate*
- does not affect client's immediate physiological/psychological status
*Low*
- reflects client's long term needs
When developing goals what should be included? - Answer // part of planning stage //
1. Nurse and client *develop goals together* whenever possible
2. *Goals are based on the Nsg Dx*, part of the X, the NANDA statement
- client-centered
- specific
- measurable
- realistic
3. Short term
- achieved in short period of time (ex. within one week)
4. Long term
- achieved over a longer period of time (ex. weeks -> months)
- often focus on prevention, rehabilitation, discharge, and health education
How do you outline expected outcomes? - Answer // part of planning stage //
- *client centered*
"client will ambulate, client will state"
- *singular*; address only one response
"client will state pain decreased to <5"
- *time*; identify when expected outcomes should occur
"client will ambulate in 1 week"
- realistic, understandable, measurable, behavioural, achievable
What are the three types of interventions? - Answer - nurse-initiated
- physician-initiated
- collaborative
, How are nursing strategies developed? - Answer // part of planning stage //
*Based on the Y part of the Nsg Dx*
- contributing factors
Address:
- who? "team leader"
- what? "reposition"
- when? "q2h"
- how? "hypoallergenic tape"
- where? "activation centre"
- why use? "reference"
What is the purpose of the evaluation? - Answer Determines a client's response to
nursing actions and to what extent the goals, expected outcomes, and strategies have
been met
- based on data obtained during evaluations NCP can be: revised, remain unchanged, or
discontinued
What are Gordon's 11 functional health patterns? - Answer *1. Health perception-health
management pattern*
- describes client's perceived pattern of health and well being and how health is
managed
- caring throughout the life span
*2. Nutritional - Metabolic Pattern*
- describes pattern of food and fluid consumption relative to metabolic need and pattern
indicators of local nutrient supply.
- fluid and electrolytes, nutrition
*3. Elimination Pattern*
- describes pattern of excretory function (bowel, bladder, and skin)
- urinary & bowel elimination
*4. Activity-Rest Pattern*
- describes pattern of exercise, activity, leisure, and recreation.
What are the steps in the nursing process? (handout) - Answer 1) Organization of data
2) Interpretation of data
3) Clustering data
4) Data gaps
5) Nursing diagnosis
6) Planning
7) Evaluation
How do you organize data in the nursing process? - Answer *1. Utilize an assessment
tool*
- Gordon's Function Health Patterns
*2. Identify type of data*
- Subjective: client's perceptions about their health; obtained from the client or family
- Objective: observations or measurements made by the nurse and/or obtained by the
nurse; includes history, physical exams, health records
- Kardex/Chart
How do you interpret data in the nursing process? - Answer *1) Interpret in terms of:*
- normal values
- principles & theories
*2) Reference appropriately*
- if intuition, state as such
*3) Identify each piece of data as:*
- strength
- weakness
How do you cluster data during the nursing process? - Answer 1. cluster (group) data
according to patterns, themes in data
2. refer to nursing diagnostic categories
3. cluster should include data from more than one category
,4. clustering of data will determine the relatedness of facts & highlight patterns in facts
5. clustering data involves:
- nurses judgement & interpretation of facts
- search in nurse's memory for previous learned meaningful groups of clinical data
6. clustering assists in judging whether or not and what type of problem exists
What is involved in identifying data gaps? - Answer 1. identify gaps from the cluster
(data may be completely missing or incomplete)
2. Identify inconsistencies
- ex. discrepancies between verbal and nonverbal data
What are the three parts of the nursing diagnosis? - Answer *X1* = NANDX Dx
*X2* = individualization of client problems (signs and symptoms)
- "as evidenced by"
*Y* = contributing factors or probable causes
- "related to"
X1 + X2 r/t Y
Ex. Constipation (no BM x 8 days) r/t immobility, decreased fluids intake
What is included as part of the planning stage? - Answer - Prioritizing Nsg Dx
- Identifying goals
- Expected outcomes
- Strategies and interventions
How do you prioritize Nsg Dx? - Answer // part of planning stage //
Rank as high, intermediate, or low based on:
- urgency
- client perspective
- Maslow's hierarchy of needs
*High priority*
- prompt resolution prevents further physiological/emotional status
,*Intermediate*
- does not affect client's immediate physiological/psychological status
*Low*
- reflects client's long term needs
When developing goals what should be included? - Answer // part of planning stage //
1. Nurse and client *develop goals together* whenever possible
2. *Goals are based on the Nsg Dx*, part of the X, the NANDA statement
- client-centered
- specific
- measurable
- realistic
3. Short term
- achieved in short period of time (ex. within one week)
4. Long term
- achieved over a longer period of time (ex. weeks -> months)
- often focus on prevention, rehabilitation, discharge, and health education
How do you outline expected outcomes? - Answer // part of planning stage //
- *client centered*
"client will ambulate, client will state"
- *singular*; address only one response
"client will state pain decreased to <5"
- *time*; identify when expected outcomes should occur
"client will ambulate in 1 week"
- realistic, understandable, measurable, behavioural, achievable
What are the three types of interventions? - Answer - nurse-initiated
- physician-initiated
- collaborative
, How are nursing strategies developed? - Answer // part of planning stage //
*Based on the Y part of the Nsg Dx*
- contributing factors
Address:
- who? "team leader"
- what? "reposition"
- when? "q2h"
- how? "hypoallergenic tape"
- where? "activation centre"
- why use? "reference"
What is the purpose of the evaluation? - Answer Determines a client's response to
nursing actions and to what extent the goals, expected outcomes, and strategies have
been met
- based on data obtained during evaluations NCP can be: revised, remain unchanged, or
discontinued
What are Gordon's 11 functional health patterns? - Answer *1. Health perception-health
management pattern*
- describes client's perceived pattern of health and well being and how health is
managed
- caring throughout the life span
*2. Nutritional - Metabolic Pattern*
- describes pattern of food and fluid consumption relative to metabolic need and pattern
indicators of local nutrient supply.
- fluid and electrolytes, nutrition
*3. Elimination Pattern*
- describes pattern of excretory function (bowel, bladder, and skin)
- urinary & bowel elimination
*4. Activity-Rest Pattern*
- describes pattern of exercise, activity, leisure, and recreation.
