Unit 7 Content

Front 1

3 concepts of the CCM nursing program organizing framework

Back 1

1. Basic needs
2. Wellness- Illness Continuum
3. The Nursing process

Front 2

5 components of the nurcing process in order

Back 2

1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

Front 3

A nurse must foloow the ______ to organize and deliver nursing care

Back 3

The Nursing Process

Front 4

Characteristics of the Nursing Process:

Back 4

- Utilizes critical thinking
- Dynamic; ever changing
- Individualized for each patient
- Enables a nurse to take action and make judgments based on reason
- Is utilized in the nursing care plan

Front 5

- Reddened 4x4 cm. area noted on sacrum
- States, “I’m 80 years old.
- ”Weight = 100 pounds
- Muscle strength - strong
- Posture – erect, gaze forward

Back 5

Objective data

Front 6

- Says “I’d rather lie on my back.”
- “I have no appetite.”

Back 6

Subjective data

Front 7

Sources of data that can provide information about a patient:

Back 7

- Patient
- Family/Significant Others
- Members of Health Care Team
- Medical Records
- Other records such as education, military, employment
- Literature Review
- Prior Experience

Front 8

Methods of data collection the nurse uses to establish a data base:

Back 8

- Interview
- Nursing Health History
- Physical Exam
- Laboratory and Diagnostic Test results

Front 9

4 types of interview techniques.

Back 9

1) Open ended questions
2) Closed ended questions
3) Back-channeling (feedback such as ah-ha to show active listening)
4) Problem seeking interview (focusing in on the stated problem)

Front 10

4 Phases of the interview

Back 10

1. Orientation Phase
2. Establishing the nurse-client relationship Phase
3. Working Phase
4. Termination Phase

Front 11

Nursing health history includes:

Back 11

- Biographical info
- Reason for seeking health care
- Patient expectations
- History of the present illness
- Past health history
- Family/Environmental/Psychosocial History
- Spiritual Health
- Review of systems
- Physical exam
- Diagnostic and lab data

Front 12

Nursing diagnosis

Back 12

- They are used to classify health problems within the domain of nursing
- A statement that describes the client’s actual or potential response to a health problem that the nurse is licensed and competent to treat.
- Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes.
- Focuses on and defines the nursing needs of the client

Front 13

4 Aspects of the nursing diagnostic process:

Back 13

1. Standards
2. Attitudes
3. Experience
4. Knoledge

Front 14

3 types of Nursing Diagnosis:

Back 14

1) Actual
2) At-risk
3) Wellness

Front 15

Nursing diagnosis vs. Medical diagnosis:

Back 15

- both based on critical thinking and review of data gathered during assessment
- Both professions are licensed to act on the diagnoses they select.
- The medical focus is on diagnosis and treatment of disease. (A nurse can never cure lung cancer, but they can treat effects of it)

Front 16

4 components of a nursing diagnosis

Back 16

1. Diagnostic process
2. Analyzing and interpreting data
3. Identifying client needs
4. Formulating the nursing diagnosis

Front 17

Components of a nursing diagnosis

Back 17

- A statement of the related factor Ex: Impaired Skin Integrity R/T Immobility
- Nursing Diagnosis statements have the “P” and “E” connected by R/T
- Each diagnosis has a definition, (characteristics that define it).
- If those characteristics are not met, but you feel it will be a potential problem, then it is a risk for diagnosis, and the patient’s primary risk factors must be listed as the r/t statement. Ex: Risk for infection, r/t immunosuppression

Front 18

P- Psychosocial of a nursing diagnosis

Back 18

- Anxiety
- Fear

Front 19

E- Elimination of a nursing diagnosis

Back 19

-Constipation
- Diarrhea

Front 20

R- Rest & Activity of a nursing diagnosis

Back 20

- Impaired physical mobility
- Pain
- Disturbed sleep pattern

Front 21

S- Safety of a nursing diagnosis

Back 21

- Risk for infection
- Skin Integrity, impaired

Front 22

O- Oxygenation of a nursing diagnosis

Back 22

- Activity Intolerance
- Ineffective Airway Clearance

Front 23

N- Nutrition of a nursing diagnosis

Back 23

- Fluid volume deficit
- Imbalanced more than body requirements

Front 24

5 Steps of the nursing diagnosis process in their appropriate sequence:

Back 24

1) Gathering the database
2) Validating data
3) Analyzing data
4) Identifying patient needs
5) Formulating the diagnosis

