Nursing process

What is critical thinking?

A combination of: Reasoned thinking Openness to alternatives Ability to reflect A desire to seek truth An important aspect of critical thinking is the process of identifying and checking your assumptions—and this is also an important part of the research process. Critical thinkers are flexible, nonjudgmental, inquisitive, honest, and interested in seeking the truth. They possess intellectual skills that allow them to use their curiosity to their advantage, and they have critical attitudes that motivate them to use those skills responsibly

What are three ways you can recognize a cue

A cue is recognized by the presence of data representing (1) a deviation from population norms, (2) a change in usual health patterns that is not explained by developmental or situational changes, (3) an indication of delayed growth and development, (4) a change in usual behaviors in roles or relationships, or (5) a nonproductive or dysfunctional behavior

What Is This Type of Evaluation? The nurse's activities in making a diagnosis, recommending or implementing an intervention

A. Process: Denotes what is actually done in giving care.

A client's activity level has decreased after hip replacement surgery. The client has been receiving opioid analgesia and has decreased fluid intake. Which type of diagnosis will the nurse choose? Risk Syndrome Actual Possible

A: risk The data (cues, defining characteristics) suggest that the client is at risk for constipation.

Accrediting agencies and delegating assessment

Accrediting agencies, such as The Joint Commission, also provide guidelines on who can perform and document assessments.

The diagnosis step of the nursing process includes which activity? Assessing and diagnosing Evaluating goal achievement Performing and documenting nursing actions Analyzing data

Analyzing data

What is the difference between a cue and an inference?

Answer: A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. You can observe a cue directly, but not an inference. You cannot directly check the accuracy of an inference

List the six phases of the nursing process

Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

How does the model work? Caring

Caring -Self-knowledge -Ethical knowledge Self-knowledge: Awareness of your values, beliefs, and biases. Ethical knowledge: Understanding your obligations; sense of right and wrong

Collaborative problem

Collaborative problem: A collaborative problem is always a potential problem

Complex etiology

Complex etiology: Some problems have too many etiological factors to list, or the etiology is too complex to explain in a brief diagnostic statement.

Preprinted, Standardized Plans: critical pathways

Critical pathways -Outcome-based, interdisciplinary plans that sequence client care based on case type Critical pathways: -Describe the minimal standard of care required to meet the recommended length of stay for patients with a particular condition or diagnosis-related group (DRG). -Are used by agencies for their most frequent case types or for situations in which standardized care can produce predictable outcomes. -Tend to emphasize medical problems and interventions. -Do not provide a way to judge nursing effectiveness.

Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Diagnosis Diagnosis includes the analysis of the data collected. This is the thinking phase needed to link the problems to the plan of action.

Planning Client Goals/Outcomes

Goals: Changes in client health status you hope to achieve Goals may also be called expected outcomes, desired outcomes, or predicted outcomes. Nursing-sensitive outcomes: Can be influenced by nursing interventions

Mrs. Clancy is a nursing home patient at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Implementation This is an example of delegation, part of the implementation phase of the nursing process.

International Classification for Nursing Practice (ICNP):

International Classification for Nursing Practice (ICNP): This system includes diagnoses, outcomes, and nursing actions

Interviewing (assessment)

Interviewing is purposeful, structured communication in which you question the patient in order to gather subjective data for the nursing database. The admission interview is structured and broad, but in ongoing assessment the interview may be informal, brief, and narrowly focused

Short-Term and Long-Term Goals

Long-term goals: To be achieved over a longer period of time (week, month, or more) Short-term goals: To be achieved within a few hours or days

Essential Versus Nonessential Goals

Nonessential goals derive from the etiology. Essential goals derive from the problem. For every nursing diagnosis, you must state one goal that, if achieved, would demonstrate resolution or improvement of the problem.

Formats for nursing diagnosis

One-part statement Two-part statement Three-part statement

Inspection

Part of physical assessment Inspection: Observation and visual examination of the client, as well as use of equipment such as an otoscope or ophthalmoscope.

Palpation

Part of physical assessment Palpation: Light touch, progressing to deeper touch, using the pads of the fingers.

Possible nursing diagnosis

Possible: Exists when your intuition and experience direct you to suspect that a diagnosis is present but you do not have enough data to support the diagnosis. You will continue to assess for more defining characteristics.

