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Nursing Process

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Jessica Dwork

on 20 January 2017

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Transcript of Nursing Process

Time lapsed
A nursing assessment duplicates a medical assessment by focusing on the patient’s responses to the health problem.
A. True
B. False
Which one of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer?
A. Initial assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment
B. Focused assessment
Medical vs. Nursing Assessments
Target data pointing to pathologic conditions
Focus on the patient’s response to health problems
A patient rates his pain as a “7” on a pain rating scale. This rating is considered to be objective data.
Sources of Data
Significant other
Other healthcare professionals
C. Working
A Nursing assessment is done to:
Establishment of a database for nursing intervention
Appraisal of health status
Identification of health problems
Purposes of the Diagnosing Step
Identify how an individual, group, or community responds to actual or potential health and life processes
Identify factors that contribute to, or cause, health problems (etiologies)
Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems
Types of Diagnoses
Describes problems for which the physician directs the primary treatment
Managed by using physician-prescribed and nursing-prescribed interventions
Medical diagnosis
Collaborative problems
4 steps to interpreting and analyzing data...
Recognizing significant data
Recognizing patterns or clusters
Identifying strengths and problems
Reaching conclusion
A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most like be determined?
A. Recognizing significant data
B. Recognizing patterns or clusters
C. Identifying strengths and problems
D. Reaching conclusions
D. Reaching conclusions
No problem
Possible problem
Actual or potential nursing diagnosis
Clinical problem other than nursing diagnosis
A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario?
Smoking cigarettes
Formulation of Nursing Diagnoses
Problem—identifies what is unhealthy about patient
Etiology—identifies factors maintaining the unhealthy state
Defining characteristics—identifies the subjective and objective data that signal the existence of a problem
Benefits of Nursing Diagnoses
Individualizing patient care
Defining domain of nursing to healthcare administrators, legislators, and providers
Seeking funding for nursing and reimbursement for nursing services
Sources of Error When Writing Nursing Diagnoses
Making legally inadvisable statements
Reversing the clauses
Identifying environmental factors rather than patient factors as the problem
Identifying as a patient response what is not necessarily unhealthy
Having both clauses say the same thing
Identifying as a patient problem what cannot be changed
Which of the following nursing diagnoses is written correctly?
A. Child Abuse related to maternal hostility
B. Breast Cancer related to family history
C. Deficient Knowledge related to alteration in diet
D. Imbalanced Nutrition related to insufficient funds in meal budget
D. Imbalanced Nutrition related to insufficient funds in meal budget
Goal of Outcome Identification and Planning Step
Right hip fracture
Acute pain
Impaired urinary elimination
Anxiety related to surgical procedure
Chronic depression
___________ related to ____________ aeb __________________

Constipation related to use of opiod analgesics as evidenced by passage of hard, formed stool
Establish priorities
Identify and write expected patient outcomes
Select evidence-based nursing interventions
Communicate the plan of care
A Formal Plan of Care Allows the Nurse To:
Individualize care that maximizes outcome achievement
Set priorities
Facilitate communication among nursing personnel and colleagues
Promote continuity of high-quality, cost-effective care
Coordinate care
Evaluate patient response
Create a record used for evaluation, research, reimbursement, and legal reasons
Promote nurse’s professional development
Three elements to planning.....
Which one of the following nursing actions would most likely occur during the ongoing planning stage of the comprehensive care plan?
A. The nurse collects new data and uses them to update the plan and resolve health problems.
B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home.
C. The nurse who performs the admission nursing history develops a patient care plan.
D. The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions.
A. The nurse collects new data and uses them to update the plan and resolve health problems.
Prioritizing nursing diagnoses
High priority—greatest threat to patient well-being
Medium priority—non-threatening diagnoses
Low priority—diagnoses not specifically related to current health problem
Which of the following nursing diagnoses would most likely be considered a high priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance
B. Impaired gas exchange
Prioritize using MASLOW'S HIERARCHY OF NEEDS!!!!!
Categories of Outcomes
—describes increases in patient knowledge or intellectual behaviors
Psychomotor —
describes patient’s achievement of new skills
describes changes in patient values, beliefs, and attitudes
Which one of the following outcomes is an affective outcome?
A. By 6/09/08, the patient will correctly demonstrate the procedure for washing her newborn baby.
B. By 6/09/08, the patient will list three benefits of eating a healthy diet.
C. By 6/09/08, the patient will use a walker to ambulate the hallway.
D. By 6/09/08, the patient will verbalize valuing his health enough to stop smoking.
D. By 6/09/08, the patient will verbalize valuing his health enough to stop smoking.
Common Errors in Writing Patient Outcomes
Expressing patient outcome as nursing intervention
Using verbs that are not observable or measurable
Including more than one patient behavior or manifestation in short-term outcomes
Writing vague outcomes
Parts of a Measurable Outcome
Performance criteria
Target time
Types of Nursing Interventions
Nurse-initiated actions performed by a nurse without a physician’s order or based on a standing order or protocol

