the nursing process chapters 4 and 5

Nursing interventions

meeting the physical needs of the patient, providing for patient safety, monitoring for potential complications, assessing and evaluating to identify changes in the patient's needs

things to remember for an older adult

A new diagnosis or treatment may seem overwhelming, impairing learning. Slow the pace of presentation. Limit duration of each session. Consider effect of lighting, glare, and noise on learning. Speak clearly without shouting.

Collaborative Problems are based on

Evidence-based practice uses research to impact nursing practice changes; the interventions used in the research findings can be implemented into care plans

Which step of the nursing process is used when the nurse identifies the therapeutic intent of a prescribed medication?

Planning Planning with reference to the prescribed medications includes eight steps, the first of which is identification of the therapeutic intent for each prescribed medication. The nurse must know why the drug was prescribed and what symptoms should be relieved. Assessment involves obtaining data about the patient's condition. Implementation refers to the actual carrying out of the medication regimen. Evaluation is determining the effectiveness of the regimen.

Motivation

Provide positive feedback when teaching Determine through patient outcomes when more teaching is needed

Focus the learning

Repeat information to help master concepts Environment should be quiet and well-lit Provide essential equipment Encourage active participation

Which stage of grief represents when the patient is most willing to learn

Resolution In the resolution and acceptance stages of the grieving process, the patient moves toward accepting responsibility and willingness to learn what is necessary to attain an optimal level of health

A clinical judgment that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis?

Risk/high risk

adherence

The degree to which the patient is likely to follow teaching relates to how much value the patient attaches to it

Which assessment finding is considered primary, objective information?

The patient states that his temperature has been 98.8°F.

Principles of Learning

Space the content, staggering the amount of material presented in one session Repetition enhances learning Consider the patient's educational level and literacy People tend to remember what is taught first Multiple shorter sessions less likely to overwhelm the learner.

What do the classification systems NIC and an NOC provide

Standardized language for reporting and analyzing nursing care delivery

Goals of Evidence Based Practice

improve patient outcomes by implementing best practices evolved from scientific studies Uses best care practices to improve patient outcomes

Example of an independent action:

listening to a patient's lung sounds after a respiratory treatment and monitoring laboratory values.

Example of a dependent action:

monitoring a patient's heart rate and rhythm while the patient is receiving antidysrhythmic therapy.

what information does a nurse collect during an assessment.

needs for medication history of medications identify problems related to drug therapy

Interdependent nursing actions

nurse performs actions in collaboration with another health care team member

Evaluation process involves

patient, family, and significant others who provide feedback and help determine goals

Review the drug monographs to

identify problems related to medication therapy

How does a nursing diagnosis differ from a medical diagnosis?

A nursing diagnosis evaluates a patient's response to actual or potential health problems.

Affective domain

Involves feelings, needs, values, and opinion

Maslow's hierarchy of needs is

used to prioritize patient needs

The nurse is teaching a patient who has been diagnosed with hypertension. Which statement by the patient indicates the need for further education?

"A sedentary lifestyle is the best way to live." A sedentary lifestyle has many negative health consequences, such as hypertension and heart disease. A healthy lifestyle may reduce the risk of hypertension and heart disease. High-fat diets can increase cholesterol levels and lead to heart disease. Quitting smoking will reduce the risk of hypertension and heart disease

Phases of Planning

-Setting priorities: identify problems and prioritize -Developing measurable goal statements: write short- and long-term goals for the patient -Formulating nursing interventions and anticipated outcomes:

Five Types of Nursing Diagnosis

1.Actual: based on human responses and supported by defining characteristics 2.Risk/high-risk: patient may be more susceptible to a particular problem 3.Possible: suspected problems requiring additional data 4.Wellness: clinical judgment about a transition from one level to a higher level 5.Syndrome: cluster signs and symptoms to predict certain circumstances or events

What is an example of ethnocentrism

A 36-year-old Asian prefers to take herbs instead of oral medication

Nursing Diagnosis is..

A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA-I) Actual nursing diagnosis consist of a three-part statement that Uses a NANDA-I diagnostic label Has contributing factors Defines characteristics

The nurse is preparing to administer morning medications. Which action(s) does the nurse implement to identify the patient before administering medications?

Checks the patient's identification band Asks the patient his or her name and birth date

Nursing Intervention or Implementation

Actual process of carrying out the established plan of care

Adult Education

Adults need to first understand why they must learn something Assess what the adult already knows and what information is desired Make the content relevant to that individual

The nurse is developing a teaching plan for a patient's prescribed medication. Which action(s) should the nurse implement to make the plan more effective?