Nursing interview

Purposeful communication Structured communication Involves questioning the client Purpose is to gather subjective data for the nursing health history A nursing interview is purposeful, structured communication in which you question the patient to gather subjective data for the nursing health history

Roy Adaptation Model

Roy Adaptation Model: Conceptualizes patients as adapting constantly to internal and external demands within a biological and psychosocial context. Using this model, you would look at the person's ability to achieve balance in specific adaptive modes. Nursing models used to organize data

Special needs assessment

Special needs assessment: A special needs assessment is a type of focused assessment. You will use it to provide in-depth information about a particular area of client functioning, and it often involves using a specially designed form. The Joint Commission requires certain special needs assessments (e.g., of nutrition status and pain) for all clients. In some settings, such as hospice, home health, and rehabilitation settings, other special needs assessments (e.g., of functional abilities) are also required. You should perform a special needs assessment any time assessment cues suggest risk factors or problems in an area of client functioning

Other formats for nursing diagnosis

Specify Secondary to Two-part NANDA-I label Unknown etiology Complex etiology Collaborative problem

Specify nursing diagnosis format

Specify: Some NANDA-I labels include the word "specify." That label is useful only if it describes the problem more specifically.

Resources to Guide Nurses in Delegating

State Nurse Practice Acts Agency policies/procedures Accrediting agencies American Nurses Association (ANA)

• Which data are most likely to need validation: laboratory data or subjective data?

Subjective data

• Are my data congruent?

Suggested response: Based on the information obtained at this point, the only discrepancy is the differing expectations of Mr. and Mrs. Nguyen.

Delegating

The ANA and NCSBN's Joint Statement on Delegation (2005, updated 2015) states that the "RN may delegate components of care but cannot delegate the nursing process itself. The functions of assessment, planning, evaluation, and nursing judgment cannot be delegated."

The Clinical Care Classification (CCC)

The Clinical Care Classification (CCC) uses a framework of care components to classify healthcare patterns.

Nursing care plans

The comprehensive nursing care plan is the central source of information needed to Guide holistic, goal-oriented care Address each client's unique needs

How does problem status influence nursing interventions?

The status of the problem (i.e., whether it is a collaborative problem or an actual, potential, possible, or wellness nursing diagnosis) determines which types of activities are required.

Different Kinds of Nursing Knowledge

Theoretical Practical Self Ethical

• What role will you play in the care of Mr. Nguyen?

To answer this question, you need theoretical knowledge of the role of the nurse and the role of the nursing student. You also need self-knowledge to evaluate what theoretical knowledge and practical skills you bring to this clinical setting and ethical knowledge to recognize when they may be in a situation that exceeds your capabilities.

Why is it important to organize your work before implementing care?

To ensure efficiency Rationale: In today's work environment, nurses have heavy workloads and cannot afford to waste time. Making good use of time helps the nurse to prevent errors and to provide the best possible care for patients.

Self-knowledge

To think critically, you must be aware of your beliefs, values, and cultural and religious biases. You can gain self-knowledge by developing personal awareness, by reflecting (asking yourself), "Why did I do that?" or "How did I come to think that?"

Criticisms of the NANDA-I System

Too abstract to be useful Not well-researched Some say nurses should not use any standardized language to describe nursing knowledge and nursing work.

Psychosocial assessment

Type of special needs assessment Psychosocial: A psychosocial assessment typically includes data about family, lifestyle, usual coping patterns, understanding of the current illness, personality style, previous psychiatric disorders, recent stressors, major issues related to the illness, and mental status

What is diagnosing?

Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status Includes strengths, problems, and factors contributing to the problems Diagnosis is critical because it links the assessment step, which precedes it, to all the steps that follow it. Assessment data must be complete and accurate for you to make an accurate nursing diagnosis. Accuracy is essential because the nursing diagnosis is the basis for planning client-centered goals and interventions

Determine the type of nursing diagnosis for each of the following: Jane Thomas regularly engages in exercise but tells you she would like to increase her endurance.

Wellness diagnosis

Validating data

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

Assessment

Your purpose is to gather data that you will use to draw conclusions about the client's health status. First phase of nursing process

Determine the type of nursing diagnosis for each of the following: Mrs. King has several of the signs and symptoms (defining characteristics) of the nursing diagnosis: Ineffective Coping.

actual diagnosis

• In which stage does the nurse collect data?

assessment

How Does Problem Status Influence Nursing Interventions? (cont'd): prevention interventions are used in

the difference between prevention interventions for the different types of nursing diagnoses. Prevention interventions are used in: Actual nursing diagnoses: To help keep the problem from becoming worse. Potential nursing diagnoses: To remove or reduce risk factors in an effort to keep the problem from developing. Collaborative problems: To implement nursing and medical orders to help prevent development of a complication. Wellness diagnoses: To assess a client's wellness practices

