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59 Cards in this Set

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  • Back
what are the steps involved in the nursing process
Explain the Assessment tasks of the Nursing Process in detail
includes systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of a group or community.

ex - if patient says pain is 8 out of 10 that is objective.
can assessment tasks be delegated?
The ANA’s Code of Ethics for Nurses, Provision 4 (2001), states: “The nurse . . . determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.”
UAPs may collect information such as temp, height, weight; however, as a nurse it is your responsibility to assign those tasks and validate teh data collected. Also, conduct the interview and complete the physical assessment.
You can only delegate down the chain of command (wilkinson pg 126). Remember the 5 rights of delegating - right task, right circumstance, right person, right direction/communication, right supervision (wilkson pg 127)
when do you validate data
When to Validate:
Subjective/objective data do not agree or make sense
Client’s statements differ at different times in the interview
Data are far outside normal range
Factors are present that interfere with accurate measurement
Assessment in Relation to Other steps
Assessment is the first phase of the nursing process - the data must be accurate & complete because the remainder of the nursing process rests on the data.
Data are used to identify the client's actual or potential health problems and strengths.
Planning Outcomes and Interventions:
Data help you formulate realistic goals and choose interventions most likely to be acceptable to and effective for the client.
You gather data by observing the client's responses as you perform interventions.
You assess client responses to interventions; client responses are data. This reassessment provides for changes in the care plan (wilk pg 38)
Components of Nursing History
Nursing History is a task in Assessment phase of ADPIE
Biographical data
Chief complaint/ Reason for seeking care
History of present illness
Perception of Health Status/ Expectations of Care
Past medical history (PMH)
Family/Social Hx
Medications (including herbs & supplements)
Complementary/Alternative Modalities (CAM)
Review of Systems
Nursing Interview
Nursing Interview is a task in Assessment phase of ADPIE Interview -
Question the patient to get subjective data from patient (wilk pg 46)
Purposeful communication
Structured communication
Involves questioning the client
Purpose is to gather subjective data for the nursing database
Types of Interview Questions
(for full details read Types of Interviews - wilk pg 47)
Nursing Interview is a task in Assessment phase of ADPIE

- Closed questions - yes/no. They elicit specific information. Usually begins with who, where, when, what, do (did, does), is (are,were). Very useful when patient is anxious or has communication difficulties.

- Open-ended questions
Allow the patient to verbalize freely. Best way to get subjective information.

- Reflective questions
Encourage patient to elaborate on thoughts and feelings

- Direct questions
Validate or clarify information
Types of Nursing Interviews
wilk pg 47
Nursing Interview is a task in Assessment phase of ADPIE

Directive Interviewing
To obtain factual, easily categorized information
Uses mostly closed questions

Nondirective Interviewing
Allows the client to control the subject matter; nurse’s role is to clarify and summarize
Uses open-ended questions (open ended ?? specify a topic to be explored but phrase them broadly to allow the patient to elaborate. best way to get subjective data.
Preparing for the Interview

(assessment phase of ADPIE)
Know the purpose of the interview and how the data will be used (have as much background before going in)
Read the client's chart
Form some goals and opening questions
Schedule uninterrupted time
Have your forms and equipment
Compose yourself before entering the room
Prepare the Space for the interview

(assessment phase of ADPIE)
Provide privacy- try to have some time alone with patient to allow for privacy.

remove distractions - shut off tv

position yourself at the same level as your client; sit down, don't hover over the bed
Preparing the client

(assessement phase of ADPIE)
Introduce yourself
call the client by name
explain to the client what you would be doing and why
Assess readiness to discuss health issues (ie if the patient state not a good time arrange to come back)
Assess and provide comfort
Assess for anxiety
conducting the interview

(assessment phase of ADPIE)
Individualize your approach - based on client's age, cultural differences, developmental level. Ask yourself what approach is best considering my clients age whether older or younger.
Use active listening
Pay attention to nonverbal communication (for example client may be in pain and may not say so; therefore you may have to stop interview & resume later.
Use mostly open-ended questions
Avoid using health care vocabulary or talking down
Curb your curiosity, don't get caught up in the client's story focus on the information needed to prepare a plan for care.
Do not give advice or voice approval/disapproval
Before you leave and end the interview thank the client, tell them you will keep them informed, ask if they need something and make sure they are comfortable before you leave.
Reflecting on the Assessment
Data complete, accurate and validated?
Did I record data, not conclusions?
Did I follow up with special needs assessment if indicated?
Review teh physical assessment, observation, and examination.
What are the differences between Medical Assessment and Nursing Assessments
Medical - focus is on disease and pathology. (ex - fractured arm is a medical diagnosis)

