EDAPT- Clinical Judgement
Using a nursing diagnosis text, match the cues from the admission assessment to type of data for each potential nursing diagnosis.
Activity intolerance cues include: Shortness of breath when walking, irregular heart rhythm and low oxygen saturation levels Decreased cardiac output cues include: Weight gain, irregular heart rhythm, low oxygen saturation at rest, and dependent edema (areas below the heart) Impaired gas exchange: Not being able to catch her breath, increased respirations, and low oxygen saturation levels
Based on the documentation in Maggie's EHR, the nurse notes that which expected outcomes have been met? Select all that apply. Click the Nurses' Notes tab to complete this activity.
All of the above
Fill in the blanks
Although anyone who experiences an infection is at risk for sepsis, individuals most at risk include those over the age of 65 and those who are immunocompromised.
The nurse is observing Maggie change the dressing on her PICC line. Which actions by Maggie does the nurse correct? Select all that apply.
Applies clean gloves before washing her hands tears the tape using her teeth
What evidence is present in Maggie's admission assessment to support a nursing diagnosis related to infection? Select the assessment data, or cues, that contribute to the Related to Statement and Defining Characteristics by clicking on them. Remember "P.E.S" as the data is reviewed and selected. Click the History & Physical and Nurses' Notes tabs to complete this activity.
Chills nausea lower back pain urinating small amounts burns when I urinate vomiting 101.2 DM2 frequent UTIs Appears unwell and uncomfortable suprapubic tenderness severe right flank pain
Select the statement that best describes a problem oriented nursing diagnosis
Diagnostic label/related to statement/defining characteristics
Using your knowledge of the urinary tract, infection, and inflammation, along with textbook and library resources, match the assessment findings below to the type of urinary tract infection (UTI) with which it is associated. NOTE: Assessment findings may be associated with more than one type of UTI.
Dysuria: both urgency: lower Flank pain: upper Malaise: upper Frequency: both suprapubic tenderness: lower hematuria: lower Fever: upper Nocturia: both costovertebral tenderness: upper
The nurse determines that further education is needed after hearing Maggie make which statements? Select all that apply.
I am so happy I do not need to do anything special to this IV when I take a bath at home." "If the IV comes out at night, I can wait until morning to call the home infusion nurse
Drag the selected interventions to the category into which it fits: information on how to protect the PICC line or how to recognize an adverse effect during treatment.
I do not know :( sorry
Select the most appropriate nursing diagnosis for Mrs. Votaw by selecting the words or phrases that complete the sentence below:
Impaired gas exchange related to fluid imbalance as evidenced by hypoxemia and bibasilar crackles.
Based on Mrs. Votaw's newest nursing diagnosis and outcome, select appropriate interventions with matching rationale for her care.
Intervention and Rationale #1: Teach to identify sodium content on food labels; helps client make smart food choices when shopping. Intervention and Rationale #2: Recommend increasing intake of fresh fruits and vegetables; fresh fruits and vegetables contribute vitamins and antioxidants to the diet.
Did Mrs. Votaw meet goals?
It is clear that Mrs. Votaw MET, and exceeded, the first expected outcome as her oxygen saturation was 98% on room air when performing activities of daily living by discharge. Mrs. Votaw DID NOT MEET the second goal because her lung sounds were not clear within 24 hours, but they were clear by discharge.
which topics should they know
It is essential she knows everything, it is desirable he knows everything except it is essential he knows the signs of infection
Drag each item (taken from Sami's Nursing Diagnosis and Plan of Care) to the correct location on the Care Focused Concept Map.
Nursing Diagnosis- Risk for infection transmission related to exposure to a contagious respiratory disease. Expected Outcome- Client has infection prevention resources to protect family during home quarantine. Interventions- Educate: household quarantine procedures. Provide: masks, hand soap, sanitizer, gloves.
The home health nurse is seeing Mrs. Votaw for the first time. During the interview, Mrs. Votaw asks what steps she can take to avoid future hospitalizations. Which diagnosis should the nurse select?
Nursing Diagnosis: Readiness for enhanced nutrition Measurable expected outcomes: Verbalizes foods she can eat that are low in sodium content
Based on your knowledge of Mrs. Votaw's current health response, use a nursing diagnosis text to select priority collaborative outcomes for the current nursing diagnosis. Select all that apply.
O2 sat >95% clear lungs on auscultation
After reviewing the nurse's notes and selecting the cues that require follow-up, the nurse now clusters the related cues to assist in identifying health promotion, risk for, or actual problems. Note: Some cues may apply to both clusters.