What are the components of a NANDA-I nursing diagnosis

• Diagnostic label • Definition • Defining characteristics • Related or risk factors

• What purpose does each part of the nursing diagno- sis serve for directing the care of the client

• What purpose does each part of the nursing diagno- sis serve for directing the care of the client? Answer: • Diagnostic label. Succinct expression that symbol- izes a pattern of associated cues; usually reflects the problem response which distinguishes the label from similar nursing diagnoses • Defining characteristics. Recognizable indications that when organized into groups reflect an actual or wellness nursing diagnosis; patient data; similar to signs and symptoms • Related or risk factors. Description of clinical cues, conditions, and circumstances associated with the problem in some way (i.e., causing, contributing to the problem); usually a part of the problem etiology

Actual nursing diagnosis

Actual: If the patient has enough signs and symptoms (defining characteristics) to identify the specific nursing diagnosis. The next step is to determine the etiology, and then intervene to treat and/or relieve symptoms

What Is This Type of Evaluation? The client's condition or well-being is improved.

B. Outcome: Describes the effects of nursing (and other healthcare providers) care on the client's health status and may represent the degree of his or her satisfaction with care.

The nurse has identified Overweight as a problem for Mr. Nguyen. • What information do you need in order to deter- mine the etiology of this problem?

C. The nurse has identified Overweight as a problem for Mr. Nguyen. • What information do you need in order to deter- mine the etiology of this problem? Suggested response: The nurse needs to gather data about Mr. Nguyen's eating habits, typical diet, and activity level. • Because you do not have that information, write a two-part diagnostic statement describing Mr. Nguyen's nutritional status. Suggested response: Overweight related to unknown etiology

Make inferences

Make inferences: This is a critical-thinking skill. Recall that cues are facts (or data), whereas inferences are conclusions (judgments, interpretations) that are based on the data.

What are his wife's concerns?

Mrs. Nguyen is worried about her husband's risk for heart disease because of a strong family car- diac history, coupled with his fatigue and short- ness of breath.

Organizing data

Nursing models Gordon's Functional Health Patterns The NANDA-International Nursing Diagnosis Taxonomy II Roy Adaptation Model Orem's Self-Care Model Non-nursing models Maslow's Hierarchy of Needs

Determine the type of nursing diagnosis for each of the following: . Alicia Hernandez seems anxious, but you are not sure whether she actually is. You would like to have more data in order to diagnose or rule out a diagnosis of Anxiety.

Possible diagnosis

• What does the nurse do in the evaluation step?

Reassess the patient to see if desired outcomes have been met; revise the care plan, if necessary.

What About Delegation and Supervision?

Transferring responsibility while retaining accountability Includes supervision Delegation is the process of directing another person to perform a task or activity; it is a transfer of authority or responsibility. The person delegating retains accountability for the outcome of the activity

Two-part NANDA-I label

Two-part NANDA-I label: The first part describes a general response; the second part, following a colon, makes it more specific.

Family assessment

Type of special needs assessment Family: A family assessment provides a better understanding of the client's family-related health values, beliefs, and behaviors.

Cultural Assessment

Type of special needs assessment Cultural: Awareness of cultural influences should guide your assessment and nursing care.

Implementation

: You carry out the actions that you previously planned, and you document your actions and the client's responses to them 5th phase of nursing process

The nurse reviews care needs for a group of clients. Which task is inappropriate to assign to nursing assistive personnel (NAP)? Make sure a client takes his pills after his meal. Ambulate a post-surgical client to the bathroom. Bathe a client who is listed as a fall risk. Feed a client with severe visual impairment.

A Medication administration is not within the scope of practice of the NAP.

What are some reasons that a client may not follow a recommended treatment regimen?

A client may not follow a treatment regimen because of the following reasons: ● The person might not understand the treatment. ● The person might not understand the reasons for/importance of the treatment. ● The person may have cultural objections to the treatment. ● The person's lifestyle may interfere; he may not be willing to change his lifestyle. ● Fear of failure. ● Reluctance to ask questions because of fear that the nurse/physician will think he should know the answers or of reluctance to bother a busy professional. ● Lack of resources (e.g., money to buy pills, transportation to a clinic).

Cluster cues

A cluster is a group of cues that are related to each other in some way. The cluster may suggest a health problem. To help ensure accuracy, you should always derive a nursing diagnosis from data clusters rather than from a single cue.

