Fundamentals of Nursing I - Exam 3 Review

Why reassessment after nursing intervention is important

Sensitivity to how the patient is responding to nursing interventions and to the patient's progress toward outcome achievement allows the nurse to modify nursing interventions appropriately.

Use cognitive, interpersonal, technical, ethical/legal, and QSEN competencies to implement a plan of nursing care.

To implement the plan of nursing care, nurses need blended intellectual, interpersonal, technical, and ethical/legal competencies as well as mastery of the Quality and Safety Education for Nurses Competencies. Each nurse has a unique blend of these competencies and can act effectively to the extent that his/her abilities match patients need for nursing care

Why do we assess each patient individually?

To provide specific care to the patient's beliefs of healthcare

Data interpretation and analysis - Partnering with the patient and family

best source of information is usually an aware patient; most patients want to play a leading role in identifying and treating their health problems

Standing Orders

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities

Emergency nursing assessment

done patients presenting with physiologic or psychological crisis to identify life-threatening problems

Physical assessment

examination of patient for objective data that may better define the patient's condition and help nurse plan care; appraisal of health status, identification of health problems, and establishment of a database for nursing interventions

smooth muscle

involuntary muscle found in internal organs

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Avoid common errors when writing patient outcomes to include: o Expressing patient outcome as nursing intervention o Using verbs that are not observable and measurable o Including more than one patient behavior/manifestation in short-term outcomes o Writing outcomes that are so vague that other nurses are unsure of goal of nursing care

Five types of nursing assessments

· Comprehensive Initial assessment · Focused assessment · Emergency assessment · Time-lapsed assessment · Assessment of communities and special populations - Patient-centered assessment method (PCAM)

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. A. The United States has become less inclusive of same-sex couples. B. Cultural diversity is limited to people of varying cultures and races. C. Cultural diversity is separate and distinct from health and illness. D. People may be members of multiple cultural groups at one time. E. Culture guides what is acceptable behavior for people in a specific group. F. Cultural practices may evolve over time but mainly remain constant.

D, E, F. Rationale: A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? A. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. B. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. C. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 inches). D. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

D. Rationale: Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A nurse in counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't eve feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? A. Collaborative problem B. Interdisciplinary problem C. Medical problem D. Nursing problem

D. Rationale: Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medial diagnostic studies.

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Consider following factors when selecting outcomes: o Type of health concern o Nursing or medical diagnoses o Patient characteristics o Available resources o Patient preferences o Treatment potential o Family involvement

When data need to be validated and ways to accomplish this

· Data need to be validated when: o There are discrepancies between what the person is saying and what you're observing o When data lack objectivity · Ways to accomplish validation: o Recheck your data via repeat assessment o Clarify data with client by asking additional questions o Verify data with another health care professional - Compare objective findings with subjective findings to uncover discrepancies

Nursing Care Plan (patient care plan)

written guide that directs the efforts of the nursing team working with the patient to meet his or her health goals

Protocols

written plan that details the nursing activities to be executed in specific situations

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· ANA Standards of Practice direct nurses to practice in manner that is congruent with cultural diversity and inclusion principles · Outcomes should support overall treatment plan and "make sense" in terms of overall goals for patient

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Aims to be met by health care systems with regard to quality of care: o Safe - avoiding injury o Effective - avoiding overuse or underuse o Patient centered - responding to patient preferences, needs, and values o Timely - reducing waits and delays o Efficient - avoiding waste o Equitable - providing care that does not vary in quality to all recipients

Prioritize patient health problems and nursing responses (continued) - Critical thinking/Clinical Reasoning and Establishing Priorities

· Alfaro-LeFevre suggests nurses ask themselves four questions: 1. What problems need immediate attention and what could happen if I wait to attend them? Nurses can then initiate actions to solve problems with simple solutions, such as repositioning a patient to improve their breathing or calling a family member in. 2. Which problems are my responsibilities and which do I need to refer to someone else? 3. Which problems can be dealt with by using standard plans? 4. Which problems aren't covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge (or simply safe care of high quality)?

Means to validate nursing diagnoses

· An affirmative response to each of the following questions validates a tentative diagnosis: o Is my patient database (assessment data) sufficient, accurate, and supported by nursing research? o Does my synthesis of data (significant cues) demonstrate the existence of a pattern? o Are the subjective and objective data I use for determining the existence of a pattern characteristic of the health problem I defined? o Is my tentative nursing diagnosis based on scientific nursing knowledge and clinical expertise? o Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action? o Is my degree of confidence above 50%, that other qualified practitioners would formulate the same nursing diagnosis based on my data?

Assess body alignment, mobility, and activity tolerance, using appropriate interview and assessment skills.

· Ask about daily activity level, endurance, exercise and fitness goals, mobility problems, physical or mental health alterations, and external factors affecting mobility · Assess general ease of movement; gait and posture; alignment; joint structure and function; muscle mass, tone, and strength; and endurance

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Ask patients to describe 2 or 3 major goals they would like to achieve; nurses should then be realistic and consider: o Patient's health state and overall prognosis o Expected length of stay o Growth and development o Patient values and cultural considerations o Other planned therapies for patient o Available human, material, and financial resources o Risks, benefits, and current scientific evidence o Changes in status that indicate need to modify usual expected outcomes

Use safe patient handling and movement techniques and equipment when positioning, moving, lifting, and ambulating patients.

· Assess patient · Assess patient's ability to assist with planned movement · Assess patient's ability to understand instructions and cooperate with staff to achieve movement · Use assistive devices for any lifting of more than 35 lb of patient's weight · Ensure enough staff are available and present to move safely move patient · Assess area for clutter, accessibility to patient, and availability of devices · Decide which equipment to use · Plan carefully before moving or lifting patient · Explain to patient what you plan to do · Administer PRN pain medication if needed · Elevate bed as necessary to comfortable height for you · Lock wheels of bed, wheelchair, or stretcher · Be sure patient is in good body alignment · Support patient's body properly · Avoid friction on patient's skin · Use friction-reducing devices whenever possible · Move your body and patient in smooth, rhythmic motion · Use mechanical devices · Ensure equipment used meets weight requirements

Common Health Problems in Hispanics

Diabetes mellitus Lactose intolerance

Tell whether the following statement is true or false: A patient rates his pain as a "7" on a pain rating scale. This rating is considered to be objective data.

False Rationale: A patient rating his pain on a pain rating scale is considered to be subjective data.

Three elements of comprehensive planning

Initial planning Ongoing planning Discharge planning

Effects of exercise and immobility on major body systems: Skin

Integument effects of exercise - Improved tone, color, and Turgor resulting from improved circulation. o Integument effects of immobility - Increase risk for skin breakdown and formation of pressure ulcers

Cardiac muscle

Involuntary muscle tissue found only in the heart.

Transcultural assessment

Involves developing awareness, acquiring knowledge, and practicing skills; each patient must be considered a unique person

Effects of exercise and immobility on major body systems: Psychosocial outlook

Psychological Well-Being effects of exercise - Increased energy, vitality, general well-bring, improved sleep, improved appearance, improved self-concept, and positive health behaviors. o Psychological well-being effects of immobility - Increase sense of powerlessness, decrease self-concept, decrease social interaction, decrease sensory stimulation. Altered sleep-wake pattern and increase risk for depression.

Parts of Nursing Diagnosis Statement / Formulation of Nursing Diagnosis Statements

Problem- what is wrong; identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of patient's health problem) Etiology - cause or contributing factor ("related to ..."); identifies factors that are maintaining unhealthy state or response (contributing or causative factors) Defining characteristics - data that signals the existence of problem ("as evidenced by ..."); identify subjective and objective data that signal existence of problem (cues that reflect existence of problem)

Three types of nursing diagnoses

Problem-focused nursing diagnoses Risk nursing diagnoses Health promotion nursing diagnoses

Documenting Nursing Care

"It wasn't done if it wasn't documented"

Critical thinking activities linked to nursing assessments are....

- Assessing systematically and comprehensively, using a nursing framework to identify nursing concerns and a body systems framework to identify medical concerns - Detecting bias and determining the credibility of information sources - Distinguishing normal from abnormal findings and identifying the risks for abnormal findings - Making judgments about the significance of data, distinguishing relevant from irrelevant - Identifying assumptions and inconsistencies, checking accuracy and reliability, and recognizing missing information

Mormonism (Church of Jesus Christ of Latter Day Saints)

- Alcohol, tobacco, tea, coffee and drugs- These are all specifically banned in the Word of Wisdom, except for drugs. The prophets have made it clear that drugs, other than for medical use, are also banned. They are also strongly discouraged from drinking soft drinks containing caffeine. - Holy garments - the garment provides the member "a constant reminder" of the covenants they made in the temple; "when properly worn ... provides protection against temptation and evil"; not to be removed by nurse for any reason

How to establish rapport - When beginning interview

- Begin by sitting at eye level with patient; place chairs at right angles to each other about 3-4 feet apart - Introduce yourself and give your name and position - Verify person's name and ask what he/she would like to be called - In unusual situations in which contractual agreement that clearly identifies responsibilities of patient and nurse is indicated, terms are discussed at this time

Cultural assessment

- Beliefs, values, traditions, and practices of a culture - Culturally defined, health-related needs of individuals, families, and communities - Culturally based belief systems of the etiology of illness and disease and those related to health and healing - Attitudes toward seeking help from health care providers

Ongoing Outcome Planning

- Carried out by any nurse who interacts with patient - Keeps the plan up to date, manages risk factors, promotes function - States nursing diagnoses more clearly - Develops new diagnoses - Makes outcomes more realistic and develops new outcomes as needed - Identifies nursing interventions to accomplish patient goals

Ongoing planning

- Carried out by any nurse who interacts with patient - Keeps the plan up to date, manages risk factors, promotes function - States nursing diagnoses more clearly - Develops new diagnoses - Makes outcomes more realistic and develops new outcomes as needed - Identifies nursing interventions to accomplish patient goals

Discharge Outcome Planning

- Carried out by the nurse wo worked most closely with the patient - Begins when the patient is admitted for treatment - Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently

Collaborative problems

- Certain physiologic complications that nurses monitor to detect onset or changes in status - Primarily responsibility of nurses - Prescription for treatment comes from nursing, medicine, and other disciplines - Involve potential complications - Must be identified early so that preventive nursing care can be instituted early

Health Promotion Nursing Diagnosis

- Clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential - Expressed by readiness to enhance specific health behaviors

Problem-focused Nursing Diagnosis

- Clinical judgment concerning an undesirable human response to a health condition/ life process that exists in an individual, family or community - Has four components: - label - definition - defining characteristics - related factor

Risk Nursing Diagnosis

- Clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes -

Risk nursing diagnosis

- Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation - Consists of two parts: the problem and what it is related to

For possible nursing diagnoses, interventions seek to:

- Collect additional data to rule out or confirm diagnosis

Initial planning

- Developed by the nurse who performs the nursing history and physical assessment - Addresses each problem listed in the prioritized nursing diagnoses - Identifies appropriate patient goals and related nursing care

Initial Outcome Planning

- Developed by the nurse who performs the nursing history and physical assessment. - Addresses each problem listed in the prioritized nursing diagnoses. - Identifies appropriate patient goals and related nursing care

Culturally Respectful Nursing Care / Cultural Competence

- Developing an awareness of one's own existence, sensations, thoughts, and environment to prevent them from having an undue influence on those from other backgrounds. - Demonstrating knowledge and understanding of the patient's culture, health-related needs, and culturally specific meanings of health and illness. - Accepting and respecting cultural differences in a manner that facilitates the patient's and family's abilities to make decisions to meet their needs and beliefs. - Not assuming that the health care provider's beliefs and values are the same as the patient's. - Resisting judgmental attitudes such as "different is not as good" - Being open to and comfortable with cultural encounters. - Accepting responsibility for one's own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices

Variables that influence body alignment and mobility

- Developmental considerations - Physical health - Mental health - Lifestyle - Attitude and values - Fatigue and stress - External factors