Risk for Infection Transmission cues: loss of smell and taste temperature 101.3 F generalized muscle pain treating patients through the current global health pandemic fatigue voices concern related to continued exposure of wife and son not able to afford to quarantine outside the apartment running out of personal protective equipment Interrupted Family Processes cues: voices concern related to continued exposure of wife and son not able to afford to quarantine outside the apartment fatigue
Based on the documented improvement in Maggie's state of health, which interventions can be decreased in frequency? Select all that apply.
Urine output continuous pulse ox incentive spirometry
teaching
infection at the insertion site, wear clothing that loosely covers the insertion site, signs of an occluded PICC line, avoid strenuous activity using the arm with the PICC, change the PICC dressing if it becomes soiled, and wash hands prior to connecting or disconnecting the IV tubing.
While reviewing Maggie's plan of care the first night of her admission, the nurse taking over her care adds which high priority, essential intervention?
monitor white blood cells
Sort potential interventions for Maggie's care according to priority (high, medium, low, or contraindicated) and necessity (essential or non-essential). Drag all essential interventions into the correct category (high, medium, or low). Not all interventions (those that are non-essential or contraindicated) will be sorted into a category.
High Priority; Essential: Monitor hourly urine output Measure vital signs q 4 hours Continuous pulse oximetry monitoring Strict intake and output (I&O) Reposition q 2 hours Encourage hourly use of incentive spirometer Medium Priority; Essential: Monitor serum electrolytes Monitor blood glucose q 4 hours Daily weights Inspect skin frequently Low Priority; Essential: Routine oral care Contraindicated; Non-essential: Fluid restriction of 1500 mL per day Daily blood cultures
Based on this information, and using a nursing diagnosis text, select the most appropriate nursing diagnosis to prepare Maggie for discharge.
Readiness for enhanced health management
diagnosis of readiness
Readiness for enhanced health management related to PICC line as evidenced by pt and partner expressing interest in learning how to provide safe care at home and pt asking questions when IV antibiotics are administered.
Based on the nursing diagnosis and information in Maggie's EHR, select the four (4) most appropriate goals of care and drag them to the Expected Outcomes on the Plan of Care (POC).
1. Temperature 98° F - 99° F 2. HR 60 - 100 bpm 3. WBC greater than 4,000 and less than 12,000 4. Urine output > 0.5mL/kg/hr
Attention to details, or cues, is key to successful patient care. It can also be a challenge. The video below will challenge your ability to see the details despite distractions.
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The boxes below represent containers on a Care Focused Concept Map. Using the drop-down menu, indicate which step of the nursing process aligns with each container in the care focus concept map.
ASSESSMENT INTERVENTION PLANNING EVALUATION DIAGNOSIS
Based on your knowledge of Mrs. Votaw's current health response, use a nursing diagnosis text to match these interventions with the supporting evidence-based rationale.
Assess lung sounds every 4 hours and as needed = Pulmonary edema will decrease as cardiac output increases. Titrate oxygen to keep oxygen levels above 95% = Will increase oxygen levels in the blood and to body tissues. Allow periods of rest between activities = Decreases oxygen consumption and decreases the risk of hypoxia.
Order the list of actions in which the nurse will complete them for a newly admitted client, with the first action at the top.
Introducing themselves to the client, verifying the client's identity assessing their level of comfort complete the admission assessment Obtain cultures Administer antibiotics
Select the words or phrases in the sentences below to create SMART goals for Mrs. Votaw based on the selected priority collaborative outcomes.
Oxygen saturation greater than 95% on room air when performing activities of daily living by discharge. Lung sounds clear in 24 hours.
After reviewing the nurse's notes and selecting the cues, the nurse now selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and related to statement, based on Sami's information.
Nursing diagnosis 1: Risk for infection transmission related to exposure to a contagious respiratory disease. Nursing Diagnosis 2: Interrupted family processes related to disrupted normal routine as evidenced by inability to meet physical and emotional needs of family.
select the most appropriate diagnosis label and defining characteristics, based on Maggie's information by selecting the correct words/phrases to complete the Nursing Diagnosis below.
Risk for complications of sepsis related to pyelonephritis as evidenced by temp 101.2, chills, nausea, and costovertebral tenderness.
Which is the priority nursing diagnosis?
Risk for infection transmission related to exposure to a contagious respiratory disease