Nursing Assessment - Focus on the client's responses to illness. (ex - fractured arm = pain, diminished ROM would focus on fractured arm) (ex - Cancer - Response to Chemo - n/v could cause nutritional imbalance)
Nursing Diagnoses

Diagnosis is the 2nd phase of ADPIE
Second phase of nursing process. This is the phase in which you determine the meaning of your assessment data. Use critical thinking skills to identify patterns in the data and draw conclusions about the clients health status including strengths problems and factors contributing to the problem.

Identify actual or potential health problems that can be prevented or resolved by independent nursing intervention.
Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (ex for pneumonia we can sit client up and have them deep breath to help the lungs).
Analyze & interpret data
Draw conclusions
Verify conclusions
Write the diagnostic statement
Prioritize the problems
Purpose of Nursing Diagnoses

Diagnosis is the 2nd phase of ADPIE
the phase in which you determine the meaning of your assessment data. Most nurses begin this process during the assessment phase. (ex medical diagnosis of of chronic renal failure you would considered teh diagnosis of Risk for Imbalanced Fluid volume but then you would obtain more data before documenting that as a nursing diagnosis)
Identify -
-How the patient responds to actual or potential health & life processes.
-Factors that contribute to or cause health problems (etiologies).
-Resources or strengths upon which the patient can draw to prevent or resolve problems (prove interventions are working)
Differentiating Between Medical Diagnosis & Nursing Diagnosis

(2nd phase of Nursing process)
Medical Diagnosis - Describes a disease, illness or injury for which the physician directs the primary treatment.

Nursing Diagnosis - A statement of client health status that nurses can identify, prevent or treat independently.
Give examples of medical vs. nursing diagnoses
Medical is sepsis - Nursing is Risk for infection.

Medical is cellulitis - Nursing is Impaired skin integrity.

Medical is COPD - Nursing is Impaired Gas Exchange

(can look up nursing diagnosis in Nanda or Ackley Nursing book)
Types of Nursing Diagnoses
see wilk pg 62 for diagram

Actual Nursing Diagnosis - is a problem response that exists at the time of the assessment. You identify it by the signs and symptoms (cues) that are present. Another definitions states the client has a human response to condition/life process. The actual nursing diagnosis is supported by defining characteristics and related factors. (NANDA-1 2009) EX- Imbalanced Nutrition: more than the body requirements r/t excessive intake in relation to metabolic needs aeb weight 20% over ideal for height and frame, concentrating food intake at the end of the day.
RISK Nursing Diagnosis - a problem response that is likely to develop in a vulnerable patient if the nurse does not intervene to prevent it. You will identify a risk diagnosis when the patient does not have signs/symptoms of a problem but does have risk factors present that increase his vulnerability. Use risk nursing diagnoses only for patients who have more susceptibility to the problem than others in the same comparable setting.
Analyzing Data

Diagnosis stage of nursing process (adpie)
Identify significant data (significant data is also referred to as cues). This is data that influence your conclusions about the client's health status. A cue should alert you to look for other cues that might be related (forming a pattern).
-Cluster cues - group of cues that are related to each other in some way (cue is an unhealthy responses). Draw off of past theoretical knowledge to compare data to norms.
-Identify data gaps and inconsistencies - as you cluster adn think about relationships among the cues you will identify the need for data that was not apparent before. (read wilk 64)
-Draw conclusions about health status - this step occurs after clustering cues and collecting any missing data. You begin drawing conclusions about the patient's health status strengths as well as problems. EX- if data seems to meet standards and norm you can conclude that the patient has a strength in that area; therefore you can conclude no problem or wellness diagnosis because no nursing intervention is needed in that

start here
WEEK 3&4 - 9/7, 9/14
WILK PG 61 & 65
Actual diagnosis - a statement about a health problem that the client has and the benefit from nursing care. An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as manifested by adventitious lung sound auscultation.
RISK Diagnosis - a statement about health problems that a client doesn't have yet, but is at a higher than normal risk of developing in the near future. An example of a risk diagnosis is: Risk for injury related to altered mobility and disorientation. These risks can become a reality without nursing intervention.
Wellness diagnosis - describes an aspect of the client that is at a low level of wellness. An example of a wellness diagnosis is: Readiness for enhanced organized infant behaviour related to prematurity as manifested by appropriate response to visual and auditory stimuli.
What steps are involved in Diagnostic Reasoning (making sense of our assessment.