• How is a nursing assessment different from a med- ical assessment?

A nursing assessment is holistic and focuses on client responses to disease, pathology, and other stressors. A medical assessment focuses on disease and pathology.

You have written a tentative outcome for a client. You are not certain that the client values this outcome. Use "thinking" as part of safe effective nursing care in this instance. Think of some client behaviors that might indicate that the client does value the outcome.

"Does the client value the outcome?" might include that the nurse will observe the client: 1 Seeking and sharing information 2 Educating self and involved persons about possible benefits or negative consequences of actions 3 Being open-minded and flexible, respecting other's differences, knowledge, and preferences 4 Discovering and sharing credible sources of information, resources, and referrals>>

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process? "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." "Mr. Sullivan will be able to walk the length of the hallway before discharge." "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance." "Ambulate Mr. Sullivan in the hallway three times today, please."

"I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."

Evolution of nursing diagnosis

"The diagnosis and treatment of human response to actual or potential health problems." (ANA, 1980) 1980s: Most state nurse practice acts began to designate nursing diagnosis as an exclusive responsibility of registered professional nurses. The formal list of nursing diagnostic labels describes health problems that can be addressed by independent nursing actions and, in that sense, form the body of knowledge that is unique to nursing

Tools for Recording Assessment Data

- Graphic flow sheet -Intake and output (I & O) sheet -Nursing admission assessment -Nursing discharge summary -Special-purpose forms -Electronic documentation

Components of caring

-Knowing -Being with -Doing for -Enabling -Maintaining belief

Evaluation

-The final step of the nursing process -Evaluate Client's progress toward goals Effectiveness of nursing care plan Quality of care in the healthcare setting

Describe a five-step process for generating and choosing nursing interventions.

1. Review the nursing diagnosis. Nursing orders should flow from the etiology and sometimes from the problem side of the diagnosis. 2. Review the desired patient outcomes. Outcomes suggest nursing strategies that are specific to the individual patient. 3. Identify several interventions/actions that might achieve the desired outcomes for the nursing diagnosis. 4. Choose the best interventions for this patient—those expected to be most effective in helping to achieve client goals. 5. Individualize the standardized interventions to meet the unique needs of the patient.

Self-knowledge is one of the types of nursing knowledge, and one aspect of safe, effective nursing care (SENC). What beliefs, values, and experiences affect your thinking and may be misleading? Are there stereotypes or biases that influence your thinking?

1.Realize that your beliefs, values, and experiences affect your thinking and can be misleading. 2.A bias is the tendency to slant your judgment based on personal opinion or unfounded beliefs, as the nurse did in the preceding example. Stereotypes are judgments and expectations about an individual based on the personal beliefs you have about this group. 3. This is like stereotyping in that you draw conclusions about an individual based on what you know about people in similar situations. 4. Medical diagnoses and statements from others can help you to think of possible explanations for your data, but they can also bias your thinking and prevent you from gathering your own data.

How Are Standards and Criteria Used in Evaluation?

ANA standards represent expected or accepted levels of performance; they provide a model for what ought to be done. In nursing, standards are used to describe quality nursing care. Criteria: Measurable or observable characteristics, properties, attributes, or qualities. They describe the specific skills, knowledge, behaviors, and attitudes that are desired or expected. -A criterion is reliable if it yields consistent results; that is, the same results every time, regardless of who uses it. -A criterion is valid if it is really measuring what it was intended to measure.

Type of nursing diagnosis

Actual Potential (risk) Possible Wellness

Agency policies/procedures and delegating assessment

Agency policies/procedures provide guidance, such as those stating which caregivers can collect and document specified data

Review problem status (actual, potential, or possible nursing diagnosis; collaborative problem; or wellness diagnosis) in Chapter 4. For which type(s) of problem(s) would you write: • Nursing orders for observation/assessments?

All problems

What are the five types of nursing diagnoses?

Answer: 1. Actual nursing diagnosis 2. Risk (potential) nursing diagnosis 3. Possible nursing diagnosis 4. Syndrome nursing diagnosis 5. Wellness nursing diagnosis

Which two nursing organizations have been respon- sible for making diagnosis a part of the professional nursing role?

Answer: American Nurses Association and NANDA International

What are the four main concepts of the full-spectrum model of nursing?

Answer: The four main concepts of the full-spectrum model are thinking, doing, caring, patient situation (or context).

Review problem status (actual, potential, or possible nursing diagnosis; collaborative problem; or wellness diagnosis) in Chapter 4. For which type(s) of problem(s) would you write: Nursing orders for health promotion interventions?