Assisting patients to meet health outcomes - Patient variables

- Developmental stage - Psychological background and culture

Variables that influence the way a care plan is implemented - Patient Variables

- Developmental stage - Addressing the developmental needs of the patient involves identifying the patient's developmental stage, as well as the developmental tasks related to this stage and their relationship to nursing care. - Psychosocial background and culture - The same is true of the psychosocial needs of patients. When choosing nursing interventions, the nurse should consider and respect the patient's socioeconomic background and culture. Confronted with a malnourished patient on a limited income who rents a single room in a boarding home, a nurse cannot simple teach the importance of including more protein in the diet. To be effective, the nurse must explore the realistic issue of whether the patient can afford and obtain foods rich in the diet

Cultural Norms of the Health Care System - Habits

- Documentation - Frequent use of jargon - Use of systematic approach and problem-solving methodology

Common Errors in Outcomes

- Expressing the patient outcome AS a nursing intervention - Using verbs that are NOT OBSERVABLE + measurable - Including more than one patient behavior/manifestation in short term outcomes - Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care

How to establish rapport - Before going into interview

- Get organized - Prepare for interview by reading current and past records and reports - Don't rely on memory - Plan enough time - Ensure privacy - Get focused - Visualize yourself as being confident, warm, and helpful - Approach patient with open mind and be aware of any stereotypes or prejudices that might affect the encounter

How to establish rapport - During interview

- Give person your full attention - Avoid rushing

Data validation Process

- Identify cues - Make inferences about cues - Validate cues and inferences

Purposes of nursing diagnoses

- Identify how a person, group, or community responds to actual or potential health and life processes - Identify factors that contribute to or cause health problems (etiologies) - Identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems

Attitude and values influence body alignment and mobility

- In some families, such as those who hike, swimming, play ball together, children learn early to value regular exercise (these children continue to value and incorporate it in their regular exercise routine) - then you have children who grow up with a sedentary lifestyle just watching sports will be the closest they ever get to exercise - attitudes and values learned early may be internalized for a lifetime - people who place a high value on physical attractiveness may be highly committed to regular exercise bc it helps produce helps produce the body they want - others exercise for physical strength - others with more disposed intellectual pursuits may perceive body development as wasting time that could be better used to develop the mind

Manipulate factors that contribute to failure in outcome achievement - Negative Health Care System Variables that may detract from quality nursing care

- Inadequate staffing - Develop and use patient classification system that incorporates an identification of the kind and amount of nursing services required. Record staffing patterns and relate to needs for nursing care and patient outcomes. Clearly demonstrate and document that adequate staffing makes a difference. Present these data to nursing administration with request for additional staff. If necessary, use professional bargaining unit. - Nursing administration has sold out nursing; insensitivity to nursing demands within the institution - It may be impossible to practice quality, progressive nursing in this environment. Look for a new practice setting if there seems to be no hope for change. Evaluate the new setting on basis of what experience has taught you.

Diagnosing (Nursing Process)

- Interpret and analyze patient data - Identify patient strengths and health problems - Formulate and validate nursing diagnoses - Develop a prioritized list of nursing diagnoses - Detect and refer signs and symptoms that may indicate a problem beyond the nurse's experience

Isokinetic exercises

- Involve muscle contraction with resistance; resistance provided at a constant rate by an external device, which has capacity for variable resistance - Examples: rehabilitative exercises for knee and elbow injuries and lifting weights

Isometric exercises

- Involve muscle contraction without shortening (i.e., there is no movement or only a minimum shortening of muscle fibers) - Examples: contractions of quadriceps and gluteal muscles, such as what occurs when holding a Yoga pose - Benefits: increased muscle mass, tone, and strength; increased circulation to exercised body part; increased osteoblastic activity

Isotonic exercises

- Involve muscle shortening and active movement - Examples: carrying out ADLs, independently performing ROM exercises, and swimming, walking, jogging, and bicycling - Benefits: increased muscle mass, tone, and strength; improved joint mobility; increased cardiac and respiratory function; increased circulation; and increased osteoblastic or bone-building activity

Prioritize patient health problems and nursing responses (continued)

- Patient Preference - person-centered nursing directs you to first meet the needs that patient thinks are most important, as long as this order does not interfere with other vital therapies - Anticipation of Future Problems - Consider potential effects of different nursing actions

Jewish

- It is forbidden to eat birds of prey. Only clean birds, meaning birds that do not eat other animals, can be eaten. Poultry is allowed. - Meat and dairy cannot be eaten together, as it says in the Torah : do not boil a kid in its mother's milk

Subculture

- Large group of people who are members of a larger cultural group - Members have certain ethnic, occupational, or physical characteristics not common to the larger culture

Assisting patients to meet health outcomes - Nurse variables

- Levels of expertise - Creativity (ability to match patient needs with specific nursing strategies) - Willingness to provide care - Available time

Standards

- Levels of performance accepted by and expected of nursing staff or other health team members - Established by authority, custom, or consent

Cultural Norms of the Health Care System - Practices

- Maintenance of health and prevention of illness - Annual physical examinations and diagnostic procedures.

Cultural assimilation (acculturation)

- Minorities living within a dominant group lose the characteristics that made them different. - Values replaced by those of dominant culture

For collaborative problems, interventions seek to:

- Monitor for changes in status - Manage changes in status with nurse-prescribed and physician-prescribed interventions - Evaluate response

Nursing interventions are actions performed by the nurse to:

- Monitor patient health status and response to treatment - Reduce risks - Resolve, prevent, or manage a problem - Promote independence with activities of daily living - Promote optimum sense of physical, psychological, and spiritual well-being - Give patients the information they need to make informed decisions and be independent

Describe the role of the muscular system in the physiology of movement

- Motion - skeletal muscle contractions pull on tendons and move the bones, creating movements as simple as extending the arm to as highly coordinated as swimming or skiing - Maintenance of posture - Skeletal muscle contractions hold the body in stationary positions - Support - Skeletal muscles support soft tissues in the abdominal wall and floor of the pelvic cavity - Heat production - skeletal muscle contractions produce heat and help maintain body temperature

Physical health variables that influence body alignment and mobility

- Muscular, skeletal, or nervous system problems - Congenital or acquired postural abnormalities - Problems with bone formation or muscle development - Problems affecting joint mobility - Trauma to the musculoskeletal system - Problems affecting the central nervous system - Problems involving other body systems When assessing a patient's response to a mobility deficit work to: 1. Encourage attempts at behaviors that promote self-care activities despite limitations (offer supportive assistance to pt. who attempts to feed themselves despite having hemiparesis) 2. Reinforce behaviors that promote healthy functioning (congratulate pt. who manages transfer well despite left-sided weakness/paralysis)

Describe the role of the nervous system in the physiology of movement

- Nerve cells (neurons) conduct impulses from one part of the body to another - Afferent neurons convey information from receptors in the periphery of the body to the central nervous system - This information is processed by the CNS, leading to a response. - The efferent neurons convey the response from the CNS to skeletal muscles by way of the somatic nervous system

Describe evaluation, its purpose, and its relation to the other steps in the nursing process

- Nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care. - The purpose of evaluation is to allow the patient's achievement of expected outcomes to direct future nurse-patient interactions. - When the nurse needs to modify the care plan, the nurse reviews each preceding step of the nursing process.

Nursing Diagnosis vs Medical Diagnosis

- Nurse relies on assessment of signs and symptoms to formulate a diagnosis; actual or potential health problems that can be prevented or resolved by independent nursing intervention; provides basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible; focus on unhealthy responses to health and illness; may change from day to day as the patient's responses change - Medical diagnosis deals with pathophysiologic factors and the cure of the disease; identify diseases; describe problems for which MD or NP directs primary treatment; remains the same for as long as the disease is present

Manipulate factors that contribute to failure in outcome achievement - Negative Nurse Variables that may detract from quality nursing care

- Nurse who sincerely desires to give 150% all the time and who becomes quickly frustrated when observing substandard care; may feel alienated from other staff; excellent candidate for burnout. - Learn to give quality care during designated work period; leave on time; avoid temptation to do work of others; leave work concerns at work. - After establishing reputation for delivering quality nursing care, seek creative solutions for nursing problems and try them, hopefully with a support network. - View concerns as challenges rather than overwhelming obstacles. - Develop a realistic sense of how much nursing care and of what quality can be delivered with existing resources. - Nurse with overwhelming outside concerns, such as preparation for marriage, childbirth, divorce, illness (self or family members), role conflict (familial roles, school, work, and the like), new apartment/house, etc. - During periods of peak demand, may need to accept less than optimal performances at work. If this becomes norm rather than the exception, carefully evaluate priorities. May need to cut work hours rather than "cheat" patients. - Nurse who is bored - After reflection, write down personal objectives related to work. - Explore avenues within work setting for professional growth and development. - Look for new position that offers new challenges within or outside institution. - Join professional organizations and participate actively. - Evaluate educational goals and explore possibilities

Deriving Outcomes from Nursing Diagnoses

- Outcomes are derived from problem statement of nursing diagnosis - For each nursing diagnosis in the care plan, at least one outcome should be written that, if achieved, demonstrates a direct resolution of problem statement - Other outcomes that contribute to resolution of problem may be written as well

Manipulate factors that contribute to failure in outcome achievement - Negative Patient Variables that may detract from quality nursing care

- Patient who is physically and cognitively capable of self-care gives up, refuses to cooperate with therapeutic regimen, or thwarts regimen. - Identify one nurse who is able to develop a trusting relationship with the patient and determine the reason underlying the observed behavior. - Counsel appropriately. - Use a team conference to develop a consistent plan of nursing care. - Patient who quietly accepts whatever is done or not done for him/her; seldom communicates needs or dissatisfaction. - Note on care plan need to assess patient thoroughly because patient will probably not advocate for self. - Educate patient to become more assertive health care consumer.

When determining patient-centered outcomes, nurses should be realistic and consider:

- Patient's health state and overall prognosis - Expected length of stay - Growth and development - Patient values and cultural considerations - Other planned therapies for patient - Available human, material, and financial resources - Risks, benefits, and current scientific evidence - Changes in status that indicate need to modify usual expected outcomes

Cultural conflict

- People become aware of differences and feel threatened - Response - ridiculing beliefs and traditions of others to make themselves feel more secure

Assessing

- Preparing for data collection - Collecting data - Identifying cues and making inferences - Validating data - Clustering related data and identifying patterns - Reporting and recording data

Structured Care Methodologies

- Procedure: set of how-to action steps - Standard of care: description of acceptable level of patient care - Algorithm: set of steps used to make a decision - Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure

Cultural Norms of the Health Care System - Customs

- Professional deference and adherence to the pecking order found in autocratic and bureaucratic systems - Use of certain procedures attending to birth and death

Muslim Religion

- Prohibited from gambling, taking interest, fortune-telling, killing, lying, stealing, cheating, oppressing or abusing others, being greedy or stingy, engaging in sex outside of marriage, disrespecting parents, and mistreating relatives, orphans or neighbors. - According to the Quran, the only foods explicitly forbidden are pork, blood, meat sacrificed in the name of someone other than God, and those that die themselves. Cud chewing animals like cattle, deer, sheep, goats, and antelope are some examples of animals that are halal (lawful) and only if they are treated like living beings and slaughtered painlessly while reciting the Basmala. If the animal is treated poorly, or tortured while being slaughtered, the meat is haram.

Cultural Norms of the Health Care System - Likes

- Promptness - Neatness and organization - Compliance

Nursing assessments should be....

- Purposeful - Prioritized - Complete - Systematic - Factual and accurate - Relevant - Recorded in a standard manner

For actual nursing diagnoses, interventions seek to...

