The Nursing Process: Nursing Diagnoses (Basics In Nursing)

Front 1

Which component of the nursing process?

Conducting initial interview

Back 1

Assessing

Front 2

Which component of the nursing process?

Collect nursing health history.

Back 2

Assessing

Front 3

Which component of the nursing process?

Perform physical assessment

Back 3

Assessing

Front 4

Which component of the nursing process?

Document assessment data.

Back 4

Assessing

Front 5

What is the primary purpose of assessing?

Back 5

To create a database for the client

Front 6

When you make a clinical judgment, you are really performing which component of the nursing process?

Back 6

Diagnosing

Front 7

Which component of the nursing process?

Analyze the data base.

Back 7

Diagnosing

Front 8

Which component of the nursing process?

Derive conclusions based on the analysis of the client's data base

Back 8

Diagnosing

Front 9

Which component of the nursing process?

Assign diagnostic labels

Back 9

Diagnosing

Front 10

Which component of the nursing process?

Determine causative factors

Back 10

Diagnosing

Front 11

Which component of the nursing process?

Formulate a diagnostic statement, including defining characteristics

Back 11

Diagnosing

Front 12

Which component of the nursing process?

Establish priorities

Back 12

Planning

Front 13

Which component of the nursing process?

Establish goals

Back 13

Planning

Front 14

Which component of the nursing process?

Formulate outcome criteria

Back 14

Planning

Front 15

Which component of the nursing process?

Identify nursing interventions

Back 15

Planning

Front 16

Which component of the nursing process?

Formulate a plan of care

Back 16

Planning

Front 17

Which component of the nursing process?

Organize interventions

Back 17

Implementing

Front 18

Which component of the nursing process?

Perform interventions

Back 18

Implementing

Front 19

Which component of the nursing process?

Review outcome criteria

Back 19

Evaluating

Front 20

Which component of the nursing process?

Collect data related to outcome criteria

Back 20

Evaluating

Front 21

Which component of the nursing process?

Compare data to outcome criteria and determine whether outcomes were attained

Back 21

Evaluating

Front 22

Which component of the nursing process?

Summarize inferences regarding evaluation outcome

Back 22

Evaluating

Front 23

Which component of the nursing process?

Take appropriate action based on the outcome of evaluations

Back 23

Evaluating

Front 24

(def)

a clinical judgment about an individual, family, or community

Back 24

Nursing diagnosis

Front 25

A nursing diagnosis is a clinical judgment that is a response to ________ and ________ health problems / life processes.

Back 25

Actual and Potential

Front 26

A proper nursing diagnosis provides the basis for what?

Back 26

the selection of interventions that will achieve outcomes that the NURSE is accountable for

Front 27

Describe what a "Wellness Nursing Diagnosis" is?

Back 27

a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness

Front 28

What 2 cues must be present for an individual or group to have a wellness diagnosis?

Back 28

1. a desire for a higher level of wellness
2. effective present status or function

Front 29

A Wellness Nursing Diagnosis will begin with what specific label?

Back 29

"Readiness for Enhanced"

Front 30

The following nursing diagnosis is an example of what type of diagnosis?

"Readiness for Enhanced Community Coping"

Back 30

Wellness Nursing Diagnosis

Front 31

What is the primary differences between a nursing diagnosis and a medical diagnosis?

Back 31

A nursing diagnosis describes a patient's response to a disease or a condition. It is dynamic (can change as the client's response changes).

A medical diagnosis describes a specific disease. It will remain constant throughout the duration of the illness.

Front 32

What is the purpose of using standard terminology (NANDA definitions) when preparing a nursing diagnosis?

Back 32

To facilitate communication among nurses

Front 33

A client's database is derived from both the health history and the physical examination. Why would you want to use both sources when determining your nursing diagnoses?

Back 33

To promote holistic care of the client

Front 34

A nursing diagnosis provides direction for what?

Back 34

the planning of independent nursing interventions

(Nursing Diagnoses should be treated by nursing interventions, not medical interventions. A proper diagnosis should be able to be treated with a proper "nursing" intervention)

Front 35

How do nursing diagnoses promote professional accountability and autonomy?

Back 35

they define and describe the independent area of the nursing practice

(there is an NANDA list of approved diagnoses that nurses can treat)

Front 36

Diagnosing is a process of ________ and _________.

Back 36

analysis and synthesis

Front 37

(def)

the portion of the diagnostic process that involves the separation of information into components

Back 37

analysis

Front 38

(def)

the portion of the diagnostic process that involves taking information and putting it together to form a whole

Back 38

synthesis

Front 39

What is the purpose of using Gordan's functional health patterns and a head-to-toe physical assessment?

Back 39

to gather and organize information

(to organize the data)

Front 40

Inferences are made how?

Back 40

by comparing the data obtained to standards

Front 41

When comparing the data you obtain to standards, you are essentially asking what basic question when looking at each piece of information?