Front 25

Relationship between defining characteristics and a nursing diagnosis

Back 25

- Complete and concise information that comes from your assessment and pertains to you diagnosis
- Clustered data that relates to you diagnosis, either an at-risk or actual one
- At CCM, one column of your care plan will be for defining characteristics
- The clinical criteria of assessment findings that support (validate) the presence of a diagnostic category.
- Clinical criteria are objective and subjective signs and symptoms, clusters of signs and symptoms, or risk factors.
- Defining characteristics support the nursing diagnosis

Front 26

Goals of care in the planning component of the nursing process:

Back 26

- The part of the nursing process in which patient centered goals/expected outcomes are created and the nursing interventions are planned
- Guideposts to the selection of nursing interventions and criteria in the evaluation of nursing interventions
- Nurses use critical thinking to develop goals and expected outcomes that are relevant to client needs as evidenced by the assessment database and the nursing diagnosis.

Front 27

- There are long-term & short-term goals.
- Priority setting is a key element here
- Determine your goals/expected outcomes

Back 27

§ Can be short term or long term
§ Must be realistic/attainable
§ Must be patient centered
§ Must have a clear time frame, (within 24hrs, 7 days, etc)
§ Must be measurable and observable

Front 28

Expected outcomes:

Back 28

- Specific step-by-step pbjectives that lead to attainment of goals and the resolution of etiology (cause) for the nursing diagnosis.
- The expected outcomes determine whether a goal has been met
Ex: Patient will maintain a patent airway throughout the hospital stay, as evidenced by: clear lung sounds, respiratory rate between 12-20 breaths/minute and O2 saturation above 95%.

Front 29

- Methods used during Nursing Interventions to achieve Expected Outcomes

Back 29

§ Assist with ADL’s and perform other physical care
§ Counseling
§ Teaching
§ Controlling for Adverse Reactions
§ Communication
§ Delegation

Front 30

7 guidelines for writing an outcome statement:

Back 30

1. Clint- centered factors
2. Singular factors
3. Observable factors
4. Measurable factors
5. Time-limited factors
6. Mutual factors
7. Realistic factros

Front 31

purpose of a nursing care plan

Back 31

1) A nursing care plan is a written guideline for client care
2) Care plans document the client’s health care needs
3) Care plans communicate to other nurses and health care professionals the client’s pertinent assessment data, problems, and therapies
4) Decrease the risk of incomplete, incorrect, or inaccurate care

Front 32

The nursing care plan:

Back 32

- The care plan is organized so the nurse can quickly identify nursing actions to be given.
- The care plan makes possible the coordination of nursing care, subspecialty consultations, and the scheduling of diagnostic tests.
- Care plans organize information exchanged by nurses in end of shift reports, transfers, and discharges.
- The complete care plan is a blueprint for nursing action.
- Provides direction for implementation of the plan and a framework for evaluation of the client’s response to nursing actions.

Front 33

Critical pathways:

Back 33

- Allow staff from all disciplines, such as medicine, nursing, pharmacy, and social work to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type.

Front 34

5 Steps of the nursing implementation process

Back 34

1) Reassess the patient
2) Review and revise the existing care plan
3) Organize resources and care delivery
4) Anticipate and prevent complications
5) Implement your interventions

Front 35

7 methods for carrying out the implementation process:

Back 35

1) Assisting with ADL’s
2) Counseling
3) Teaching
4) Providing direct nursing care
5) Compensation for adverse reactions
6) Preventive/lifesaving measures
7) Delegating, supervising, and evaluating the work of others

Front 36

5 Steps needed for the objective evaluation of patient expected outcomes.

Back 36

1) Examine the goal statement to identify the exact desired client behavior or response
2) Assess the client for the presence of that behavior or response
3) Compare the established outcome criteria with the behavior or response
4) Judge the degree of agreement between outcome criteria and behavior or response
5) If the is no agreement (or partial agreement) between the outcome criteria and the behavior or response, What is/are the barriers? Why did they not agree?