- Reduce or eliminate contributing factors of the diagnosis - Promote higher-level wellness - Monitor and evaluate status

For risk nursing diagnoses, interventions seek to:

- Reduce or eliminate risk factors - Prevent the problem - Monitor and evaluate status

Jehovah's Witnesses

- Reject foods containing blood but have no other special dietary requirements - Some may be vegetarian and others may abstain from alcohol, but this is a personal choice - Do not smoke or use other tobacco products - Do not believe in receiving blood transfusions or any blood products

Variables that influence the way a care plan is implemented (Continued)

- Resources - The most elaborately designed plan of care cannot be fully effective without adequate staff, equipment, and supplies. These resources are all important determinants of patient care. - Current standards of Care - All nursing actions for implementing the plan of care must be consistent with standards of practice. All nurses are responsible for learning the standards that dictate practice in their specialty. Failure to practice according to these standards may result in a charge of negligence. - Research Findings - Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Reading professional nursing journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective. - Ethical and Legal Guides to Practice - To practice good nursing, you need to be knowledgeable about the laws and regulations that affect health care and the ethical dimensions of clinical practice. Without this understanding, a sincere motivation to benefit the patient and a conscientious attempt to implement nursing orders will not be sufficient.

Ethnicity

- Sense of identification with a collective cultural group - Largely based on group's common heritage - One can belong to an ethnic group through birth or adoption of characteristics of that group - Groups share unique cultural and social benefits and behavior patterns - Largely develops through day-to-day life with family and friends within the community

Culture

- Shared system of beliefs, values, and behavioral expectations - Provides social structure for daily living - Defines roles and interactions with others and in families and communities - Apparent in attitudes and institutions unique to the culture

Minority group in society

- Smaller group - Physical or cultural characteristic identifies the people as different from dominant group

Cultural Norms of the Health Care System - Beliefs

- Standardized definitions of health and illness - Omnipotence of technology - Critical importance of safety and quality measures

Nursing diagnosis

- Statement of a specific health problem - CANNOT include a medical diagnosis - Convert initial conclusion into a diagnostic statement - Links assessment to other steps in the nursing process - Formulated by problem (identifies what is unhealthy about patient), etiology (identifies factors maintaining the unhealthy state), and defining characteristics (identify the subjective and objective data that signal the existence of a problem)

Describe the role of the skeletal system in the physiology of movement

- Support soft tissues of the body (maintains body form and posture) - Protects crucial components of the body (brain, lung, heart, spinal cord) - Furnishes surfaces for the attachments of muscles, tendons, and ligaments, which, in turn, pull on the individual bones and produce movement - Provide storage areas for minerals (such as calcium) and fat - Produce blood cells (hematopoiesis)

Cultural Norms of the Health Care System - Dislikes

- Tardiness - Disorderliness and disorganization

Stereotyping

- The assumption that all members of a culture or ethnic group act alike - May be positive or negative - Negative includes racism, ageism, and sexism

Culture shock

- The feelings a person experiences when placed in a different culture - May result in psychological discomfort or disturbances

Dominant group in society

- Usually largest group - Group has the most authority to control values and sanctions of society

Collaborative Interventions

- Therapies that require the knowledge, skill, and expertise of multiple health care professionals. - Treatments initiated by other providers and carried out by nurses

Race

- Typically based on specific characteristics, such as skin pigmentation, body stature, facial features, and hair texture - Five major categories: - American Indian or Alaska Native - Asian - Black or African American - Native Hawaiian or Other Pacific Islander - White

Outcome identification and planning

- What we expect patient to achieve based on the diagnostic label (goal) - Patient-centered ("The patient will.....") - Planning starts on patient's admission and initial assessment - Provides direction for nursing interventions - Collaborative effort - Label and goal should be in direct relation to each other - Provides criteria for evaluation

Common Errors in Writing Nursing Diagnoses

- Writing diagnosis in terms of needs and response - Making legally inadvisable statements - Identifying as a problem a patient response that is not necessarily unhealthy - Identifying as a problem signs and symptoms of illness - Identifying as a patient problem or etiology what cannot be changed - Identifying environmental factors rather than patient factors as a problem - Reversing clauses - Having both clauses say the same thing -Including value judgments in the nursing diagnosis - Including the medical diagnosis in the diagnostic statement

Common Errors in Writing Nursing Diagnoses

- Writing the diagnosis in terms of need and not response - Making legally inadvisable statements - Identifying as a problem a patient response that is not necessarily unhealthy - Identifying as a problem signs and symptoms of illness - Identifying as a patient problem or etiology what CANNOT BE CHANGED - Identifying environmental factors rather than patient factors as a problem - Reversing clauses - Having both clauses say the same thing - Including value judgements in the nursing diagnosis - Including the medical diagnosis in the diagnostic statement

Nurse-initiated intervention

- an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes - do NOT require health care provider's (or other team member's) order - derived from nursing diagnosis

Fatigue and stress influence body alignment and mobility

- chronic stress may deplete body energy to the point that fatigue makes even the thought of exercise overwhelming - ironically, exercise is energizing and can better equip a person to deal with stress

Clinical outcomes

- describe the expected status of health issues at certain points in time, after treatment is complete. - address whether the problems are resolved or to what degree they are improved.

The ESFT Model

- guides providers in understanding a patient's explanatory model (a patient's conception of his/her illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches - E - Explanatory Model of Health and Illness - What do you think caused your problem? - Why do you think it started when it did? - How does it affect you? - What worries you most? - What kind of treatment do you think you should receive? - S - Social and Environmental Factors - How do you get your medications? - Are they difficult to afford? - Do you have time to pick them up? - How quickly do you get them? - Do you have help getting them if you need it? - F - Fears and Concerns - Does the medication sound okay to you? - Are you concerned about the dosage? - Have you heard anything about this medication? - Are you worried about the adverse effects? - T - Therapeutic Contracting - Do you understand how to take the medication? - Can you tell me how you will take it?

Long-term outcomes

- require a longer period (usually longer than a week) to be achieved than do short-term outcomes - may be used as discharge goals, in which case they are more broadly written and communicate to entire nursing team desired end results of nursing care for particular patient

Clustering data

- set of signs and symptoms clustered logically together - identifies relationship between factors and symptoms

Discharge planning

- should begin when client is admitted (with the exception of LTC) - assess if the client will be able to return home and/or if they will need assistance at home - assess residence to see if adaptations or specific equipment will be necessary - make referral to social worker if needed - communicate client health status and needs to community service providers - if client chooses to leave before discharged, notify provider and have patient sign off

External factors that influence body alignment and mobility

- weather exerts the greatest influence over outside exercise - brisk clear day is invigorating and invites increased activity - hot, high humid day or cold temp, rain, snow discourage outdoor exercise - discouraging factors include lack of free time, insufficient financial resources for equipment purchase or gym membership, air pollution, unsafe neighborhood, and lack of support and reinforcement encouraging factors: sufficient money for gym, big mall to walk at, safe outdoor park

Ensuring Quality Outcomes

-Safe: Avoiding injury -Effective: avoid over/under use -Patient-centered: pt preferences, needs and values -Timely: reducing waits/delays -Efficient: avoiding waste -Equitable: providing care that does not vary in quality to all

When to validate data

1) Subjective/objective data do not agree or make sense 2) Client's statements differ at different times in the interview 3) Data are far outside normal range 4) Factors are present that interfere with accurate measurement

Seven Crucial Conversations in Health Care

1. Broken rules 2. Mistakes 3. Lack of support 4. Incompetence 5. Poor teamwork 6. Disrespect 7. Micromanagement

Four types of outcomes specified in the care plan

1. Cognitive Outcome - increases in patient knowledge 2. Psychomotor Outcome - describe the patient's achievement of new skills; they are evaluated by asking the patient to demonstrate the new skill. 3. Affective Outcome - pertain to changes in patient values, beliefs, and attitudes and are more complex to evaluate. 4. Physiologic Outcome - physical changes in the patient are the targeted outcome.

Five Classic Elements of Evaluation

1. Identifying evaluative criteria and standards (what you are looking for when you evaluate - i.e., expected patient outcomes) 2. Collecting data to determine whether these criteria and standards are met 3. Interpreting and summarizing findings 4. Documenting your judgment 5. Terminating, continuing, or modifying the plan

Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility's policy.

1. Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. 2. Prioritized: The nurse gets the most important information first. 3. Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a care plan. 4. Systematic: The nurse gathers the information in an organized manner. 5. Accurate and relevant: The nurse verifies that the information is reliable. 6. Recorded in a standard format: The nurse records the data according to the facility's policy so that all caregivers can easily access what is learned.

Nurses should answer four key questions when determining individualized evidence-based interventions:

1. What can be done to prevent or minimize the risks or causes of this problem? 2. What can be done to manage the problem? 3. How can I tailor interventions to meet expected outcomes? 4. How likely are we to get desired versus adverse responses to the interventions, and what can we do to reduce the risks and increase the likelihood of beneficial responses?

Four components of a nursing diagnosis

1. nursing diagnosis title or label - what the problem is 2. definition of the title or label - what problem means 3. contributing, etiologic, or related factors - what's happening with patient 4. defining characteristics - why is this happening/what is it related to

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A. Carefully assessing the patient care environment B. Using two nurses to lift a patient who cannot assist C. Wearing a back belt to perform routine duties D. Properly documenting the patient lift

A Rationale: Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

A Rationale: The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother - in spite of the fact that African women have safely carried babies in these slings for years.

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? A. Support weight on stronger leg and cane and advance weaker foot forward. B. Hold the cane in the same hand of the leg with the most severe deficit. C. Stand with as much weight distributed on the cane as possible. D. Do not use the cane to rise from a sitting position, as this is unsafe.

A Rationale: The proper procedure for using a can is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the can and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. heh patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? A. Compare this reading to standards. B. Check the taxonomy of nursing diagnoses for a pertinent label. C. Check a medical text for the signs and symptoms of high blood pressure. D. Consult with colleagues.

A. Rationale: A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis

Health promotion nursing diagnosis

A clinical judgment concerning a patient's motivation and desire to increase well-being and actualize human health potential

Health problem

A condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness

Developmental variables that influence body alignment and mobility

A person's age and degree of neuromuscular development markedly influence body proportions, posture, body mass, movements, and reflexes

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all the apply. A. A patient tells the nurse that she is feeling nauseous. B. A patient's ankles are swollen. C. A patient tells the nurse that she is nervous about her test results. D. A patient complains that the skin on her arms is tingling. E. A patient rates his pain as a 7 on a scale of 1 to 10. F. A patient vomits after eating supper.

A, C, D, E Rationale: Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading, edema, and vomiting.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. A. Basing patient care on continuous healing relationships B. Customizing care to reflect the competencies of the staff C. Using evidence-based decision making D. Having a charge nurse as the source of control E. Using safety as a system priority F. Recognizing the need for secrecy to protect patient privacy

A, C, E Rationale: Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. A. Monitoring patient status every hour B. Using intuition to troubleshoot patient problems C. Turning a patient on bed rest every 2 hours D. Becoming a nurse mentor to a student nurse E. Administering pain medication ordered by the physician F. Becoming involved in community nursing events

A, C, E Rationale: Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, turning a patient on bed rest every 2 hours, and administering pain medication ordered by the physician. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not patient care standards.

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A. A Native American patient B. An African-American patient C. An Alaska Native D. An Asian patient E. A White patient F. A Hispanic patient

A, C, E, F Rationale: Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance.

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. A. Stop performing the exercises. B. Decrease the number of repetitions performed. C. Reevaluate the nursing care plan. D. Move to the patient's other side to perform exercises. E. Encourage the patient to finish the exercises and then rest. F. Assess the patient for other symptoms.

A, C, F Rationale: When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could them be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. A. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. B. The nurse uses a binary decision tree for stepwise assessment and intervention. C. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. D. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. E. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. F. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

A, C. Rationale: A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A. A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. B. A nurse treats all patients the same whether or not they come from a different culture. C. A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. D. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E. A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. F. A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

A, D Rationale: Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult's ability to speak for himself/herself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping.

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. A. Instruct the patient to avoid sudden position changes that may cause dizziness. B. Recommend that the patient restrict fluid until after exercising is finished. C. Instruct the patient to push a little further beyond fatigue each session. D. Instruct the patient to avoid exercising in very cold or very hot temperatures. E. Encourage the patient to modify exercise if weak or ill. F. Recommend that the patient consume a high-carb, low-protein diet.