WEEK 3&4 - 9/7, 9/14 - Nursing Process\Care Plan
Use Critical thinking to
Analyze & interpret data-identify the significant data, cluster cues (cues are unhealthy responses), data gaps & inconsistencies (read wilk 64&65), make conclusions about health status, make inferences, identify problem etiologies, verify problem findings with patient. Remember that etilogy will direct nursing interventions.

Problem will initiate a goal
Etiology will initiate an intervention
What are cluster cues & how do they fit into the diagnoses phase

week 3&4, 9/7 - 9/14 - Nursing Process\Care Plan
Cluster cues - is a group of cues (unhealthy responses) that are related to each other in some way. Try to always derive a nursing diagnosis from data clusters rather than from one cue. Example - CVA patient cannot speak or use her hands she is frequently incontinent so the diagnosis is Total Urinary Incontinence. She makes loid sounds so the nursing student looks for cues in addition to urinary incontinence. She makes the connection that urinary incontinence often happens after loud vocalizing so she realizes that the patient cannot communicate verbally so she changes teh nursing diagnosis to Self-Care Deficit: Toileting related to immobility and inability to communicate the need to void. The student puts a call device under her arm and she is able to signal when she needs to void
Why is making inferences critical when forming a nursing diagnoses?

pg 65
week 3&4, 9/7 - 9/14 - Nursing Process\Care Plan
Critical thinking skill. Recall cues are facts or data and inferences are conclusions or judgements, interpretations that are based on data. AN INFERENCE IS NOT A FACT BECAUSE YOU CANNOT DIRECTLY CHECK ITS TRUTH OR ACCURACY. EXAMPLE -
FACT: Patient is crying (you can observe)
Inference: Patient is anxious (you cannot observe anxiety but you know that crying and tembling may be signs of anxiety. Important to read pg 65
Prioritizing Problems

week 3&4, 9/7 - 9/14 - Nursing Process\Care Plan
Places problems in order of importance i.e. airway, breathing, circulation.
ACTUAL problems usually take priority over potential ones.
THEORETICAL FRAMEWORK- determines - ex airway, breathing, circulation, Maslow's Hierarchy of needs.
what are the parts of a nursing diagnostic statement.

week 3&4, 9/7 - 9/14 - Nursing Process\Care Plan
Problem - describes health state or health problem of the patient. Identifies a response that needs to be changed. Try to use a NANDA label when possible. (pg 73)

Etiology - identifies factors believed to cause or contribute to the problem or create a risk for the problem. May include a NANDA label. Etiology will help yo uto individualize nursing care because etiologies are unique to individual. Example - John - Anxiety r/t lack of knowledge of the treatment procedure. Janet - Anxiety r/t prior negative experiences and lac of trust in health professionals. (pg 73)

Defining characteristics - subjective and objective data that signal the existence of a problem.
example of parts of a nursing diagnostic statement

week 3&4, 9/7 - 9/14 - Nursing Process\Care Plan - pg 75
Bathing/hygiene self-care deficit
Fear of falling in the tub
Defining characteristics
Strong body and urine odor, unclean hair, pt stating “I’m afraid I’ll fall in the tub and break something”
How to choose a NANDA label

week 3&4, 9/7 - 9/14 - Nursing Process\Care
Identify the broad topic (or domain) that seems to fit the cue cluster
Narrow your search (to the class or most likely labels)
Use a nursing diagnosis handbook, compare definitions and defining characteristics of the diagnostic labels with your cue cluster
How to write a quality statement

week 3&4, 9/7 - 9/14 - Nursing Process\Care
In choosing a NANDA label, do not rely on the label definition alone
Include both problem and etiology
Be sure that the etiology does not merely restate the problem
Avoid using medical diagnoses and treatments as etiological factors
Use a connecting phrase, i.e. “related to”
definition of a 1 part diagnosis statement.

