Fundamentals: Exam 1 Study Guide

what is the validation of assessment data?

comparison of data with another source to determine data accuracy

psychomotor skills?

integration of cognitive and motor activities

what is the order of the nursing process?

1. Assessment (gather information about patient condition) 2. Diagnosis (identify patient problem) 3. Planning (which includes Outcomes and Interventions) 4. Implementation (Carrying out Interventions) 5. Evaluation (determine if goal and expected outcomes achieved)

what is the purpose of evaluation in nursing care?

5th step in nursing process. determines a patients condition or well being improved after nursing interventions were delivered. monitors progress of each patient and gives valuable information about efficacy of intervention. critical to knowing patients health status.

The nurse is gathering data on a patient. Which data will the nurse report as objective data? a.States "doesn't feel good" b.Reports a headache c.Respirations 16 d.Nauseated

ANS: C Objective data are observations or measurements of a patient's health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States "doesn't feel good," reports a headache, and nausea are all subjective data. Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition.

5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? a.The patient can now perform the dressing changes without help. b.The patient can begin retaking all of the previous medications. c.The patient is apprehensive about discharge. d.The patient's surgery was not successful.

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a.Gordon's Functional Health Patterns b.Activity-exercise pattern assessment c.General to specific assessment d.Problem-oriented assessment

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problem-oriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question.

explain critical thinking approach to assessment

Collect primary information from primary source (patient) and secondary sources (family, caregiver, family members, friends, health professional, medical record) interpretation and validation of data to determine of data to determine whether more data are needed or the database is complete

The nurse teaches the client how to change his ostomy appliance. This is an example of a. An indirect-care intervention b. An independent intervention c. A dependent intervention d. A collaborative intervention

Correct answer: B Teaching a client about ostomy care does not require a physician's order and is in response to the nursing diagnosis of Deficient Knowledge. Teaching falls under the category of direct-care interventions and there is no evidence that the nurse needed to collaborate with the wound-ostomy nurse to complete this teaching

interpersonal skills?

Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family

what is a medical diagnosis?

Identification of a disease condition based on specific evaluation of signs and symptoms, medical history, result of diagnostic test, and procedures

what does the acronym SMART mean?

S: specific M: measurable A: attainable R: realistic T: timed

classification of pain: low?

affect patients future well being

what are nursing interventions?

any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

cognitive skills?

application of critical thinking in the nursing process

validation: you observe a patient that is crying and you infer that is is related to hospitalization or a medical diagnosis. problems can result if you don't validate information, it is wrong to make an assumption of the patient. what do you do?

ask, I notice that you have been crying. can you tell me about it?

what is data interpretation? what is a cue? what is an inference?

being able to differentiate important data from what you collect. symptoms and signs that you obtain through observation and measurement determine what the patients problem is

what is a nursing diagnosis?

clinical judgement about the patient in response to an actual or potential health problem

nursing intervention: conducting family care plan conference?

collaborative

what are the components of evaluation?

collecting data to related to the desired outcomes comparing data with outcome relating nursing activities to outcome drawing conclusion continue modifying care plan

what is the purpose of a goal? mutual goal setting?

desired changed in patient condition or behavior. includes patient and family.

nursing diagnosis: what must the assessment prove?

diagnosis is appropriate

how do we make a database?

diagnostic and laboratory results to establish database. also by physical assessment

direct or indirect care: a patient receives intervention in the form of medication administration, insertion of a urinary catheter, discharge instructions, or counseling

direct

nursing intervention: a nurse is helping and teaching a patient about how to press a call button?

direct care

when could errors be made during the nursing diagnostic process?

during data, collection, analysis of data, clusters, or patterns; and interpretation in choosing a nursing diagnostic statement.

classification of priorities: high?

emergent

diagnostic statement: what are the symptoms or defining characteristics?

evidence and "how do you know"

the patient is crying, what is that a cue of?

fear, pain, sadness

what is the problem oriented approach assessment? who would you assess first?

focus on patients presenting situation and begin with problem areas.

critical thinking approach: what is the ultimate goal?

gather all information necessary to reveal a patients health care needs.

example of goal and expected outcome

goal: patient will achieve pain relief outcome: patient will state pain is 3/10 on hour after IV morphine is administered.

direct and indirect care: managing patients environment, safety and infection control.

indirect care

nursing intervention: collaborative?

initiated by nurse or with healthcare team members and conducted by other members.

what is indirect care?

interventions are treatments performed away from a patient but on behalf of the patient or group of patients.

critical thinking approach: what are the 4 processes?

knowledge standards experience attitudes

What should goals and outcomes be?

measurable

diagnostic statement: what is the diagnosis label? (problem)

name of nursing diagnosis approved by NANDA, ICNP, or other institution.

can you use the medical diagnosis as the related factor?

no

can nurses treat medical diagnoses? what do they do?

no, they that patients response to health conditions

classification of pain: intermediate?

non life threatening

nursing intervention: independant?

nurse initiated (no ordered needed)

types of data collected in assessment: what is objective data?

observations and measurements of patients health status

diagnostic statement: what are the related factors for NANDA-1 diagnoses that have been categorized into 4 groups?

pathophysiological, treatment related, situational, maturational.

diagnostic statement: what are related factors? (etiology) give examples.

patients health response to health problem is related to set of conditions that caused or influence response. etiologies, circumstances, facts, or influences that have relationship with nursing diagnosis.

what is a patient centered goal/outcome?

patients highest possible level of wellness and independence in function, based on patients needs, abilities, and resources.

types of data collected in assessment: what is subjective data?

patients verbal descriptions of their health problems (feelings perceptions and self reported symptoms)

what is the 3 part diagnostic statement?

phrases or words a nurse uses that affect how you communicate a patients problems to other health care staff, which nursing interventions you use, and how you evaluate patient outcomes.

what is a diagnostic statement?

phrases or words a nurse uses that affects how you communicate a patients problems to other health care staff, which nursing intervention you choose, and how you evaluate the outcome.

critical thinking approach: what do you apply knowledge from to ask relevant questions?

physical, biological, and social science. reliable sources

what are the 3 parts to a diagnostic statement?

problem, etiology, symptoms

Nursing diagnosis: A patient has rheumatoid arthritis, what can a nurse do?

provide interventions to minimize and control pain

nursing intervention: dependent?

requires an MD order

What would a nurse do when there is a change in patient condition?

review the patients priorities to ensure you meet their needs in a safe, timely, and effective way.

A male patient is lying still with arms along side, tense and reports pain a 7 on a scale of 0-10. What inference can you make?

severe pain pain limits patients ability to move

types of data collected in assessment: what are the two types of data collected?

subjective data and objective data

what is a direct care intervention?

treatments nurses provide through interactions with patients or a group of patients.

When do nurses use critical thinking in implementation?

when considering complexities of interventions, changing priorities, alternative approaches, and amount of time available to act.