A, D Rationale: Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick." C. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E. "We need to check your health status and see what kind of nursing care you may need." F. "We need to see if you require a referral to a physician or other health care professional."

A, E, F Rationale: Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgement about a patient's health status, the ability to manage his/her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. B. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. C. Following physical therapy, patient will begin to gradually participate in walking/running events. D. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

A. Rationale: Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

A. Rationale: Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? A. "Was this diagnosis derived from a cluster of significant data or a single clue?" B. "This early diagnosis will help us manage the problem before it becomes more acute." C. "Have you determined if this is an actual or a possible diagnosis?" D. "This condition is a medical problem that should not have a nursing diagnosis."

A. Rationale: Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person's normal pattern.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of : A. Quality by inspection B. Quality by punishment C. Quality by surveillance D. Quality by opportunity

A. Rationale: Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by punishment and quality by surveillance are not quality-assurance methods used in the health acre field.

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A. "You made an inference that she is fine because she has no complaints. How did you validate this?" B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C. "Sometimes everyone gets lucky. Why don't you try to help another patient." D. "Maybe you should reassess the patient. She has to have a problem - why else would she be here?"

A. Rationale: The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Accepting the invalidated inference is not acceptable. It is also possible the condition is resolving so the patient may be feeling better.

The nurse practitioner sees patients in a community clinic that is located in a predominantly White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? A. Cultural assimilation B. Cultural imposition C. Culture shock D. Ethnocentrism

A. Rationale: When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Culture imposition occurs when one person believes that everyone should conform to his/her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? A. 2, 4, 1, 3 B. 3, 1, 4, 2 C. 2, 4, 3, 1 D. 3, 2, 4, 1

A. 2, 4, 1, 3. Rationale: Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

Which action should the nurse take when a patient has achieved each expected outcome in the care plan? A. Terminate the care plan. B. Modify the care plan. C. Continue the care plan.

A. Terminate the care plan Rationale: The care plan is terminated when the patient has achieved all of its goals. The care plan is modified when there are difficulties achieving outcomes. The care plan is continued if more time is needed to achieve the outcomes.

Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan? A. The nurse collects new data and uses them to update the plan and resolve health problems. B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home. C. The nurse who performs the admission nursing history develops a patient care plan. D. The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions.

A. The nurse collects new data and uses them to update the plan and resolve health problems. Rationale: In the ongoing planning stage, any nurse who interacts with the patient updates the plan to facilitate the resolution of health problems, manage risk factors, and promote function. Teaching and counseling are the key to discharge planning. The nurse performing the admission nursing history consults standardized care plans during initial planning to formulate the initial care plan.

How nursing interventions and nursing outcomes classifications can be used to implement care

Advantages of having a standard classification of nursing interventions are the NIC taxonomy structure designed to help clinicians locate and select the interventions most helpful for patients. The researchers involved in the development of NICs are also committed to developing a classification of patient outcomes for nursing interventions, called Nursing Outcomes Classifications (NOCs) This research is to aim to: 1. Identify, label, validate, and classify nursing-sensitive patient outcomes and indicators 2. Evaluate the validity and usefulness of the classification in clinical field testing 3. Define and test measurement procedures for the outcomes and indicators

Goal

An aim or an end

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A. A 4-month-old infant who is unable to roll over B. A 6-month-old infant who is unable to hold his head up himself C. An 11-month-old infant who cannot walk unassisted D. An 18-month-old toddler who cannot jump

B Rationale: By 5 months, head control is usually achieved. An infant usually rolls over by 6 or 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction

B Rationale: For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? A. Improved renal blood supply to the kidneys B. Urinary stasis C. Decreased urinary calcium D. Acidic urine formation

B Rationale: In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model - Explanatory model of health and illness? A. How do you get your medications? B. How does having COPD affect your lifestyle? C. Are you concerned about the side effects of your medication? D. Can you describe how you will take your medications?

B Rationale: The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of his/her illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medication?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? A. Use the axillae to bear body weight. B. Keep elbows close to the sides of the body. C. When rising, extend the uninjured leg to prevent weight bearing. D. To climb stairs, place weight on affected leg first.

B Rationale: The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg flat when climbing stairs.

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A. 2 B. 4 C. 5 D. 6

B Rationale: The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. A. The nurse formulates nursing diagnoses. B. The nurse identifies expected patient outcomes. C. The nurse selects evidence-based nursing interventions. D. The nurse explains the nursing care plan to the patient. E. The nurse assesses the patient's mental status. F. The nurse evaluates the patient's outcome achievement.

B, C, D Rationale: During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all the steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A. Do full-body pushups in bed six to eight times daily. B. Breathe in and out smoothly during quadriceps drills. C. Place the bed in the lowest position or use a footstool for dangling. D. Dangle on the side of the bed for 30 to 60 minutes. E. Allow the nurse to bathe the patient completely to prevent fatigue. F. Perform quadriceps two to three times per hour, four to six times a day.

B, C, F Rationale: Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three to four times a day and involve only the upper body. Dangling for 30 to 60 mintues is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever What would be appropriate nursing diagnoses for this patient? Select all that apply. A. Bronchial pneumonia B. Impaired gas exchange C. Ineffective airway clearance D. Potential complication: sepsis E. Infection related to pneumonia F. Risk for septic shock

B, C, F Rationale: Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A. A Nurse sits down with a patient and prioritizes existing diagnoses. B. A nurse assesses a woman for postpartum depression during routine care. C. A nurse plans interventions for a patient who is diagnosed with epilepsy. D. A busy nurse rakes time to speak to a patient who received bad news. E. A nurse reassesses a patient whose PRN pain medication is not working. F. A nurse coordinates the home care of a patient being discharged.

B, D, E Rationale: Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. A. The nurse uses the nursing interview to collect patient data. B. The nurse analyzes data collected in the nursing assessment. C. The nurse develops a care plan for the patient. D. The nurse points out the patient's strengths. E. The nurse assess the patient's mental status. F. The nurse identifies community resources to help his family cope.

B, D, F Rationale: The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on th prevent or resolve the problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

Which classification describes the bones located in the wrist? A. Long bones B. Short bones C. Flat bones D. Irregular bones

B. Short bones Rationale: Short bones located in the wrist and ankle contribute to movement. Long bones found in the upper and lower extremities contribute to height and length. Flat bones (ribs, skull) are thin and contribute to shape. Irregular bones are all the remaining bones not included in the previous classifications (e.g., jaw and spinal column)

Accommodation of cultural practices in health care

Incorporating factors of patients background into care plan

A nurses assess a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? A. Risk for impaired skin integrity B. Related to prescribed bed rest C. As evidenced by D. As evidenced by reddened areas of skin on the heels and back

B. Rationale: "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1. Disabled Family Coping related to lack of knowledge about home care of child on ventilator. 2. Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4. Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" 5. Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression A. (1) and (3) B. (2) and (4) C. (1), (2), and (3) D. (1), (2), (3), (4), and (5)

B. Rationale: (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic.

A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? A. Actual B. Risk C. Possible D. Wellness

B. Rationale: A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? A. Actual B. Possible C. Risk D. Collaborative

B. Rationale: An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse and physician-prescribed interventions.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?". The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A. Maslow's human needs B. Gordon's functional health patterns C. Human response patterns D. Body system model

B. Rationale: Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you do it in your sleep." B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C. "No one every really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

B. Rationale: Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? A. Use short words and talk more loudly. B. Ask an interpreter for help. C. Explain why care can't be provided. D. Provide instructions in writing.

B. Rationale: The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can't be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn't speak English, she won't understand what the nurse is saying.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? A. Offer the patient 60-mL fluid every 2 hours while awake. B. During the next 24-hour period, the patient's fluid intake will total at least 2,000mL. C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. D. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

B. Rationale: The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60-mL fluid every 2 hours while awake." Correct: "The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn,: and "become aware."

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: A. Quality assurance B. Quality improvement C. Process evaluation D. Outcome evaluation

B. Rationale: Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions ahs the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? A. No problem B. Possible problem C. Actual nursing diagnosis D. Clinical problem other than nursing diagnosis

B. Rationale: When a possible problems exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

Which one of the following nursing interventions is an indirect care intervention? A. A nurse explains available birth control measures to a young couple. B. A nurse meets with the collaborative care team to plan nursing measures for a patient. C. A nurse prays with a patient prior to surgery. D. A nurse administers pain medication to a patient with end-stage renal cancer.

B. A nurse meets with the collaborative care team to plan nursing measures for a patient. Rationale: An indirect care intervention is treatment performed away from the patient but on behalf of a patient or group of patients, such as the example in answer B. The remaining answer options are direct care interventions or treatment performed through interaction with the patient.

Which example is a psychomotor outcome? A. A patient learns how to control his weight using the Choose MyPlate food guide. B. A patient is able to test for glucose levels and inject insulin as needed. C. A patient values his health enough to decide to quit smoking. D. A patient is able to ambulate the hallway following knee surgery.

B. A patient is able to test for glucose levels and inject insulin as needed. Rationale: Psychomotor outcomes involve the patient's achievement of a new skill, such as controlling diabetes. Cognitive outcomes involve an increase in patient knowledge (A). Affective outcomes pertain to changes in patient values (C). Physiologic outcomes target physical changes in the patient (D).

Which one of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer? A. Initial comprehensive assessment B. Focused assessment C. Emergency assessment D. Time-lapsed assessment

B. Focused assessment Rationale: In a focused assessment, the nurse gathers data about a condition that has already been diagnosed. An initial comprehensive assessment is performed shortly after the patient is admitted to a health care agency or service. When a physiologic or psychological crisis presents, the nurse performs an emergency assessment. A time-lapsed assessment compares a patient's current status to baseline data obtained earlier.

Which nursing diagnosis would most likely be considered a high priority? A. Disturbed personal identity B. Impaired gas exchange C. Risk for powerlessness D. Activity tolerance

B. Impaired gas exchange Rationale: Impaired gas exchange poses a threat to the patient's well-being. Disturbed personal identity and risk for powerlessness are non-life-threatening and are ranked as medium priorities. Activity intolerance, if not specifically related to the current health problem, is a low priority.

Dorsiflexion

Backward bending of the hand or foot

Cultural imposition

Belief that everyone should conform to the majority belief system

Ethnocentrism

Belief that one's ideas, beliefs, and practice are the best or superior or are more preferred to those of others

Plantar flexion

Bending of the sole of the foot by curling the toes toward the ground

What Patients Should Expect From Their Health Care

Beyond patient visits Individualization Control Information Science Safety Transparency Anticipation Value Cooperation

Body alignment and mobility

Body balance increases when people spread the feet farther apart and flex the hips and knees. This broadens the base of support and lowers the center of gravity.

External rotation

Body part turning on its axis away from midline of the body

Internal rotation

Body part turning on its axis toward the midline of the body

Saddle joint

Bone surfaces are convex on one side and concave on the other; movements include flexion-extension, adduction-abduction, circumduction, and opposition (e.g., joint between the trapezium and metacarpal of the thumb).

Common Health Problems in Whites

Breast cancer Heart disease Hypertension Diabetes mellitus Obesity

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? A. "Do you think you will be able to eat the food we have here?" B. "Do you understand that we can't prepare special meals?" C. "What types of food do you eat for meals?" D. "Why can't you just eat out food while you are here?"

C Rationale: Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A. Dorsal recumbent position B. Lateral position C. Fowler's position D. Sims' position

C Rationale: Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Laying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? A. Wait a few minutes and then continue the move to the chair. B. Call for assistance and continue the move with the help of another nurse. C. Lower the patient back to the side of the bed and pivot her back into bed. D. Have the patient sit down on the bed and dangle her feet before moving.

C Rationale: If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. Teh nurse should lower the patient bac to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? A. Learning the predominant language of the community. B. Obtaining significant information about the community. C. Treating each patient at the clinic as an individual. D. Recognizing the importance of the patient's family.