Back 41

Is this normal or abnormal?

Front 42

What are 5 examples of standards that you may compare data with?

Back 42

1. normal health patterns
2. normal vital signs
3. laboratory values
4. growth and development
5. Erickson's developmental stages

Front 43

The process of determining the relatedness of data and grouping the data is known as what?

Back 43

Clustering Data

Front 44

Clustering data increases the accuracy of what?

Back 44

inferences

Front 45

What are the 4 guidelines you should follow when clustering data?

Back 45

1. search for abnormal cues
2. look for patterns in the database
3. use references to compare the client's cues with defining characteristics and etiologic factors of accepted nursing diagnoses
4. make an inference about the data cluster and label with a tentative diagnostic label

Front 46

What is the next step in developing a diagnosis after you have developed a tentative diagnostic label?

Back 46

Verify the interpretation with the client.

Front 47

Upon discussion of the tentative diagnostic label with the patient, the nurse and patient can make what (4) possible conclusions?

Back 47

1. No problem exists
2. No problem exists, but a potential problem is present
3. A problem exists that the nurse can treat
4. A problem exists that the nurse cannot treat and must be referred.

Front 48

After discussing your interpretation of data with the client and determining a conclusion based off of your interaction with the client, what is your next step?

Back 48

Finalizing the diagnostic statement

Front 49

(def)

the part of the nursing diagnosis statement which is a description of the client's health problem (actual or risk) for which nursing therapy is given

Back 49

diagnostic label

Front 50

(def)

the part of a nursing diagnosis statement which refers to the etiology or contributing factors

Back 50

Related factors

Front 51

What are the 3 purposes of "related factors" within the diagnostic statement?

Back 51

1. identify one or more probable causes of the health problems/diagnostic label
2. give direction to the nursing intervention
3. individualize the nursing diagnosis

Front 52

(def)

cluster of signs and symptoms/clinical criteria that support the presence of the diagnostic category label

Back 52

Defining characteristics

Front 53

In formulating a nursing diagnosis, what is the next step after you have determined your related factors and defining characteristics?

Back 53

You complete your nursing diagnosis

Front 54

When completing your nursing diagnosis, what determines if you will use a two-part or three-part statement?

Back 54

You will use a two-part statement for risk diagnosis. (PE - will consist of the problems/diagnostic label and the etiology/related-to factors)

You will use a three-part statement for actual diagnoses. (PES- will consist of Problem/diagnostic label, Etiology/Related-to factors, and Signs and symptoms/defining characteristics)

Front 55

Correct the following diagnostic label and explain the reasoning for the correction:

"needs suctioning"

Back 55

"Risk for aspiration"

- "needs suctioning" would be an intervention, not a diagnostic label. Diagnostic labels must come from the NANDA approved list

Front 56

Correct the following Nursing Diagnosis:

Risk for injury due to change in mental status

Back 56

Risk for injury R/T change in mental status

(never use the term due to)

Front 57

Correct the following diagnostic label and explain the reasoning for the correction:

Impaired skin integrity R/T infrequent turning.

Back 57

Impaired skin integrity R/T immobility.

(Never imply negligence or blame in a nursing diagnosis)

Front 58

Correct the following diagnostic label and explain the reasoning for the correction:

Spiritual distress R/T strict rules necessitating church attendance.

Back 58

Spiritual distress R/T inability to attend services.

(Never write a diagnosis with a value judgment, which means including your personal values and beliefs)

Front 59

Correct the following diagnostic label and explain the reasoning for the correction:

Rapid respirations R/T increased airway secretions.

Back 59

Ineffective Breathing Pattern R/T increased airway secretions.

(Never use a sign/symptom as your diagnostic statement. Use the NANDA list of diagnostic statements)

Front 60

Correct the following diagnostic label and explain the reasoning for the correction:

Risk for ineffective airway clearance R/T Emphysema

Back 60

Risk for ineffective airway clearance R/T accumulation of lung secretions.

(a medical diagnosis is never used UNLESS it is secondary to. Your R/T should always be something that can be treated by a nursing intervention.)

Front 61

Correct the following diagnostic label and explain the reasoning for the correction:

Anxiety R/T cardiac monitoring.

Back 61

Deficient knowledge: purposes and need for cardiac monitoring R/T lack of exposure to information.

(identify the client's response to equipment or treatment, not the equipment or treatment itself)

Front 62

Correct the following diagnostic label and explain the reasoning for the correction:

Offer bedpan frequently R/T of diarrhea.

Back 62

Diarrhea R/T intolerance to milk-based foods.

(your statement should never include your interventions.)

Front 63

Correct the following diagnostic label and explain the reasoning for the correction:

Pain and anxiety R/T difficulty ambulating.

Back 63

- Anxiety R/T difficulty in ambulating.
- Impaired physical mobility R/T discomfort in (R) knee.