Answer: Wellness diagnoses

• What is the purpose of initial planning? Ongoing planning? Discharge planning?

Answer: • Initial planning is done for the purpose of identify- ing patient problems and creating the care plan. • Ongoing planning allows you to revise and indi- vidualize the patient's care plan as new data are obtained. • Discharge planning is done to evaluate the pa- tient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hos- pital or other healthcare agency

List the "five rights" of delegation.

Answer: • Right task • Right circumstance (patient) • Right person (personnel) • Right direction/communication • Right supervision/evaluation

Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Assessment CORRECT. The nurse knows that a diet high in sodium can impact hypertension. By inquiring about dietary intake, the nurse can identify areas of education that must be included in the plan of care.

Phases of nursing process

Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Mary is a 17-year-old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asks her how being hospitalized is impacting her senior year of high school. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Assessment CORRECT. The assessment of psychosocial needs is important information for the development of the care plan, which must reflect the social aspects of Mary's care.

What are the four features common to all definitions of assessment?

Assessment involves data collection, use of a system- atic and ongoing process, categorizing of data, and recording of data.

Professional Standards and Assessment

Assessment is an essential skill that is endorsed by American Nurses Association National Council of State Boards of Nursing The Joint Commission Standards of governmental agencies, professional organizations, and accrediting bodies, all address assessment

Patient preference

Assign high priority to problems that the patient thinks are the most important if they do not conflict with basic needs or medical treatment. Give high priority to problems the patient thinks are most important, provided that this does not conflict with basic/survival needs or medical treatments. When you explain the importance of your priorities, patients often come to agree.

Based on Maslow's hierarchy of needs, which problem has highest priority

Based on Maslow's hierarchy of needs, which problem has highest priority? Suggested response: Choose one of the collaborative problems, such as pulmonary edema or congestive heart failure. Fluid overload is a collaborative problem, but it is also listed in NANDA-I as Risk for Imbalanced Fluid Volume, Excess Fluid Volume, Deficient Fluid Volume, and Risk for Deficient Fluid Volume. It is not important to agree on the absolutely highest priority problem; the point is to talk about how the problems you and your classmates suggest relate to Maslow's framework, and why one is or may be more important than another

What Information Is Contained in a Comprehensive Nursing Care Plan?

Basic needs and activities of daily living: Include the routine assistance that the patient needs with hygiene, nutrition, elimination, and so forth, regardless of his or her nursing diagnoses. Medical/multidisciplinary treatment: Nurses need to know the medical orders for each patient and the nursing activities necessary for carrying out those orders. Nursing diagnoses and collaborative problems: These can be the nursing diagnosis care plan, which contains goals and nursing orders for the patient's nursing diagnosis and collaborative problems. Special discharge needs or teaching needs: The plan should contain instructions for formal discharge planning and special teaching if they are needed

Basic two-part nursing diagnosis

Basic two-part statement: Two-part statements can be used for actual, risk, and possible diagnoses. The format is: Problem (NANDA-I label) r/t Etiology (related factors).

What Is This Type of Evaluation? Utilizes all members of the multidisciplinary team in design of care systems

C. Structure: Structural indicators describe the type and amount of resources used to deliver programs and services. It requires standards and data about policies, procedures, and fiscal resources

Implementing the Plan

Cognitive skills: Thinking skills Interpersonal skills: Communicating with patients Psychomotor skills: Example: Insertion of an IV catheter Promote client participation: 1) Assess the client's knowledge, 2) Provide teaching, 3) Assess the client's supports and resources, 4) Be sensitive to the client's cultural, spiritual, and other needs and viewpoints, 5) Realize and accept that some attitudes cannot be changed, 6) Determine the client's main concerns, 7) Help the client to set realistic goals, 8) Talk openly and regularly about adherence. Coordinate care: You will be expected to put together the bits and pieces of information (e.g., the patient's response to physical therapy, dietary intake, emotional status, and vital signs) to provide a holistic view of the person. You will need to read the reports of other professionals, help interpret the results for the patient and family, and make rounds with other professionals to be sure that everyone sees the whole picture

Comprehensive assessment

Comprehensive assessment: Also called a global assessment, patient database, or nursing database. You will use data from a comprehensive assessment to obtain holistic information about the client's overall health status. This assessment includes subjective and objective data about the client's body systems and functional abilities, emotional status, spiritual health, and psychosocial situation, including information about the family and community. It enables you to identify client problems and strengths. You need comprehensive data to enhance your sensitivity to a patient's culture, values, beliefs, and economic situation.