C Rationale: In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? A. Have the patient extend his arms outward and cross his legs on top of a pillow. B. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. C. Have the patient cross his arms on his chest and place a pillow between his knees. D. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

C Rationale: The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2)have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: A. Grasp the gait belt. B. Stay with the patient and call for help. C. Place feet wide apart with one foot in front. D. Gently slide patient down to the floor, protecting her head. E. Pull the weight of the patient backward against your body. F. Rock your pelvis out on the side of the patient.

C, F, A, E, D, B Rationale: If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? A. Protocols for treating the patient problem B. Standardized treatment guidelines C. The nurse's ideas about the patient problem and treatment D. Clinical pathways for the treatment of sickle cell anemia.

C. Rationale: A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plans for patients.

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

C. Rationale: Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? A. Initial planning B. Standardized planning C. Ongoing planning D. Discharge planning

C. Rationale: Ongoing planning is problem oriented and has its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate - i.e., expected patient outcomes) Which item below places them in their correct sequence? A. 1, 2, 3, 4, 5 B. 3, 2, 1, 4, 5 C. 5, 2, 1, 3, 4 D. 2, 3, 1, 4, 5

C. Rationale: The five classic elements of evaluation in order are: (1) identifying evaluative criteria and standards (what you are looking for when you evaluate - i.e., expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

The nurse is surprised to detect an elevated temperature (102 degrees F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? A. Inform the charge nurse B. Inform the surgeon C. Validate the finding D. Document the finding

C. Rationale: The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

A nurse stretches out a patient's leg and moves it in a circle. This is an example of what type of body movement? A. Abduction B. Flexion C. Circumduction D. Dorsiflexion

C. Circumduction Rationale: Circumduction occurs when the distal part of the limb is moved to trace a circle while the proximal end of the bone remains fixed. Abduction occurs with the lateral movement of a body part away from the midline of the body. Flexion is the state of being bent. Dorsiflexion is the backward bending of the hand or foot.

Which of the following occurs when members of a minority group, living with a dominant group, begins to blend in an lose the characteristics that made them distinct? A. Cultural imposition B. Cultural conflict C. Cultural assimilation D. Cultural shock

C. Cultural assimilation Rationale: Cultural assimilation occurs when one's values are replaced by the values of the dominant culture. Cultural imposition is the belief that everyone should conform to the majority belief system. Cultural conflict occurs when people become aware of cultural differences, feel threatened, and act negatively. Cultural shock refers to the feelings a person experiences when placed in a different culture.

A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario? A. Lung cancer B. Test results C. Smoking cigarettes D. The subjective and objective data

C. Smoking cigarettes Rationale: The etiology is the factor that maintains the unhealthy condition (smoking cigarettes). Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.

Limitations of nursing diagnoses

Classification of standardized nursing diagnoses; if diagnostic process is used incorrectly a patient might be "misdiagnosed" (not so much limitations of nursing diagnosis as they are problems of nursing diagnosing incorrectly)

Syndrome

Clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions

Types of Outcomes

Cognitive Psychomotor Affective Physiologic

Common Health Problems in Eastern European Jews

Cystic fibrosis Gaucher's disease Spinal muscular atrophy Tay-Sachs' disease

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? A. The nurse collects data to identify health problems. B. The nurse collects data to identify patient strengths. C. The nurse collects data to justify terminating the care plan. D. The nurse collects data to measure outcome achievement.

D Rationale: The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? A. Thank the wife for being present B. Ask the wife if she wants to remain C. Ask the wife to leave D. Ask the patient if he would like the wife to stay

D Rationale: The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? A. Side-lying B. Fowler's C. Sims' D. Prone

D Rationale: The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1.. Ineffective Coping related to inability to maintain marriage 2. Defensive Coping related to loss of job and economic security 3. Altered Though Processes related to panic state 4. Decisional Conflict related to placement of parent in a long-term care facility A. (1) and (2) B. (3) and (4) C. (1), (2), and (3) D. (1), (2), (3), and (4)

D. Rationale: Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? A. Correct the initial assessment form. B. Redo the initial assessment and document current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.

D. Rationale: Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response? A. Congratulate the student and continue the care plan. B. Terminate the care plan since it is not working. C. Try giving the student more time to reach the targeted outcome. D. Modify the care plan after discussing possible reasons for the student's partial success.

D. Rationale: Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the care plan since the student has not met her targeted outcome. The student may need more than just additional time to reach her outcome.

A nurse states, "That patient is 78 years old - too old to learn how to change a dressing." What is the nurse demonstrating? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

D. Rationale: Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. Clustering is not an applicable concept.

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? A. "Outcome not met." B. "1/21/20 - Patient reports no change in diet." C. "Outcome not met. Patient reports no change in diet or activity level." D. "1/21/20 - Outcome not met. Patient reports no change in diet or activity level."

D. Rationale: The evaluative statement must contain a date, the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

Which example illustrates a nurse variable influencing patient outcomes? A. A patient in a nursing home refuses to take his medications. B. A low-income family is unable to afford formula for their newborn infant. C. An alcoholic patient is unwilling to participate in AA meetings. D. A rape victim does not receive counseling in the emergency department because a counselor is not available.

D. A rape victim does not receive counseling in the emergency department because a counselor is not available. Rationale: Nurse variables that influence the care plan resources (answer D), current standards of care, research findings, and ethical and legal guides to practice. The remaining answer options are patient variables, which include the patient's changing ability and willingness to participate in the care plan and personal responses to nursing interventions implemented.

Which outcome is an affective outcome? A. By 6/09/19, the patient will correctly demonstrate the procedure for washing her newborn baby. B. By 6/09/19, the patient will list three benefits of eating a healthy diet. C. By 6/09/19, the patient will use a walker to ambulate the hallway. D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking.

D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking. Rationale: An affective outcome describes changes in patient values, beliefs, and attitudes. Answers A and C are psychomotor outcomes (learning a new skill) and answer B is a cognitive outcome (increase in patient knowledge).

Which term describes what occurs when a nurse believes that one's own ideas, beliefs, and practices are the best or superior to those of colleagues and patients? A. Cultural diversity B. Culture shock C. Stereotyping D. Ethnocentrism

D. Ethnocentrism Rationale: Ethnocentrism is the belief that one's ideas, beliefs, and practices are superior or preferred to those of others. Cultural diversity refers to the existence of diverse groups in society with varying cultural characteristics. Culture shock describes the feelings a person experiences when placed in a different culture. Stereotyping is the practice of assuming that all members of a cultural group act alike.

Which of the following nursing diagnoses is written correctly? A. Child abuse related to maternal hostility B. Breast cancer related to family history C. Deficient knowledge related to alteration in diet D. Imbalanced nutrition related to insufficient funds in meal budget

D. Imbalanced nutrition related to insufficient funds in meal budget Rationale: Answer A makes legally inadvisable statements, answer B is a medical diagnosis, and answer C reverses the clauses in the statement.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

D. Quick priority Rationale: Quick priority assessments are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined? A. Recognizing significant data B. Recognizing patterns or clusters C. Identifying strengths and problems D. Reaching conclusions

D. Reaching conclusions Rationale: A possible problem, such as high blood pressure, is diagnosed as a conclusion of data interpretation. Recognizing significant data refers to the comparison of data to a standard or norm (e.g. normal blood pressure values). A data cluster is a grouping of patient data or cues that points to the existence of a problem (e.g. a series of readings). The nurse must then identify strengths and problems to determine if the patient is motivated to address them.

Nurse Practice Acts

Describe and define the legal boundaries of nursing practice within each state ** Know the legal parameters of nursing interventions **

Clinical Outcomes

Describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved.

Functional Outcomes

Describe the person's ability to function in relation to the desired usual activities

Problem-focused nursing diagnosis

Describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.

Affective Outcomes

Describes changes in patient values, beliefs, and attitudes

Cognitive Outcomes

Describes increases in patient knowledge or intellectual behaviors

Psychomotor Outcomes

Describes patient's achievement of new skills

Basic principles of diagnostic reasoning to identify actual and potential problems in clinical settings

Dynamic thinking process that leads to the identification of a hypothesis that best explains the clinical evidence. Nurses in advanced practice today frequently diagnose the origin of medical and nursing problems that develop in acutely and critically ill adults.

Why it is critical to partner with the patient and family to identify priority diagnoses

Essential for diagnosing human responses. Patients are more likely to work toward the achievement of improved health outcomes if they agree with the nurses' diagnoses and proposed interventions.

Effective interviewing techniques

Establish rapport Listen Ask questions Observe Terminate interview properly

Patient Outcome

Expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation

Tell whether the following statement is true or false. A nursing assessment duplicates a medical assessment by focusing on the patient's responses to the health problem.

False Rationale: A nursing assessment does not duplicate a medical assessment, rather it focuses on the patient's response to the health problem.

Tell whether the following statement is true or false: Stereotyping occurs when people ignore differences in cultures in which they live and proceed as if they do not exist.

False Rationale: Cultural blindness occurs when people ignore differences in cultures in which they live and proceed as if they do not exist.

Tell whether the following statement is true or false: When a patient fails to cooperate with the care plan despite the nurse's best efforts, it is time to reassign the patient to another caretaker.

False Rationale: When a patient fails to cooperate with the care plan despite the nurse's best efforts, it is time to reassess the strategy.

Tell whether the following statement is true or false: A collaborative intervention is an intervention initiated by a physician in response to a medical diagnosis by carried out by a nurse in response to a physician's order.

False. Rationale: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis, but carried out by a nurse in response to a physician's order.

Tell whether the following statement is true or false. Asking a patient to plan an exercise program to lower blood pressure based on information provided to the patient in an A/V presentation is an excellent method to evaluate a physiologic outcome.

False. Rationale: Asking a patient to plan an exercise program to lower blood pressure based on information provided in an A/V presentation is an excellent method to evaluate a cognitive outcome.

Tell whether the following statement is true or false: Jogging is an example of isometric exercise.

False. Rationale: Jogging is an example of isotonic exercise.

Nursing process

Five-step systematic method for giving patient care Involves: - assessing - diagnosing - planning - implementing - evaluating

Gliding joint

Flat surfaces of the bone slide over one another; flexion-extension and abduction-adduction can occur (e.g., carpal bones of wrist and tarsal bones of feet).

Quality-of-life Outcomes

Focus on key factors that affect someone's ability to enjoy life and achieve personal goals

Standard (or a norm)

Generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category

Data Cluster

Grouping of patient data or cues that points to the existence of a patient health problem

Common Health Problems in Native American and Alaska Natives

Heart disease Cirrhosis of the liver Diabetes mellitus Fetal alcohol syndrome

Common Health Problems in Asians

Hypertension Cancer of the liver Lactose intolerance Thalassemia

Common Health Problems in African Americans

Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids

Value self-evaluation as a critical element in developing the ability to deliver quality, person-centered nursing care

Identify strengths and weaknesses, learn daily and apply learnings the next day, monitor values regarding patient care

Cultural blindness

Ignores differences and proceeds as if they did not exist

Use ongoing data collection to determine how to safely and effectively implement a care plan

In every patient encounter, be sensitive to both subtle and dramatic changes in the patient's condition. Skilled nurses monitor the patient's responses to planned interventions to determine if the plan of care is working. If the plan of care is working. These assessment findings are used to update and revise the plan of care.

Criteria to evaluate planning skills

In nursing, expected outcomes are used. This refers to specific and measurable criteria which is used to evaluate the extent to which a goal has been met.

Comprehensive Planning

Includes initial, ongoing, and discharge planning

Benefits of nursing diagnoses

Individualized patient care; allows patients to be informed and willing participants in their care; defines the role of nursing

Inference

Judgment reached about a cue

Abduction

Lateral movement of a body part away from the midline of the body

Maslow's Hierarchy of Needs

Level 1 - Physiological Needs Level 2 - Safety and Security Level 3 - Relationships, Love and Affection Level 4 - Self Esteem Level 5 - Self Actualization

Lifestyle variables that influence body alignment and mobility

Many variables including occupation, leisure activity preferences, and cultural influences influence a person's lifestyle, whether active or sedentary - many occupations are sedentary (desk job), so people wishing to exercise regularly need to plan ahead for these leisure activities by preparing to exercise before or after work hours or during a lunch break) - person's diet and smoking history influence mobility - culture and gender may also play a role encouraging/discouraging exercise

Explain the relationship between nursing assessment and medical assessment.

Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems.

Mental health variables that influence body alignment and mobility

Mental health affects body appearance and movement as much as person's physical health - body processes tend to slow down with depression - body posture also changes (patient with depression often sits with head bowed and shoulders slumped, may lack energy to eat or even to use the toilet.)

Skeletal muscle

Muscle that is connected to the skeleton to form part of the mechanical system that moves the limbs and other parts of the body; striated

Evaluating Step of Nursing Process

Nurse and patient together measure how well patient has achieved the outcomes specified in care plan

Develop nursing diagnoses that correctly identify mobility problems amenable to nursing interventions.

Nursing diagnoses specifically addressing problems of mobility include: activity intolerance, impaired physical mobility, risk for injury, impaired transfer ability, and risk for activity intolerance

Key Terms of Nursing Diagnoses at a Glance

Nursing diagnosis - Problem, strength, or risk identified for a patient, family, group, or community Defining characteristic - Sign or symptom (objective or subjective cues) Related factor - Cause or contributing factors (etiologic factors) Risk factor - Determinant (increase risk) At-risk Populations - Groups of people who share a characteristic that causes each member to be susceptible to a particular human response; characteristics that are not modifiable by the professional nurse Associated conditions - medical diagnoses, injury procedures, medical devices, or pharmaceutical agents; conditions are not independently modifiable by professional nurse

Privacy, confidentiality, and professionalism issues related to patient assessment and data storage

One of our primary ethical responsibilities is safeguarding the privacy of patients. Be familiar with your institutions policies on Health Insurance Portability and Accountability Act (HIPAA).

Data interpretation and analysis - Identifying potential complications

Patients may experience many complications related to their diagnoses, medications or treatment regimens, or invasive diagnostic studies. While new to nursing, you can more easily prevent potential complications or at least make sure that they are detected early and managed well if you research the potential complications associated with your patient's diagnoses, diagnostics, and treatment, and if you report all abnormal data. For example, slurred speech, changes in skin color or moistness, inability to move an extremity or abnormal movement, and changes in levels of consciousness may all be indications of serious and life-threatening complications

Influences that affect culturally respectful health care

Physiological variations, reactions to pain, mental health, language & communication, gender roles, orientation to space and time, food & nutrition, family support, socioeconomic factors, health disparities

Plan patient assessments by identifying assessment priorities and structuring the data to be collected systematically.

Purposes of the nursing physical assessment include the appraisal of health status, the identification of health problems, and the establishment of a database for nursing intervention. Head-to-toe.

Four steps involved in data interpretation and analysis

Recognizing significant data Recognizing patterns or clusters Identifying strengths and problems Identifying potential complications Reaching conclusions Partnering with the patient and family

Respecting culturally based family roles

Respect the family individual who makes the decisions, even if it isn't the patient

Opposition

Rotation of the thumb around its long access (movement of the thumb across the palm to touch each fingertip of the same hand).

Data interpretation and analysis - Recognizing patterns or clusters

Some data are similar or have a pattern or connection are are identified as symptoms. Patterns may occur at a particular time of day or night, after eating, after walking, or when the client is in a certain position. These symptoms can be grouped together in clusters for further analysis. For example, you will see a relationship among symptoms when a client reports pain and bloating in the abdomen and no bowel movement for 3 days.

SMART goals

Specific, Measurable, Attainable, Realistic, Time-bound

Expected outcomes

Specific, measurable criteria used to evaluate the extent to which a goal has been met or whether the patient goal has been met

Flexion

State of being bent

Extension

State of being in a straight line

Hyperextension

State of exaggerated extension

Parts of a measurable outcome

Subject (who) Verb (what) Target time (when) Conditions (where) Performance criteria (how)

Cues

Subjective and objective data we identify

Writing Patient-Centered Measurable Outcomes

To be measurable, outcomes should have the following: - Subject - Verb (indicates the action the patient will perform) - Conditions - Performance Criteria - Target Time

Clinical inquiry

The ongoing process of questioning and evaluating practice and providing informed practice.

Condyloid joint

The oval head of one bone fits into a shallow cavity of another bone; flexion-extension and abduction-adduction can occur (e.g., wrist joint and joints connecting fingers to palm).

Ball-and-socket joint

The rounded head of one bone fits into a cuplike cavity in the other; flexion-extension, abduction-adduction, and rotation can occur (e.g., shoulder and hip joints).

Documenting Your (the nurse's) Judgment

The two-part evaluative statement includes a decision about how well the outcome was met, along with the patient data or behaviors that support this decision. Outcomes may be met, partially met, or not met.

Tell whether the following statement is true or false: A nursing diagnosis may be used to seek reimbursement for nursing services.

True Rationale: A nursing diagnosis may be used to seek reimbursement for nursing services.

Tell whether the following state is true or false: A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.

True Rationale: A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.

Tell whether the following statement is true or false: Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one's family.

True Rationale: Culture is defined as a shared system of beliefs, values, and behavioral expectations that provides social structure for daily living. It includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one's family.

Tell whether the following statement is true or false: Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.

True Rationale: Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.

Tell whether the following statement is true or false: One of the advantages of using Nursing Intervention Classifications in nursing practice is to ensure appropriate reimbursement for nursing services.

True Rationale: One of the advantages of using Nursing Intervention Classifications in nursing practice is to ensure appropriate reimbursement for nursing services.

Tell whether the following statement is true or false: The health care system is a culture of its own, with nursing being its largest subculture.

True Rationale: The health care system is a culture of its own, with nursing being its largest subculture.

Tell whether the following statement is true or false: The nursing diagnosis risk for impaired skin integrity is an example of a correctly written risk diagnosis.

True Rationale: The nursing diagnosis risk for impaired skin integrity is an example of a risk diagnosis.

Tell whether the following statement is true or false: The oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter region.

True Rationale: The oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter region.

Tell whether the following statement is true or false: The purpose of evaluation is to allow the patient's achievement of expected outcomes to direct future nurse-patient interactions.

True Rationale: The purpose of evaluation is to allow the patient's achievement of expected outcomes to direct future nurse-patient interactions.

Tell whether the following statement is true or false: An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care.

True. Rationale: An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care.

Circumduction

Turning in a circular motion

Rotation

Turning on an axis

Inversion

Turning the sole of the foot inward

Effects of exercise and immobility on major body systems: Urinary system

Urinary system effects of exercise - Increase blood circulation, blood flow to the kidneys, efficiency in maintaining fluid and acid-base balance, and efficiency in excreting body wastes. o Urinary system effects of immobility - Increase in urinary stasis (UTI), increase risk for renal calculi(kidney stones), and decrease. In bladder muscle tone

Intervention

What the nurse will do to assist the patient to achieve the goal or outcome

Use the patient's response to the care plan to modify the plan as needed

When evaluation reveals that the patient has made little or no progress toward outcome achievement, the nurse needs to re-evaluate each preceding step of the nursing process to try to identify the contributing factors causing problems with the plan of care.

Problem-focused nursing diagnoses

a clinical judgement concerning an undesirable human response to a health condition / life process that exists in an individual, family, group, or community; has four components: label, definition, defining characteristics, and related factor

Health promotion nursing diagnoses

a clinical judgement concerning motivation and desire to increase well-being and to actualize human health potential; responses are expressed by readiness to enhance specific health behaviors, and can be used in any health state; responses may exist in an individual, family, group, or community

Risk nursing diagnoses

a clinical judgement concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions / life processes

Evaluative statement

a judgment summarizing the nurse's findings after data have been collected and interpreted to determine patient outcome achievement

Pivot joint

a ring-like structure that turns on a pivot; movement limited to rotation; vertebrae (atlas and axis)

Hinge joint

a spool-like (rounded) surface of one bone fits into a concave surface of another bone; only flexion-extension can occur (elbow, knee, ankle joint)

Five Rights of Delegation

a) Right Task b) Right Circumstance c) Right Person d) Right Direction/Communication e) Right Supervision

Nursing diagnosis

actual or potential health problems that can be prevented or resolved by independent nursing interventions; problems treated by nurses within scope of independent nursing practice; may change from day to day as patient's responses change; clinical judgement about individual, family or community responses to actual or potential health problems or life processes; provides basic selection of nursing interventions to achieve outcomes for which nurse is accountable; focus is monitoring human responses to actual and potential health problems

Nursing intervention

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes

Nursing Intervention

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated, and collaborative interventions

Collaborative problem

certain physiologic complications that nurses monitor to detect onset or changes in status; nurses manage these using physician-prescribed and nurse interventions to minimize complications of the event; primary responsibility of nurses; prescription for treatment comes from nursing, medicine, and other disciplines; involve potential complications so they must be identified early so that preventive nursing care can be instituted early; focus is monitoring pathophysiologic responses of body organs or systems

Functional Outcomes

describe the person's ability to function in relation to the desired usual activities

Quality-of-life outcomes

focus on key factors that affect someone's ability to enjoy life and achieve personal goals

Medical diagnosis

identify diseases; describe problems for which physician or advanced practice nurse directs primary treatment; remains same for as long as disease is present; traumatic or disease condition or syndrome validated by medical diagnostic studies; focus is correcting or preventing pathology of specific organs or body systems

Factors that contribute to success in outcome achievement

include a patient's strong motivation to learn new health behaviors, a nurse who comes to work well rested and with a new care idea learned from a nursing journal.

Nursing-Sensitive Quality Indicators

indicators specific to nursing that identify structures of care and care processes that influence care outcome

Subjective data

information perceived only by the affected person; cannot be perceived or verified by another person; feelings, pain, etc

Physician-Initiated Interventions

initiated in response to a medical diagnosis but is carried out by a nurse in response to a doctor's order

Observation

key nursing skill when performing nursing history and physical assessment; conscious and deliberate use of five senses to gather data; nurses observe and interpret meaningful stimuli (data) in each nurse-patient interaction

Adduction

lateral movement of a body part toward the midline of the body

How to ask questions during interview

o Ask questions about person's main problems first o Focus questions to gain specific information about signs and symptoms o Don't use leading questions o Do use exploratory statements o Use communication techniques that enhance your ability to think critically and get facts § Use phrases that help you see other person's perspective § Restate person's own words § Ask open-ended questions § Avoid close-ended questions

Criteria

measurable qualities, attributes, or characteristics that identify skills, knowledge, or health states

Supination

movement that turns the palm up

Discharge planning element of comprehensive planning

o Best carried out by nurse who has worked most closely with patient and family, possibly in conjunction with nurse or social worker with broad knowledge of existing community resources o In acute care settings, this begins when patient is admitted for treatment Nurse uses teaching and counseling skills to help patient and family develop sufficient knowledge of health problem and therapeutic regimen to carry out necessary self-care behaviors at home competently

Objective data

observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them; vital signs, etc; aka signs or overt data; inspection, palpation, auscultation, percussion

Focused nursing assessment

nurse gathers data about specific problem that has already been identified; routinely part of ongoing data collection; identifies new or overlooked problems

Evidence-based practice

nursing care provided that is supported by sound scientific rationale

Effects of exercise and immobility on major body systems: Cardiovascular system

o Cardiovascular System effects of exercise - Increase efficiency of heart, decrease resting heart rate and blood pressure, and increase blood flow and oxygenation of all body parts. Increased circulating fibrinolysis (substance that breaks up small clots) o Cardiovascular System effects of immobility - Increase cardiac workload, increase risk for orthostatic hypotension (decreases blood pressure) and venous thrombosis. Increases heart rate, cardiac output, and stroke volume.