Assess the patient's readiness to learn. Request patient feedback of the information being taught. Incorporate multiple practice sessions

Older Adults

Assess vision, hearing, short- and long-term memory, and fine and gross motor skills Assess concerns regarding cost Older adults may consider the balance between proposed treatment and quality of life Slow pace of the presentation, allow time to process new information

Evaluation procedure for determining therapeutic outcomes of drug therapy include

Assessing patient responses to medications Determining signs and symptoms of recurring illness Assessing any adverse effects Determining the patient's ability to receive education and self-administer medication, as well as the potential for compliance

Foundation for the clinical practice of nursing Involves

Assessment Nursing diagnosis Planning Nursing intervention or implementation Evaluating and recording therapeutic outcomes

first step in nursing process

Assessment: -Systematic collection -Physical examination -Nursing history -Medication history -Professional observation -Documentation of Data

An older adult patient is being prepared for discharge after experiencing a stroke with some residual damage. The patient and family are scheduled to receive a large amount of information from the nurse regarding proper care and safety at home. What is the nurse's best course of action?

Break the teaching content down into manageable sections and present them individually in the days before discharge.

Response and compliance depend on numerous variables

Comprehension and understanding Multiple physicians Costs of treatment Family support Control over disease Side effects Expectations and fears Physical limitations

Consider patient's what

Consider patient's educational level and ability to read and understand written material. Consider patient's preference for written material or audiovisual. The nurse may need to "translate" medical terms into terms patient can understand.

What is the purpose of the nursing assessment

Determining the clients mental status

The nurse who is new to a large urban hospital has found that many of the hospitalized patients are of different cultural groups in the area. Which approach is best for the nurse to take in caring for these patients?

Develop a plan of care that is individualized to each patient's needs.

Which type of nursing action occurs when the nurse administers a medication to a patient?

Dependent Administration of medications is based on the prescriptions of a healthcare provider and is a dependent nursing action. The nurse functions independently in areas such as selecting equipment for medication administration and verifying medication orders and correct administration. The nurse functions interdependently in areas such as making assessments that help determine the effectiveness of the drug and scheduling administration of medications, etc. Collaborative is a word used to describe a patient problem that cannot be resolved by nursing actions; it does not describe a type of nursing action

Nursing actions are suggested

Dependent actions: performed by a nurse based on health care provider's orders Interdependent actions: implemented with the cooperation of a team Independent actions: provided by nurse by virtue of education and license

Learning pace

Depends on learning style Depends on age of patient

Which teaching method is the most effective when teaching patients about medications?

Designing a teaching method and pace for each patient

The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that there will be little time for teaching on the day of discharge. What is the nurse's best course of action?

Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.

Collaborative Problems

Different from nursing diagnoses when the intervention used is to prevent or treat a problem and is worded with potential complication in the diagnosis

Psychosocial adaptation to illness

During grieving, patient will not be able to learn

The nurse is preparing a client prescribed medication in order to ensure client safety the nurse should perform which interventions prior to administration

Educate client regarding medication prescribed check two identifiers

Readiness to Learn

Ensure patient's basic needs are met first Depends on what patient already knows and motivation to learn Make the content relevant

Culture and ethnic diversity

Ethnocentrism—recognize its impact Work with an interpreter Consider the patient's outlook on health and illness Internet—impact on health information

Learning Styles

Fit teaching techniques to learner's style Provide a variety of media for learning such as pamphlets, videos, models, slides, photographs, charts, and computer instruction

method used to help with nursing diagnosis

Gordon's Functional Health Patterns Model

planning phase

Identify the therapeutic intent and common and serious adverse effects Check that scheduling of administration of medicine is based on the provider's orders

Which teaching strategy does the nurse use when teaching an elderly patient?

Incorporating time for practicing Time for practicing should be incorporated because it will give elderly patients an opportunity to master the content. Teaching should be done at a slower pace because elderly patients process things more slowly. Elderly patients may be embarrassed by their inability to master a task. Asking them if they understand is ineffective because they want to avoid embarrassment

Cognitive Domain

Involves learning and storing knowledge

Psychomotor Domain

Involves learning and storing knowledge physical skills

Which statement about a critical care pathway is true?

It is a standardized care plan derived from "best practice" patterns. Critical care pathways are standardized plans derived from "best practice" patterns that aid in developing detailed treatment plans for a specific case type or disease process. Critical care pathways are not specific to patients in critical condition. A critical care pathway documents the plan for discharge and serves as a communication tool for all healthcare providers.

Which information is considered objective data?

Laboratory results Laboratory results are considered objective data because they are data, signs, or observations made by the healthcare provider

medical diagnosis vs nursing diagnosis

Medical diagnosis is a diagnosis of a disease or disorder that impairs normal physiologic function

independent nursing actions

Not prescribed by a healthcare provider, but nurse can provide by virtue of the education and licensure held. example: actions that do not require a physician's orders

Nursing Diagnosis vs Medical Diagnosis

Nursing diagnosis refers to the patient's ability to function in ADLs; it identifies the patient's response to the illness

Which correctly identifies the NMDS classification system?

Nursing Minimum Data Set NMDS stands for Nursing Minimum Data Set

All care is evaluated against

Nursing diagnoses (goal statements) Nursing interventions Patient responses

Which correctly distinguishes a nursing diagnosis from a medical diagnosis?

Nursing diagnosis refers to the patient's ability to function in activities of daily living. Nursing diagnosis refers to clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A medical diagnosis focuses on alterations in patient function and structure. A nursing diagnosis tends to vary depending on the patient's rate of recovery, whereas a medical diagnosis tends to remain unchanged throughout the illness. A medical diagnosis results in diagnosis of disease that impairs normal physiologic function.