Physician-initiated actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

Collaborative- preformed jointly by the nurse and other healthcare team members
Nursing actions....
Reduce risks
Monitor health status
Resolve, prevent, or manage a problem
Facilitate independence or assist with ADLs
Promote optimum sense of physical, psychological, and spiritual well-being
A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.
A. True
B. False
Problems Related to Outcome Identification and Planning
Failure to involve patient
Insufficient data collection
Nursing diagnoses developed from inaccurate or insufficient data
Outcomes stated too broadly

Outcomes derived from poorly developed nursing diagnoses
Failure to update the plan of care
Writing nursing orders that do not resolve the problem
A nurse who follows the protocol for taking vital signs following surgery is performing a physician-initiated intervention.
Variables Influencing Outcome Achievement
Patient variables
Developmental stage
Psychosocial background
Nurse variables
Current standards of care
Research findings
Ethical and legal guides to practice
Which one of the following is an example of a nurse variable influencing patient outcomes?
A. A patient in a nursing home refuses to take his medications.
B. A low-income family is unable to afford formula for their newborn infant.
C. An alcoholic patient is unwilling to participate in AA meetings.
D. A rape victim does not receive counseling at the ER because a counselor is not available.
D. A rape victim does not receive counseling at the ER because a counselor is not available
Common Reasons for Noncompliance
Lack of family support
Lack of understanding about the benefits
Low value attached to outcomes
Adverse physical or emotional effects of treatment
Inability to afford treatment
When a patient fails to cooperate with the plan of care despite the nurse’s best efforts, it is time to reassign the patient to another caretaker.
T or F
Allows achievement of outcomes
Directs nurse-patient interactions
Measures patient outcome achievement
Identifies factors to achieve outcomes
Modifies the plan of care, if necessary
The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions.
A. True
B. False
Actions taken by the nurse....
Terminate, modify, or continue the plan of care
B. Discontinue the plan of care
Which one of the following examples is a psychomotor outcome?

A. A patient learns how to control his weight using the MyPyramid Food Guide.
B. A patient is able to test for glucose levels and inject insulin as needed.
C. A patient values his health enough to decide to quit smoking.
D. A patient is able to ambulate the hallway following knee surgery.

B. A patient is able to test for glucose levels and inject insulin as needed.
Asking a patient to plan an exercise program to lower blood pressure based on information provided to him in an A/V presentation is an excellent method to evaluate a cognitive outcome.
True or False
Variables Affecting Outcome Achievement
Healthcare system
A patient gives up and refuses treatment
A nurse is suffering from burn-out
No interest or lack of patience in helping the patient

Inadequate staffing
Lack of resources

Decide how well outcome was met (met, partially met, or not met)
List patient data or behaviors that support this decision
Make changes to the plan....
Delete or modify
Make outcome/goal more realistic
Adjust the time frame
Change nursing interventions
An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care.
Most healthcare institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.
Guidelines for writing diagnoses:
Phrase as a patient problem rather than a need
Make sure to put the problem first and then the etiology linked with "related to"
defining characteristics when included, should follow the etiology and be linked with "as manifested by"
Write in nonjudgemental language
avoid using medical diagnoses in a nursing diagnosis
avoid writing diagnoses for things you can not change
reread to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing interventions
Planning Outcomes
Prioritize based on patient's preferences and the needs/problems that they think are more important
Prioritize based on anticipation of future problems
You want me to do what?!?
NIC- Nursing intervention classification
Catagories of interventions that includes a label, definition, and nursing actions a nurse performs to carry out the intervention
NOC- Nursing Outcomes Classification
Standardized outcomes that are responsive to nursing interventions
Carrying out the plan in order to meet outcomes
Whats the point of the implementation phase?!?
Five-Step Nursing Process