What to observe during interview

o Carefully assess areas connected to verbal complaints o Use your senses o Note general appearance o Observe body language o Notice interaction patterns

Ongoing planning element of comprehensive planning

o Carried out by any nurse who interacts with patient o Chief purpose - keep plan up to date to facilitate resolution of health problems, manage risk factors, and promote function o Includes stating nursing diagnoses more clearly (problem statement and cause), developing new diagnoses, adjusting patient outcomes to be more realistic, developing new outcomes as needed, and identifying nursing interventions that will best accomplish patient goals o Standardized plans based on medical conditions or procedures may be useful in developing new nursing diagnoses and related nursing interventions, but must individualize plan to meet unique patient needs

Effects of exercise and immobility on major body systems: Gastrointestinal system

o Gastrointestinal system effects of exercise - Increase appetite and intestinal tone. Weight may be controlled o GI system effects of immobility - Disturbance in peptide altered protein metabolism and digestion and utilization of nutrients. Decreased food intake, and disturbance in appetite.

How to terminate interview

o Give a warning o Ask people to summarize their most important concerns and then summarize most important concerns as you see them o Ask, "What else?" o Offer yourself as a resource o Explain care routines and provide information about who is accountable for nursing care decisions o Explain where the data being recorded are stored, how they will be used, and who has access to them o End on a positive note and encourage person to become an active participant

How to listen during interview

o Listen actively - listen for feelings as well as words o Let person know when you see body language that sends message that conflicts with what is being said o Use short, supplemental phrases that let person know you understand and encourage person to continue o Be patient if person has memory block o Avoid impulse to interrupt o Allow for pauses in conversation

Effects of exercise and immobility on major body systems: Metabolic processes

o Metabolic System effects on exercise - Increase efficient metabolic system and body temperature regulation o Metabolic system effects on immobility - Increase risk for electrolyte imbalance. Altered exchange of nutrients and gases.

Effects of exercise and immobility on major body systems:. Musculoskeletal system

o Musculoskeletal system effects of exercise - Increase in muscle efficiency, coordination, and efficiency of nerve impulse transmission o Musculoskeletal system effects of immobility - Decrease muscle size, tone, and strength(atrophy ), decrease joint mobility, flexibility, increased bone demineralization, decrease endurance and stability and increase risk for contracture formation

Initial planning element of comprehensive planning

o Performed by nurse with admission nursing history and physical assessment o Addresses each problem listed in prioritized nursing diagnoses and identifies appropriate patient goals and related nursing care Standardized care plans - prepared care plans that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem; can provide basis for initial care plan if nurse individualizes them; resources include computerized plans, textbooks with prepared care plans, and facility-developed plans / maps / critical pathways; using these allows nurse to be free to direct time and experience to individualizing plan

Effects of exercise and immobility on major body systems:. Respiratory system

o Respiratory system effects of exercise - Increase depth of respiration, respiratory rate, gas exchange at alveolar level, and rate of carbon dioxide excretion. o Respiratory effects of immobility - Decrease depth respiration and rate of respiration. Decreased Pooling of secretions (respiratory congestion) and impaired gas exchange of co2 and oxygen (results in acid-base imbalance). Decreased movement in thoracic cage (loss of to us, pressure on chest from patient's position in bed, or various pharmaceutical agents.

Risks and responsibilities of delegating nursing interventions

o Right task § Activity falls within delegatee's job description or is included as part of established written policies and procedures of nursing practice setting. Facility needs to ensure that policies and procedures describe expectations and limits of the activity and provide any necessary competency training. o Right circumstances § Health condition of patient must be stable. If patient's condition changes, delegatee must communicate this to licensed nurse, and licensed nurse must reassess situation and appropriateness of delegation. o Right person § Licensed nurse along with employer and delegatee is responsible for ensuring that delegatee possesses appropriate skills and knowledge to perform activity. o Right directions and communication § Each delegation situation should be specific to patient, licensed nurse, and delegatee. § Licensed nurse is expected to communicate specific instructions for delegated activity to delegatee. Delegatee should ask any clarifying questions. Communication includes any data that need to be collected, method for collecting data, time frame for reporting results to licensed nurse, and additional information pertinent to situation. § Delegatee must understand terms of delegation and must agree to accept delegated activity. § Licensed nurse should ensure that delegatee understands that he/she cannot make any decisions or modifications in carrying out activity without first consulting licensed nurse. o Right supervision and evaluation § Licensed nurse is responsible for monitoring delegated activity, following up with delegatee at completion of activity, and evaluating patient outcomes. Delegatee is responsible for communicating patient information to licensed nurse during delegation situation. Licensed nurse should be ready and available to intervene as necessary. § Licensed nurse should ensure appropriate documentation of activity is completed.

Initial Nursing Assessment

performed shortly after patient is admitted to health care facility or service; establishes complete database for problem identification and care planning

Physiologic Outcomes

physical changes in the patient; using physical assessment skill to collect and compare data

Interview

planned communication; establishes successful working partnership with patient, to communicate care and concern for patient, and to obtain necessary patient data

Consultation

process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

Time-lapsed nursing assessment

scheduled to compare patient's current status to baseline data obtained earlier; can be comprehensive or focused

Autonomic Nervous System (ANS)

the part of the peripheral nervous system that controls internal biological functions

Somatic Nervous System (SNS)

the part of the peripheral nervous system that controls voluntary movement of skeletal muscles

Patient-centered assessment method (PCAM)

tool for health care practitioners can use to assess patient complexity using social determinants of health, which may explain why some patients engage and respond well in managing their health while others with the same or similar health conditions do not experience the same outcomes; helps nurse ask questions to gain understanding about patient's health and well-being (lifestyle behaviors, impact of physical health on mental health, ability to enjoy daily activities), social environment (status of employment, housing, transportation, and social networks), health literacy and communication skills (understanding of symptoms and risk factors, language and cultural differences, learning difficulties); may help nurse discover other factors affecting a person's ability to manage his/her health; action oriented, with final section focused on actions that can be taken to address needs and issues identified in the assessment

Indirect care intervention

treatment performed away from the patient but on behalf of a patient or group of patients

Direct care intervention

treatment performed through interactions with the patient

Collaborative interventions

treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants; carried out by nurses

Pronation

turning the palm downward

Eversion

turning the sole of the foot outward

When to report significant patient data and of proper documentation

· Data should be reported verbally immediately whenever assessment findings reveal critical change in patient's health status that necessitates involvement of other nurses or health care professionals. · A nurse who is unsure of the significance of a particular finding should consult with another nurse. · Patient's initial database is entered into computer or recorded in ink the same day patient is admitted to facility. If important data cannot be obtained during initial assessment, this should be documented so that they are obtained ASAP. · Objective and subjective patient data should be summarized and written so that data communicate unique sense of patient and are comprehensive, concise, and easily retrievable. · Data should be written legibly, using good grammar and only standard medical abbreviations. · To facilitate quick data retrieval, data should be presented under clearly marked headings. · When possible, subjective data should be recorded using patient's own words within quotation marks. Patient reports may also be paraphrased. · Avoid tendency to record data using nonspecific terms with different meanings or interpretations. · Always be specific.

Common problems encountered in data collection, noting their possible causes

· Database inappropriately organized - failure to plan for assessment by identifying needed date; use of inappropriate tools for data collection · Pertinent data omitted - Not following up on cues during data collection; inappropriate guidelines · Irrelevant or duplicate data collected - failure to identify specific purpose or data collection; failure to review available patient records; use of inappropriate tools for data collection · Erroneous or misinterpreted data collection - failure to observe carefully or validate during data collection; interviewer prejudices or stereotypes · Failure to establish rapport - failure to establish sufficient rapport or use appropriate communication techniques with patient; failure to know what information is wanted · Interpretation of data is recorded rather than the observed behavior - nurse jumps to hasty conclusion about patient's behavior and deprives others of exploring with patient possible causes of behavior; deficient validation · Failure to update the database - erroneous belief that assessment is concluded after initial database is recorded; low priority attached to ongoing data collection

Practice cultural respect when assessing and providing nursing care for patients from diverse cultural groups.

· Develop cultural self-awareness · Develop cultural knowledge · Accommodate cultural practices in health care · Respect culturally based family roles · Avoid mandating change - Seek cultural assistance

Culturally competent nursing care

· Ensure that all patients/families receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. · Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. · Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. · Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/family with limited English proficiency at all points of contact, in a timely manner during all hours of operation. · Make available easily understood patient-related materials and post signs in the language of the commonly encountered groups and/or groups represented in the service area. · Ensure that data on the individual patient's/family's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. · Maintain a current demographic, cultural, and epidemiologic profile of the community, as well as a needs assessment, to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Utilize principles of ergonomics when appropriate.

· Erect posture (correct alignment) · Use longest and strongest muscles of the arms and legs to help provide power needed in strenuous activity · Use internal girdle and long midriff to stabilize pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling · Work as closely as possible to object that is to be lifted or moved · Face the direction of your movement (avoid twisting) · Use weight of body as a force for pulling or pushing, by rocking on feet or leaning forward or backward · Slide, roll, push, or pull an object, rather than lift it · Use weight of body to push an object by falling or rocking forward and to pull an object by falling or rocking backward · Push rather than pull equipment when possible · Begin activities by broadening base of support · Make sure surface is dry and smooth when moving an object · Flex knees, put on internal girdle, and come down close to an object that is to be lifted · Break up heavy loads into smaller loads

Design exercise programs

· Explore patient's fitness goals, interests, skills, exercise opportunities, and exercise capacity · Assist patient in obtaining medical clearance for exercise · Explore feasible exercise activities with patient · Develop exercise program that specifies warm-up and cool-down activities and 3-4 major exercise activities from which patient can choose · Specify frequency, duration, intensity of exercise activity · Encourage patient to complement exercise program with everyday activities that require exercise · Try to identify with patient any potential threats to exercise program's successful implementation · Use ongoing evaluation to determine whether exercise prescription is meeting patient's needs and whether patient is adhering to prescription · Encourage patient to have an exercise partner to encourage each other

Common problems related to planning

· Failure to involve patient in planning process · Insufficient data collection · Use of inaccurate or insufficient data to develop nursing diagnoses · Outcomes stated too broadly · Outcomes derived from poorly developed nursing diagnoses · Failure to write nursing orders clearly · Written nursing orders that do not resolve the problem Failure to update the plan of care

How patient goals/expected outcomes and nursing orders are derived from nursing diagnoses

· For each diagnosis, there is a care plan and at least one outcome/patient goal should be written and if achieved it demonstrates a direct resolution of the problem statement.

Prioritize patient health problems and nursing responses

· High-priority diagnoses pose greatest threat to patient's health and well-being. · Medium priorities are diagnoses that are not life threatening · Low priority are diagnoses that are not specifically related to current level of health or well-being

How diversity affects health and illness care, including culturally based traditional care

· Illness Classifications: o Natural Illness- Caused by dangerous agents o Unnatural Illness- Punishments for failing to follow God's rules, resulting in evil forces or witchcraft causing physical or mental health problems · Some Cultures: o The power to heal is thought to be a gift from GOD bestowed on certain people o Different beliefs about the best way to treat an illness or disease is by herbal medication/ natural remedies o Use of cutaneous stimulation, therapeutic touch, acupuncture, and acupressure · Culturally based traditional care o What a patient believes about healthcare needs based on their own cultural values

Prioritize patient health problems and nursing responses (continued)

· Look at all problems to determine relationships among the problems (what's causing or contributing to what) · Deal with medical (or suspected medical) problems first. If these can be resolved, many human response problems are gone.