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk-75, lewis pg 11
Omit the etiology portion from certain kinds of statements
syndrome diagnoses - syndrome diagnosis is a label that represents a collection of several nursing diagnoses and does not need an etiology.
WELLNESS DIAGNOSIS - NANDA wellness diagnosis are one-part statements beginning with the phrase Readiness for Enhanced. Older classifications might read Effective Breastfeeding, health-seeking behaviors. wellness labels do not represent a problem so there is no etiology which is a cause needed.
definition of a 2 part diagnosis statement.

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk-75, lewis pg 11
Use for risk diagnosis (dx) - it consists of risk factors.
Problem related to etiology
NANDA label r/t related factors.

example - for a client with excessive vomiting you might write Risk for Deficient Fluid Volume r/t excessive losses through vomiting.
definition of a 3 part diagnosis statement.

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk-75, lewis pg 11
Problem, etiology symptom
Problem r/t etiology AMB s/sx
Cannot be used for risk diagnosis because there are no symptoms.
Collaborative problems - (don't worry about them at this time per Karen)

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk-76
Physiological complications of diseases, medical treatments, or diagnostic studies

Clients with certain diseases or treatments are at risk for developing the same complications

Always a potential problem

Collaborative problems require both physician-prescribed and independent nursing interventions
sample of a nursing diagnosis

week 3&4, 9/7 - 9/14 - Nursing Process\Care
print out
Nursing Diagnosis and the Nursing Process

week 3&4, 9/7 - 9/14 - Nursing Process\Care
print out
Planning stage of Nursing Process\care plan

week 3&4, 9/7 - 9/14 - Nursing Process\Care
print out
Goals of Planning Phase
Outcomes aka Goals

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5
work with patient to establish patient centered goals. All about the patient.
Establish priorities
Identify and write expected patient outcomes
Select evidence-based nursing interventions
Communicate the plan of care
Planning outcome phase

Deriving outcomes from Nursing Diagnoses
week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5
Risk for infection r/t surgical procedure
The client will show no signs or symptoms of infection this shift

Pain (chest) r/t imbalance of myocardial oxygen supply and demand
Pt will verbalize relief of chest pain by the end of this shift
Planning outcome phase

Definition of Initial & Ongoing Planning

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5
Initial Planning:
Begins with first client contact
Written as soon as possible after initial assessment
Development of the initial comprehensive care plan should ideally be done by the admission nurse since this nurse has had the benefit of physical contact

Changes made in the plan as you evaluate the patient’s responses to care
(all patients require discharge plan. ex - client with diabetes needs a plan to discharge - might include education on how to give injection.
Explanation of NOC

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes pg 97
NOC is a standardized vocabulary of more than 260 nursing-sensitive outcomes.
-Each NOC outcome consists of an outcome label, indicators, and a measurement scale. It is a neutral label to allow for positive\negative or no change in patient health status. NOC outcomes are linked to NANDA nursing diagnoses so you can look up a nursing diagnosis to see the list of outcomes suggested. see pg 98 for NOC rating scale
short term and long term goals

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes
Short-Term Goals: To be achieved within a few hours or days
Provides + reinforcement for those clients working toward long-term goals

Long-Term Goals: To be achieved over a longer period of time (week, month, or more)
Describe the optimum level of functioning you expect the patient to achieve
Patient may be discharged prior to evaluating long term goals
(see pg 12 of care plan)
components of a goal (outcome) statement

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes
Subject = Patient always
Action (Verb)- Indicates action that patient will perform - concrete verb feel measure. (see pg 93) example - Client will walk. Walk is the action verb.
Performance criteria - details about something to be done - measurable. these are teh standards for evaluating the clients performance. describe extent to which you expect to see the action or behavior. write them in concrete, observable terms. Ex - this example specifies the distance the client is expected to walk - Client will walk to the doorway with the help of one person by 12/13/06
Target time - realistic time to acheive when part of statement. ex - walk to the doorway by 12/13/06. the date is the target time.
Special conditions - not always going to have a special condition. Amount of resources or treatment a patient needs to perform behavior. Ex - Client will walk to the doorway with the help of one person by 12/13/06. "The help of one person is the special condition. or After two teaching session is another example.
Outcomes must be

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes
Patient centered
Time limited
client centered outcomes (goals)

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes
State what the patient will do or experience at the completion of care
Give direction to the patient’s overall care
Patient behaviors…not nurse behaviors!!