(There should only be one problem in a diagnostic statement. Write out each separately)

Front 64

True/False:

There should only be one related factor in a diagnostic statement.

Back 64

False- Although you can only have one problem, you can have one or more related factors.

For Example:

Impaired Nutrition: more than body requirements R/T limited physical activity and increase in fat and calories in diet.

Front 65

When planning your care, the diagnoses you have identified are ranked by order of what?

Back 65

importance - higher priority items are placed at the top

Front 66

What framework is often used to help determine priority of diagnoses?

Back 66

Maslow's hierarchy of needs

Front 67

Would the following have a high, intermediate, or low priority:

Ineffective airway clearance

Back 67

High Priority

Front 68

Needs that required immediate attention are ranked a ______ priority.

Back 68

High

Front 69

Needs that involve non-emergency, non-life threatening situations would be ranked a ______ priority.

Back 69

Intermediate

Front 70

Needs that may not be directly related to a specific illness or prognosis, but may affect their future well-being would be ranked a _____ priority.

Back 70

low

Front 71

When establishing your client's Expected Outcome, you will include both goals and outcome criteria. Describe each.

Back 71

Goals = broad statements reflecting resolution of the diagnostic label/problem

Outcome criteria = specific, measurable, observable statements that reflect the resolution of the defining characteristics

Front 72

True/False:

An expected outcome is realistic in relation to the client's present and potential capabilities.

Back 72

True

Front 73

True/False:

An expected outcome is attainable in relation to the resources available to the client.

Back 73

True

Front 74

True/False:

An expected outcome is vague and may explain positive and negative outcomes.

Back 74

False-

An expected outcome is clear, concise, and in positive terms

Front 75

True/False:

An expected outcome should include a time estimate for attainment.

Back 75

True

Front 76

Who should formulate the expected outcome?

Back 76

When possible, both the nurse and client should formulate the expected outcome.

Front 77

What is the overall purpose of an expected outcome?

Back 77

It is used to provide direction to nursing interventions and measure the validity of the interventions.

Front 78

True/False:

An expected outcome is essentially a nursing intervention.

Back 78

False- an expected outcome would be the result of a nursing intervention. They are not one in the same.

Front 79

(def)

specific actions the nurse takes that are designed to assist the client to achieve expected client outcomes

Back 79

Nursing interventions

Front 80

Nursing interventions are individually tailored to meet the specific needs of a client. They should be designed to resolve what?

Back 80

the "related factors"

Front 81

True/False:

Nursing interventions should only include your actions (care), never assessing, assisting, or teaching

Back 81

False-

Include nursing interventions that are assessing, assisting, and teaching

Front 82

Nursing interventions reflect the prescribed care that is required to do what (3) things?

Back 82

- monitor a problem (assessing)
- prevention of a problem
- treatment/resolution of a problem

Front 83

What is the goal of nursing interventions if the nursing diagnosis is "Risk for..."?

Back 83

They should provide protection or precautionary measures

Front 84

The verbs used in a nursing intervention are specific ones that direct what?

Back 84

They direct the nurse's actions (for example, assess, instruct, place, observe, etc.)

Front 85

How would YOU guarantee that others are able to follow your care plan when you are not available?

Back 85

Make sure that your nursing interventions are specific! Use specific times, frequencies, amounts, etc.

Front 86

Nursing interventions can be what (3) types?

Back 86

1. Physician-Initiated
2. Nurse-Initiated
3. Collaborative

Front 87

What is wrong with the following nursing intervention:

Provide hydrogen peroxide mouthwash for client.

Back 87

It is not specific. A correctly stated nursing intervention would be -

Provide 50mL of hydrogen peroxide mouthwash for the client every 2 hours while awake.

Front 88

True/False:

As a student, it is not important to understand the rationale behind a nursing intervention as long as you implement it properly.

Back 88

False- you should be able to identify rationales for all nursing interventions. You can find rationales in your text books, notes, care plan books, etc.

Front 89

What are critical pathways and computerized care plans?

Back 89

standard plans of care developed to set daily care priorities for specific diagnoses, promote timely achievement of outcomes, and reduce the length of hospital stays.

Front 90

(def)

a system of organizing client information to develop a comprehensive plan of care

Back 90

Care Map

Front 91

_________ is simply carrying out the plan of care.

Back 91

Implementing

Front 92

What are the 4 components of evaluating the plan of care?

Back 92

1. Review outcome criteria
2. collect data related to the outcome
3. compare data collected with the outcome to determine if they were attained
4. Make inferences and take appropriate action if needed.

Front 93

(def)

nursing interventions performed when implementing the medical regimen, such as giving medications and treatments

Back 93

Physician-Initiated interventions

Front 94

(def)

nursing interventions that evolve form the nursing diagnosis and do not require a physician's order

Back 94

Nurse-Initiated interventions

Front 95

(def)

Nursing orders that are performed by nurses in collaboration with other members of the health team

Back 95

Collaborative interventions