Front 37

objective evaluation:

Back 37

- Evaluation is the final, but crucial step in successfully achieving a goal
- Did our care make a difference in the patient’s well being?
- Use same assessment skills and techniques as in the assessment stage
- May need to be done over time
- Care plan may require modification

Front 38

Clustering Data During Data Collection:

Back 38

- A critical aspect of assessment
- Will help you move forward into the other steps of the nursing process
- Example: Fever 101.4F, Erythema at wound site, Patient complaint of increased incisional pain, Increased WBC count

Front 39

Errors In Nursing Diagnosis:

Back 39

- The related to statement being a medical diagnosis is incorrect. EX: Ineffective airway clearance r/t pneumonia
- Writing a patient’s response to their condition as need instead of a problem EX: Fluid replacement r/t fever
- Legally inadvisable statements EX: Impaired skin integrity r/t improper positioning
- Redundancy EX: Impaired skin integrity r/t ulceration of sacral area
- Using multiple diagnoses in one statement EX: Pain and anxiety related to mastectomy incision and uncertain prognosis

Front 40

Types of Nursing Interventions:

Back 40

- Nurse initiated
- Physician/HCP initiated
- Collaborative
- Your patient care: direct or indirect

Front 41

Utilization of the Nursing Process:

Back 41

- Nursing Care Plans
- Critical Pathways
- Concept Maps
- Evidenced based practice
- Interaction with other disciplines
- Everyday interactions with our patients

Front 42

Writing the Plan of care/ Nursing Interventions:

Back 42

- Measure intake and output every 8 hours.
- Weigh patient daily at 0700 using the bed scale.
- Measure blood sugar before meals at 7:30 am, 12:30 pm, and 5:00 pm.
- Administer pain medication as ordered by MD/HCP.

Front 43

Techniques in a physical assessment

Back 43

1) Inspection
2) Palpation
3) Percussion
4) Auscultation
5) Olfaction

Front 44

You observe a patient holding his knee and crying. This type of data is considered:

Back 44

Objective

Front 45

The focus for evaluation of client care is directly related to the selection of

Back 45

Goals or expected outcomes

Front 46

A client-centered goal is specific, measurable, time limited, and:

Back 46

Mutually set with the client when possible

Front 47

Before initiating an intervention, it is important for the nurse to have the appropriate psychomotor and interpersonal skills and:

Back 47

Know the scientific rationale

Front 48

A multidisciplinary treatment plan that predicts interventions and outcomes for selected clients over a projected length of stay is called:

Back 48

A critical pathway

Front 49

A standardized system for assisting nurses in selecting suitable interventions is the:

Back 49

Nursing Interventions Classification taxonomy

Front 50

In addition to who is to perform it, a correctly written nursing intervention includes what four things?

Back 50

1. Action to be done
2. Frequency
3. Quantity
4. Method

Front 51

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:

Back 51

A. Encourage client to implement guided imagery when pain begins.
B. Determine effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay.
d. It is measurable and objective.

Front 52

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including:

Back 52

A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.
b. This does not need a physician's order.

Front 53

A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:

Back 53

A. Notifying the physician
B. Calling the wound care nurse
C. Changing the wound care treatment
D. Consulting with another nurse
b. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation.

Front 54

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following:

Back 54

A. Length of time current treatment has been in place.
B. The spouse’s reaction to the client’s dressing change
C. Client’s concern about the current treatment
D. Physician’s reluctance to change the current treatment plan
a. This gives the consulting nurse facts that will influence a new plan.