Assessment involves collecting information from the patient and from secondary sources (e.g., family members), along with interpreting and validating the information to form a complete database.
Two stages of assessment:
Collection and verification of data
Analysis of data

Critical Thinking Approach
to Assessment

Ms. Carla Thompkins is being admitted to the medical-surgical unit as a postop patient. Ms. Thompkins, a 52-year-old schoolteacher, is recovering from a below-the-knee amputation (BKA) secondary to complications of type 2 diabetes.
Ms. Thompkins is admitted to the unit not only so her recovery from the BKA may be monitored, but also because Ms. Thompkins is going to receive preliminary occupational and physical therapy to help her adapt to the amputation.

Case Study

During the assessment, Ms. Thompkins complains of pain at the incision site.
Ms. Thompkins’ report of pain is an example of what type of data?

Case Study (cont’d)

Which of the following statements or questions made by Yolanda to Ms. Thompkins addresses the nature of Ms. Thompkins’ pain?
(Select all that apply.)
A. “Describe your pain to me.”
B. “Is the pain worse in the morning or in the evening?”
C. “Place your hand over the area that is uncomfortable.”
D. “Rate your pain on a scale of 0 to 10.”

Case Study (cont’d)

True or False: Yolanda knows that the best source of information regarding Ms. Thompkins’ care is the surgeon.

Types of Nursing Diagnoses

For a student to avoid a data collection error, the student should
A. Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.
B. Review his or her own comfort level and competency with assessment skills.
C. Ask another student to perform the assessment.
D. Consider whether the diagnosis should be actual, potential, or risk.

Quick Quiz!

A. Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.

Goals of Care

Goals of Care (cont’d)

Direct Care vs. Indirect Care

Miyoko is a nursing student assigned to Mr. Mashoud, a 48-year-old Arab male admitted to the hospital with kidney stones.
Upon Mr. Mashoud’s admission to the emergency department (ED) this morning, he was experiencing excruciating pain.
The treatment plan for Mr. Mashoud includes keeping him in the hospital until he passes the stones and adjusting his pain medication as needed.

D. The patient will identify the need to increase dietary intake of fiber by June 5.

Miyoko evaluates Mr. Mashoud’s response to the medication therapy to update his care plan. Miyoko assesses Mr. Mashoud’s pain before NSAID administration and then approximately one hour after administration.
Miyoko knows that evaluation is an ____________ process that occurs whenever contact with a patient occurs.

Case Study (cont’d)

Miyoko determines the patient outcomes for Mr. Mashoud based on his reaction to the medication regimen. Which of the following is an end result that translates into observable patient behaviors that are measurable and desirable?

A. Unexpected outcome
B. Expected outcome
C. Sensitive outcome
D. Accomplished outcome

Answer: B

Answer: ongoing

1. Your patient has met the goals set for improvement of ambulatory status. You would now
A. Modify the care plan.
B. Discontinue the care plan.
C. Create a new nursing diagnosis that states goals have been met.
D. Reassess the patient’s response to care and evaluate the implementation step of the nursing process.

Redefine diagnoses
Nursing Process 101
Time lapsed
Yolanda is the student nurse who has been assigned to admit Ms. Thompkins. Yolanda enters Ms. Thompkins’ room, introduces herself, and begins the admission health history and physical assessment.

Answer: False
Rationale: The best source of information regarding the patient’s care is typically the patient, as long as the patient is conscious, alert, and able to accurately answer questions.

Answers: A and C
Rationale: Asking the patient to describe or show the location of pain addresses the nature of pain. Asking the patient about pain during certain periods of the day or in association with movement addresses precipitating factors of pain. Severity of pain is addressed by a pain scale rating.
Subjective: Verbal descriptions
Objective: Observations or measurements
You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly?

A. The patient will eat 80% of all meals.
B. The nursing assistant will set the patient up for a bath every day.
C. The patient will have improved airway clearance by June 5.
D. The patient will identify the need to increase dietary intake of fiber by June 5.

Protocols and Standing Orders

Which of the following is considered direct nursing care? (Select all that apply)

1. Teaching a patient about their diagnosis
2. Counseling a patient who is grieving
3. Delegating a task to the NAP
4. Documenting care
5. Helping a patient ambulate
Answer: 1,2,5
Types of nursing assessments
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