What is the foundation for the clinical practice of nursing?

Nursing process

Which piece of information obtained during a patient assessment is a subjective finding?

Patient states, "I have pain in my abdomen."

Encourage Adherence

Patients have right to make their own life choices Positive reinforcement helps patients succeed Response and compliance depend on numerous variables

Variables influencing the patient's response to the therapeutic regimen

Perceptions of the benefits, attitude toward health care providers, effect on own lifestyle, family situations, understanding of the illness Cost, family support, presence or loss of control, side effects, convenience, physical ability to shop, open containers

patients beliefs

Perform a cultural assessment to determine factors that relate to the beliefs of the patient. Understand that each nurse brings beliefs about health practices that affect relationships with patients.

dependent nursing actions

Performed by the nurse on the basis of the healthcare providers orders example: Actions that need a physician order

Assessment relies on

Primary source: produced by patient Secondary sources: relatives, significant others, medical records, lab reports Tertiary sources: literature to provide background information, diagnostic tests, diet

fear and anxiety

Provide information in small increments Ability to focus on details is reduced Anticipate inopportune times to initiate teaching Allow time for practice and review Praise efforts and positive aspects

nursing diagnosis statements

Provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding patients' needs Allows nurses to communicate what they do among themselves and with other health care professionals and the public Distinguishes the nurse's role from that of the physician or other health care provider Helps nurses focus on the scope of nursing practice

The nurse is preparing to teach a postsurgical patient who has a new colostomy about proper colostomy care. The patient says, "Just show me how to do it; let me try, and I'll learn what to do." Which domain of learning is indicated by this statement?

Psychomotor

Which phase of the five-step nursing process is diagnosis?

Second Diagnosis is the second phase of the nursing process. Assessment is the first phase of the nursing process. Planning is the third phase of the nursing process. Intervention or implementation is the fourth phase of the nursing process

Nurses prepare the prescribed medications using procedures to ensure patient safety

Select correct supplies (syringes, etc.) Verify all aspects before preparation Collect appropriate data to serve as baseline for later assessments Administer medication by correct route Document all aspects of administration Implement actions to minimize expected side effects Educate patient as appropriate

Phases of Planning (4)

Setting priorities Developing measurable goal/outcome statements Formulating nursing interventions Formulating anticipated therapeutic outcomes

Which statement describes a characteristic of Case Management Adherence Guidelines version 1 (CMAG 1)?

The caregiver and patient have ownership of the goals to be achieved. The CMAG 1 model focuses on the patient to implement actions that result in positive change. This approach gives the caregiver and the patient ownership of the goals to be achieved. A key principle of this model is that the caregiver must recognize that the patient will make the final decisions. The caregiver must negotiate with, not dictate to, the patient to implement actions that may result in positive change. Interventions are initiated early in care.

Which is a measurable goal statement for a patient taking insulin injections?

The patient will be able to self-administer insulin injections 2 weeks after initial training This goal is patient focused and includes measurable behavioral changes and a time frame for it to be accomplished

Which is a priority outcome for patient teaching about prescribed drug therapy?

The patient will take the medication as prescribed, not changing or discontinuing it without contacting the healthcare provider

Which portion of the learning process is involved in the cognitive domain?

Thinking

Three reasons for obtaining a drug history

To evaluate need for medication To obtain current and past use of over-the-counter medication To identify problems related to drug therapy

Which statement is true about culture and ethnic diversity?

Unless an assessment of psychosocial needs is performed on the patient, the true meaning of an illness may never be uncovered

Organization of material to be learned

Use objectives and an outline for teaching Allow time to practice and ask questions Review what has been taught

Ethnography

Used to observe how patients follow health care regimen at home

The nurse is preparing a patient for discharge after a surgical procedure. Which method is best for teaching the patient about his or her prescribed drugs?

Verbal explanations along with drug summary sheets

example of independent nursing action?

Verifies the correct route of medication administration

Which scenario represents the best time for the nurse to initiate patient teaching?

When the patient spontaneously starts asking questions

Which outcome statement identified by the nurses writing correctly

Within the next four hours client will report pain level less than 3 out of 10

Client expresses concern about feeling different from his peers

affective

Nursing diagnoses often can be formulated

based on the patient's drug therapy

holistic care

care that promotes physical, emotional, social, intellectual, and spiritual well-being

Learning Domains

cognitive, affective, psychomotor

Therapeutic outcomes are

developed to evaluate the effectiveness of the care given

The Nursing Interventions Classification (NIC) system provides

scientifically validated nursing interventions to treat a diagnosis.

The Nursing Outcome Classification (NOC) system provides

standardized outcomes and specific indicators to assess the effectiveness of nursing interventions

Case Management Adherence Guidelines include

the patient's motivation and knowledge level of prescribed medications. It also assesses social support systems.

purpose of nursing process

to diagnose and treat human responses to actual or potential health problems

Primary patient information may be

unreliable or patients may be poor historians.

Assessment is an ongoing process that starts

with admission and continues until the patient is discharged from care