Front 55

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to:

Back 55

A. Implement the specialist’s recommendations
B. Report the recommendations to the primary physician
C. Clarify the suggestions with the client and family members
D. Discuss and review advised strategies with CNS
d. Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations.

Front 56

Nursing interventions for a specific problem developed in the hospital setting do not require a _______________, but this aspect is important for the nursing student in order to reinforce the importance of evidence-based nursing practice.

Back 56

Rationale

Front 57

After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first.

Back 57

3. Ineffective airway clearance
4. Ineffective tissue perfusion
1. Constipation
2. Anticipatory grieving

Front 58

During the planning phase of the nursing process, the nurse along with the client decides

Back 58

B. Client-centered goals
E. Expected outcomes

Front 59

A client with a spinal cord injury was admitted today to a rehabilitation institution. The rehabilitation nurse develops long-term goals that focus on four aspects of care. Those four aspects are:

Back 59

1. Prevention (of complications)
2. Rehabilitation (return to maximum function)
3. Discharge (returning to the community)
4. Health education (knowledge regarding maintaining wellness based on age and gender)

Front 60

Preparation for implementation ensures efficient, safe, and effective nursing care. List four preparatory activities.

Back 60

1. Reassess to determine that the planned intervention is appropriate.
2. Review and revise (if needed) the existing nursing care plan.
3. Organize resources, including equipment, environment, and personnel.
4. Anticipate and prevent complications by identifying risks.

Front 61

List three types of skills required for implementation of direct and indirect nursing interventions.

Back 61

1. Cognitive skills: good judgment and sound clinical decisions based on knowledge
2. Interpersonal skills: trusting relationships, expressed caring, and effective communication
3. Psychomotor skills: Eye-hand coordination with integration of cognitive and motor activities to manipulate equipment effectively (e.g., a dressing change)

Front 62

Selection of nursing interventions for a specific client involves critical thinking. List six factors that need to be considered when choosing interventions.

Back 62

1. Expected outcomes that can reasonably be attained
2. Altering or eliminating related factors for the nursing diagnosis
3. Research- or evidence-based practice guidelines
4. Feasibility, cost, and time required
5. Acceptability to the client
6. Capability of the nurse

Front 63

Give two examples of life-saving measures.

Back 63

1. Cardiopulmonary resuscitation (CPR)
2. Administering emergency medications

Front 64

Therapy requiring knowledge beyond the scope of basic nursing practice that is designed to assist in coping with crisis and provide anticipatory guidance is:

Back 64

Crisis intervention

Front 65

When a nurse enables a client in reminiscing about a deceased loved one or supports family in removal of belongings from the hospital room and attends the funeral, the nurse is providing:

Back 65

Bereavement care

Front 66

Preventive nursing actions include assessment and promotion of the client's health potential and preventing illness. List three types of interventions included in preventive health measures.

Back 66

1. Promoting immunizations
2. Health teaching
3. Identification of risk factors

Front 67

The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to:

Back 67

A. Have the client void
B. Place the client in Sims’ position
C. Premedicate the client with analgesics
D. Insert a peripheral intravenous (IV) catheter
a. The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications.

Front 68

The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. The skill the nurse is demonstrating is:

Back 68

A. Cognitive skill
B. Interpersonal skill
C. Psychomotor skill
D. Behavioral skill
a: The nurse is using sound judgment and clinical decisions based on individualization of care. b. Decision is made without direct interaction with client, but based on knowledge about the client. c. There is no psychomotor skill relative to this decision-making process. d. There is no such thing as a behavioral skill.

Front 69

A nurse provides counseling to a family in spiritual distress from a recent, but expected, family member death when implementing the following intervention:

Back 69

A. Obtaining a consult for a psychiatric clinical nurse specialist
B. Praying with the family
C. Reminiscing with the family
D. Arranging for the chaplain to visit the family
c. Reminiscing is an active intervention that allows family members to remember the deceased in a positive way.