“The patient will demonstrate…”
How do goals relate to nursing diagnosis

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes
Expected outcomes derive directly from the nursing diagnosis. Ex. Nursing diagnosis Ineffective Airway Clearance Goal - lungs clear to auscultation (see pg 95 table 5-2)
Problem statement describes the response/health status to be changed
Desired outcome states the opposite of the problem response
Common Errors in Writing Outcomes

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning 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
common errors in writing outcomes

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning 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
example of nursing diagnosis with goals and outcome

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 5 - planning outcomes
what are nursing interventions

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning interventions
Purpose: to achieve client outcomes (goals)
Also called nursing actions, measures, strategies, activities
Based on clinical judgment and nursing knowledge
Reflect direct and indirect care - for patient. Example of direct care is walking patient. Example of indirect is doing for the patient but not with the patient so if you get social svcs involved for family issues or to arrange physical therapy.
types of interventions

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning interventions
Nurse initiated
Autonomous actions based on scientific rationale
Derived from nursing diagnosis
Do not require an Dr's order
example of nurse initiated is taking a b/p you don't need a Dr's order to take vitals)
Physician initiated
Initiated by physician in response to medical diagnosis
Carried out by nurse in response to physician’s order (example of physician initiated is dr may order that you check the b/p every 4 hours)
Initiated by other providers (pharmacist, RT, PA, PT) or interdisciplinary. example is pharmacy instructs to check b/p before giving meds and only give the b/p meds if it meets the criteria set up in the range provided. (also could be collaborative with dr, physical therapy, respiratory therapy).
selecting nursing interventions

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning interventions
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects
Nursing interventions must be:
Within the legal scope of nursing practice
Compatible with medical orders
Like outcomes/goals, they should be specific and realistic

review ackley pg 129 it lists interventions for medical issues.

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning interventio
NANDA - write problem statement
NIC - write interventions
NOC - write outcomes
Process for Generating and Selecting Interventions

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning intervention
1 Review the nursing diagnosis
2 Review the desired client outcomes
3 Identify several interventions/actions
4 Choose the best interventions for this client
5 Individualize the standardized interventions (example if the book suggests every 4 hours do a urine checkand you thinkg every 2 hrs is better than use 2 hours in intervention)

Look at the book to address items 3 & 4 above.
how would these nursing interventions differ?

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning intervention
Constipation r/t lack of knowledge about laxative use…

Constipation r/t weakened abdominal muscles secondary to long-term immobility…

The first example focuses in on teaching about laxative use. The second example focuses in on teaching and helping them to strengthen abdominal muscles.
sample of care plan with interventions

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 6 - planning intervention
print out
Nursing process - Implementation phase

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 7 - implementation
Implementation is the action phase - doing or delegating and carrying out the plan

Check your knowledge and abilities
Organize your work
- Establish feedback points - from patients. (example patient is dizzy. Would you walk him?)
- Prepare supplies & equipment
- Prepare the client - assess readiness explain what u are going to be doing. If necessary provide privacy.
Purpose of Implementation

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 7 - implementation
Assist patient in achieving valued health outcomes. (you are trying to get them to do for self).
Promote health
Prevent disease and illness
Promote self-care
Restore health
Facilitate coping with altered functioning
Implementing the plan

week 3&4, 9/7 - 9/14 - Nursing Process\Care wilk - chpt 7 - implementation
Promote client participation
Assess their current knowledge because they may already have some knowledge of disease.
Assess their support system & resources
Determine their main concerns
Help them set realistic goals
Accept that some attitudes cannot be changed

Coordinate care
Schedule treatments/activities with other departments
Review reports from other departments
Make sure everyone sees “the whole picture”
Delegate when appropriate - 5 rights apply. If you delegate make sure to monitor and give and get feedback. Cannot delegate outside of scope of practice . Critical patients yo should check vitals yourself. When delegating leave no room for interpretation. (ex - be specific when giving a task - ex get vitals if over 120/80 let me know).