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Memory jog for writing goals and outcomes is the word SMART: o S - specific o M - measurable o A - attainable o R - realistic o T - time-bound

Develop a nursing care plan with properly constructed outcomes and related nursing interventions

· Outcomes are derived from problem statement of nursing diagnosis; each nursing diagnosis should have at least one outcome written that, if achieved, demonstrates a direct resolution of problem statement · Long-term outcomes require longer period (usually more than a week) to be achieved than do short-term outcomes; may also be used as discharge goals

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Outcomes can be categorized as clinical, functional, or quality of life o Clinical outcomes describe expected status of health issues at certain points in time, after treatment is complete; address whether problems are resolved or to what degree they are improved o Functional outcomes describe person's ability to function in relation to desired usual activities - Quality-of-life outcomes focus on key factors that affect someone's ability to enjoy life and achieve personal goals

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· Outcomes may be categorized according to type of change needed by patient o Cognitive outcomes describe increases in patient knowledge or intellectual behaviors o Psychomotor outcomes describe patient's achievement of new skills o Affective outcomes describe changes in patient values, beliefs, and attitudes; difficult to write and evaluate; could be critical to resolution of complex patient problem

Developing diagnostic statements using the guidelines for writing nursing diagnoses

· Phrase nursing diagnosis as a patient problem or alteration in health state rather than as a patient need. · Check to make sure that the patient problem precedes the etiology & that the 2 are linked by the phrase "related to" · Consider when at-risk populations or associated conditions should be identified · Define characteristics, when included in the nursing diagnosis, should follow etiology & be linked by the phrase "as manifested by" or "as evidenced by." · Write in legally advisable terms · Use nonjudgmental language · Be sure problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance) · Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement · Reread the dx to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

The relation between quality-assurance/quality-improvement programs and excellence in health care

· Quality-assurance programs - enable nurses to be accountable to society for the quality of nursing care; promote excellence in nursing; respond to public mandate for professional accountability; help ensure survival of the profession, encourage nursing's fidelity to its moral and ethical responsibilities, and assist nursing to comply with other external pressures · Quality-improvement - the commitment and approach used to systematically and continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes

The AACN's six essential standards for establishing and sustaining healthy work environments and the seven crucial conversations in health care

· Skilled communication - Nurses must be as proficient in communication skills as they are in clinical skills · True collaboration - Nurses must be relentless in pursuing and fostering true collaboration Effective decision making - Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations · Appropriate staffing - Staffing must ensure the effective match between patient needs and nurse competencies · Meaningful recognition - Nurses must be recognized and must recognize others for the value each brings to the work of the organization · Authentic leadership - Nurse leaders must fully embrace the imperativeness of a healthy work environment, authentically live it, and engage others in its achievement

Concepts of cultural diversity and respect

· The coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit · These groups include, but are not limited to, people of varying religion, occupational status, and geographic location · Culture is integral component of health and illness because of the cultural values and beliefs that we learn in our families and communities · Cultural respect enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. It is also critical to reducing health disparities and improving access to high-quality health care o Remember that each individual may be a member of multiple cultural, ethnic, and racial groups at one time o Different cultural values may guide an individual in different situations based on what is most important to that person at the time o Any person should be viewed foremost as an individual, not as a representative of a cultural group

Purpose and benefits of outcome identification and planning

· The nurse works in partnership with patient and family to: o Establish priorities o Identify and write expected patient outcomes o Select evidence-based nursing interventions o Communicate the nursing care plan · A formal care plan allows nurses to: o Individualize care that maximizes outcome achievement o Set priorities o Facilitate communication among nursing personnel and their colleagues o Promote continuity of high-quality, cost-effective care o Coordinate care o Evaluate patient's responses to nursing care o Create a record that can be used for evaluation, research, reimbursement, and legal purposes o Promote nurse's professional development · Unique focus of nursing outcome identification and planning: o Used to design a plan of care with and for the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient's health expectations, as identified in patient outcomes - Comprehensive care plan also specifies any routine nursing assistance patient needs to meet basic human needs and describes appropriate nursing responsibilities for fulfilling the collaborative and medical care plan

Five sources of patient data useful to the nurse

· The patient (primary source) · The family and significant others · The patient record · Assessment technology · Nursing and other health care literature

Develop a nursing care plan with properly constructed outcomes and related nursing interventions (continued)

· To be measurable, outcomes should have the following: o Subject - patient or some part of the patient o Verb - action patient will perform; verbs helpful in writing measurable outcomes include: define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, and demonstrate o Conditions - particular circumstances in or by which outcome is to be achieved; not every outcome specifies conditions o Performance criteria - expected patient behavior or other manifestation described in observable, measurable terms o Target time - when patient is expected to be able to achieve outcome; may be realistic, actual date or other statement indicating time, such as "before discharge" or "after viewing film" or "whenever observed"

Factors commonly included in a transcultural assessment of health-related beliefs and practices

· To what cause(s) does the patient attribute illness and disease (e.g., divine wrath, imbalance in hot/cold or yin/yang, punishment for moral transgressions, hex, soul loss, pathogenic organism)? · What are the patient's cultural beliefs about the ideal body size and shape? What is the patient's self-image compared to the ideal? · What name does the patient give to his/her health-related condition? · What does the patient believe promotes health (e.g., eating certain foods; wearing amulets to bring good luck; sleep; rest; good nutrition; reducing stress; exercise; prayer; rituals to ancestors, saints, or intermediate deities)? · What is the patient's religious affiliation (e.g., Judaism, Islam, Pentecostalism, West African voodooism, Seventh-Day Adventism, Catholicism, Mormonism)? How actively involved in the practice of this religion is the patient? · Does the patient rely on cultural healers (e.g., curandero, shaman, spiritualist, priest, minister, monk)? Who determines when the patient is sick and when the patient is healthy? Who influences the choice/type of healer and treatment that should be sought? · In what types of cultural healing practices does the patient engage (e.g., use of herbal remedies, potions, massage; wearing of talismans, copper bracelets, or charms to discourage evil spirits; healing rituals, incantations, prayers)? · How are biomedical/scientific health care providers perceived? How do the patient and the patient's family perceive nurses? What are the expectations of nurses and nursing care? · What comprises appropriate "sick role" behavior? Who determines what symptoms constitute disease/illness? Who decides when the patient is no longer sick? Who cares for the patient at home? · How does the patient's cultural group view mental disorders? Are there differences in acceptable behaviors for physical versus psychological illnesses?

What to do if a patient does not cooperate with the care plan

· When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. One possibility is that the plan of care may not be right for this patient. Common reasons for noncompliance include: o Lack of family support o Lack of understanding about the benefits of compliance o Low value attached to outcomes or related interventions o Adverse physical or emotional effects of treatment (such as pain and fatigue) o Inability to afford treatment o Limited access to treatment

Eight implementation guidelines

· When implementing nursing care, remember to act in partnership with the patient/family · Before implementing any nursing action, reassess the patient to determine whether the action is still needed · Approach the patient competently. Know how to perform the nursing action, why the action is being performed, and potential adverse responses. Have all equipment and supplies ready · Approach the patient caringly. Explain the nursing action using language the patient understands. Communicate genuine concern for what the patient is experiencing · Modify nursing interventions according to the patient's (1) developmental and psychosocial background. (2) ability and willingness to participate in the plan of care, and (3) responses to previous nursing measures and progress toward goal/outcome achievement · Check to make sure that the nursing interventions selected are consistent with standards of care and within legal and ethical guides to practice · Always question that the nursing intervention selected is the best of all possible alternatives. Consult colleagues and the nursing and related literature to see if other approaches might be more successful. Evaluate the effectiveness of the intervention selected, noting any factors that positively or negatively influenced outcome - Develop a repertoire of skilled nursing interventions. The more options one can choose from, the greater the likelihood of success

Nurse-initiated interventions

· an autonomous action based on scientific rationale that a nurse executes to benefit patient in predictable way related to nursing diagnosis and projected outcomes; do not require health care provider's (or other team member's) order; derived from nursing diagnosis; per Alfaro-LeFevre, are actions performed by nurse to: o Monitor patient health status and response to treatment o Reduces risks o Resolve, prevent, or manage a problem o Promote independence with ADLs o Promote optimum sense of physical, psychological, and spiritual well-being - Give patients information they need to make informed decisions and be independent

Use of NIC (Nursing Interventions Classification)

· any treatment based upon clinical judgement and knowledge that nurse performs to enhance patient/client outcomes o Helps demonstrate impact nurses have on system of health care delivery o Standardizes and defines knowledge base for nursing curricula and practice o Facilitates appropriate selection of nursing intervention o Facilitates communication of nursing treatments to other nurses and providers o Enables researchers to examine effectiveness and cost of nursing care o Assists educators to develop curricula that better articulate with clinical practice o Facilitates teaching of clinical decision making to novice nurses o Assists administrators in planning more effectively for staff and equipment needs o Promotes development of reimbursement system for nursing services o Promotes development and use of nursing information systems - Communicates nature of nursing to public

Prioritize patient health problems and nursing responses (continued) - Maslow's Hierarchy of Human Needs

· basic needs must be met before a person can focus on higher ones; patient needs may be prioritized according to the following hierarchy: 1. Physiologic needs 2. Safety needs 3. Love and belonging needs 4. Self-esteem needs 5. Self-actualization needs

Prioritize patient health problems and nursing responses (continued) - planning nursing care for each day

· consider the following to rank diagnoses in order in which they should be addressed: o Have changes in patient's health status influenced priority of nursing diagnoses? o Have changes in the way patient is responding to health or illness or care plan affected those nursing diagnoses that can be realistically addressed? o Are there relationships among diagnoses that require that one be worked on before another can be resolved? o Can several patient problems be dealt with together?

NOC (Nursing Outcomes Classification)

· developed by the Iowa Outcomes Project o First comprehensive standardized language used to describe patient outcomes that are responsive to nursing intervention o Facilitates comprehensive approach to care planning o When using standardized language to ensure that it adequately captures uniqueness of your patients and families - Aims to help nurse identify/select interventions that produce optimal care, reduce legal risks, and lower healthcare costs

Data interpretation and analysis - Identifying strengths and problems

· helps to determine whether patient agrees with nurse's identification of strengths and problems and is motivated to work toward problem resolution o Determining patient and family strengths - patient strengths might include healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths; resources such as presence of support people, adequate finances, and a healthy environment may contribute to patient strengths o Determining the patient's problem areas o Determining problems the patient is likely to experience

Data interpretation and analysis - Reaching conclusions

· nurse reaches one of four basic conclusions after interpreting and analyzing patient data: o No problem § No nursing response is indicated § Reinforce patient's health habits and patterns § Initiate health promotion activities to prevent disease or illness or to promote a higher level of wellness § Wellness diagnosis might be indicated o Possible problem § Collect more data to confirm or disprove a suspected problem o Actual or potential nursing diagnosis or problem or issue § Begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve the problem § If unable to treat problem because patient denies problem and refuses treatment, make sure that patient understands possible outcomes of this stance o Clinical problem other than nursing diagnosis § Consult with appropriate health care professional and work collaboratively on problem § Refer to medical or other services, as indicated

Data interpretation and analysis - Recognizing significant data

· this data should "raise a red flag" for the nurse; deviations from the standard, or norm (generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category), such as: o Changes in a patient's usual health patterns that are unexplained by expected norms for growth & development - example: infant who took to breastfeeding easily as newborn suddenly stops sucking when put to breast & begins to lose weight o Deviation from an appropriate population norm - example: A first-year college student begins to accelerate her exercise habits dramatically & starts inducing vomiting after binge eating; she rapidly loses weight. o Behavior that is nonproductive in the whole-person context - example: college student breaks up with her boyfriend & begins to believe that she is "unfit" for any relationship, withdrawing from her friends & social activities. o Behavior that indicates a developmental lag or evolving dysfunctional pattern - example: 16 y/o single mother with a 6 month old infant continues to "party hard" with friends, hang out at mall, and shows no interest in caring for her son, who is repeatedly left with concerned family members.

Implementing Guidelines

• Act in partnership with the patient/family. • Before implementing, reassess the patient to determine whether the action is still needed. • Approach the patient competently. • Approach the patient caringly. • Modify nursing interventions according to the patient's (1) developmental and psychosocial background, (2) ability and willingness to participate in the plan of care, and (3) responses to previous nursing measures and progress toward goal/outcome achievement. • Check to make sure that the nursing interventions selected are consistent with standards of care. • Always question that the nursing intervention selected is the best of all possible alternatives. • Develop a repertoire of skilled nursing interventions. The more options one can choose from, the greater the likelihood of success.