Front 70

The nurse requests a stimulant laxative for a client receiving an opioid around-the-clock. By making this request the nurse is demonstrating:

Back 70

A. Promoting client health
B. Concern for safety
C. Controlling adverse reactions
D. Colleague health education
c. The nurse is demonstrating knowledge of opioid side effects and being pro-active by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids.
a. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. b. Safety is not an issue. d. Requesting does not provide education.

Front 71

For all clients admitted to a cardiac unit, in the unit policy and procedure manual it states: if client experiences chest pain, administer 1/150 grain nitroglycerine SL and obtain a STAT ECG. This is an example of: _____________

Back 71

A protocol—care of clients with a select clinical problem.
- It provides a standard of care and can be individualized.

Front 72

The nurse is developing a plan of care for a client with chronic low back pain, who was admitted from the postanesthesia recovery room following back surgery. Appropriately sequence the following goals, starting with the goal the client should achieve first:

Back 72

1. Stand at the bedside
4. Transfer to bedside commode
2. Ambulate with assistance
3. Participate in rehabilitative physical therapy

Front 73

When determining a client's ability to perform instrumental activities of daily living, the nurse assesses the following skills (select all that apply):

Back 73

B. Ability to write checks
D. Ability to take medications
E. Ability to cook meals

Front 74

The nurse provides a variety of indirect care activities, which include (select all that apply):

Back 74

B. Documenting
C. Delegating
E. Evaluating new products

Front 75

A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client’s pain rating stayed the same (8 out of 10). The nurse recognizes that:

Back 75

A. The client is overrating the pain.
B. The pain plan needs changing.
C. Nonpharmacological pain-relieving strategies are now appropriate.
D. Complications from surgery are occurring.
b. The current pain medications are not effectively relieving the pain. The nurse needs to call the physician and discuss changing the medication is some way (type, dose, frequency, formulation).

Front 76

The nurse caring for a client with a nursing diagnosis of impaired physical mobility for the past 3 days recognizes that the client is not eating as expected. The nurse recognizes the need to:

Back 76

A. Change the nursing diagnosis to feeding self-care deficit
B. Consult with occupational therapy about feeding aids
C. Order a liquid diet to make it easier for the client to swallow
D. Place the client on NPO (nothing by mouth) status until the physician assesses the client
a. The nurse has assessed the problem and now recognizes that the focus needs to be on self-feeding. Nursing diagnoses should change as the client's condition changes, based on assessment.

Front 77

The nurse determines that the current care plan for a client needs to be changed because the goal has not been reached even after a sufficient period of time. New interventions are implemented. What is essential for the nurse to do after the implementation of these new interventions?

Back 77

A. Determine the safety of the interventions
B. Ascertain appropriateness of the interventions
C. Confirm the availability of the interventions
D. Reevaluate the interventions
d. The nurse must continuously reevaluate new interventions to see if they are helping to alleviate the problem and/or attain the goal. Only through reevaluation can the nurse evaluate the effectiveness of the interventions.

Front 78

Although assessment may be part of the evaluation, evaluation may not be part of the assessment. The nurse understands that the difference between assessment and evaluation is _______________________.

Back 78

For evaluation to occur, one or more interventions must have been implemented

Front 79

The following are steps in the evaluation process, comparing expected and actual findings. Place them in correct order.

Back 79

b. Examine goal to determine desired client behavior.
d. Assess client for expected behavior.
a. Compare outcome criteria with actual client response.
c. Judge agreement between desired and actual findings.
e. Determine why expected and actual findings do not agree.

Front 80

The nurse develops a nursing diagnosis of sleep deprivation. What evaluative measure would the nurse use to determine the client’s progress in alleviating this problem?

Back 80

The nurse would compare the amount of sleep the client had usually been getting when he was sleep deprived and compare it to the amount of sleep he is currently receiving after implementing interventions. If the number of hours of sleep increased and the client was feeling more rested, this would indicate a partial or full resolution of the problem.

Front 81

In order for a nursing quality improvement (QI) process to be successful, which of the following is true?

Back 81

B. Outcomes are based on standards of care.
C. Client satisfaction is an important indicator.
D. Recurrent problems are identified.