The nurse has identified the nursing diagnosis Risk for Aspiration for a client with a swallowing disorder. What should the nurse do when deciding which feeding technique will prevent aspiration? Ask the nursing assistive personnel (NAP), who has 20 years of experience. Perform an Internet search on the topic. Ask the physician to write an order with specific instructions. Search for evidence-based, clinical practice guidelines.

D. Nursing interventions should be based on the most current clinical evidence that is based on science and research.

List the five components of a nursing order.

Date, subject, action verb, times and limits, signature

Nursing order contains

Date: The date the order was written. Change the date each time you review or revise the order. Subject: Nursing orders are instructions to nurses, so they are written in terms of nurse behaviors. Action verb: This tells the nurse what action to take—what to do. Examples of action verbs are assist, assess, auscultate, bathe, change, demonstrate, explain, give, teach, and turn. Times and limits: The following nursing orders show times and limits: Teach the components of a healthy diet on 9/13, day shift. Offer 100 mL water every hour between 0700 and 1900. Signature: The nurse writing the order should sign it. A signature indicates that you accept legal and ethical accountability for your orders and allows others to know whom to contact if they have questions or comments about the order.

NANDA-I Nursing Diagnosis: Components: defining characteristics

Defining characteristics: The cues (signs and symptoms) that allow you to identify a problem or wellness diagnosis are called defining characteristics. To use a problem label appropriately, a cluster of defining characteristics must be present in the patient data.

Nursing process, purpose and definition

Definition A systematic problem-solving process that guides all nursing actions Purpose To help the nurse provide goal-directed, client-centered care The nursing process, like nursing itself, involves both thinking and doing. Nurses must have good psychomotor and interpersonal skills, and they must use a sound knowledge base and good judgment to use the nursing process effectively`

What is full-spectrum nursing? Definition and model concepts

Definition A unique blend of thinking, doing, and caring for the purpose of affecting good outcomes from a patient situation What are the model concepts? -Thinking -Doing -Caring -Patient situation Nurses use critical thinking in all steps of the nursing process. They also apply critical thinking to the four kinds of nursing knowledge and what they are doing for the patient. Caring motivates and facilitates the thinking and doing. The goal of all this is to have a positive effect on a patient's health outcomes

NANDA-I Nursing Diagnosis: Components: definition

Definition: The definition explains the meaning of the label and distinguishes it from similar nursing diagnoses.

Goals for Wellness Diagnoses

Describe behaviors/responses that Demonstrate health maintenance OR Achievement of an even higher level of health

Medical diagnosis

Describes a disease, illness, or injury -The purpose of the medical diagnosis is to identify a pathology so that appropriate treatment can be given. A medical diagnosis is more narrowly focused than a nursing diagnosis. The following are differences between medical and nursing diagnoses: -You cannot predict a patient's nursing diagnoses just by knowing his or her medical diagnosis or pathology. -A medical diagnosis, disease, or pathological condition can have any number of nursing diagnoses associated with it. -Clients with the same medical diagnosis may have different nursing diagnoses

Why is the diagnosis step so critical to the other phases of the nursing process?

Diagnosis is critical because it links the assessment step, which precedes it, to all of the steps that follow it. Assessment data must be comprehensive and accurate to make an accurate nursing diagnosis. The nursing diagnosis must be accurate because it is the basis for the goals and interventions you will plan and implement for your patients.

Assessment relation to other steps

Diagnosis: You will use data to identify the client's actual or potential health problems and strengths, thus establishing a diagnosis. Planning outcomes: You will use data about the patient's motivation, family, and available resources to help you formulate realistic goals. Planning interventions: Assessment data helps you to choose the interventions most likely to be acceptable to and effective for the client Implementation: As you perform nursing actions, you will also gather data by observing the client's responses. For example, while helping a client ambulate, you might observe that she becomes short of breath. If this is new information, you might then identify a new diagnosis of activity intolerance. Evaluation: After performing interventions for existing diagnoses, you assess the client's responses. This reassessment provides the basis for changes in the care plan.

NANDA-I Nursing Diagnosis: Components

Diagnostic label Definition Defining characteristics Related factors Risk factors

Directive interviewing

Directive interviewing To obtain factual, easily categorized information Directive interviewing: In this type of interview, you control the topics and ask mostly closed questions to obtain specific information

Why Is a Written Nursing Care Plan Important?

Ensures care is complete: Specific written directions are less likely to be overlooked by busy caregivers. Provides continuity of care: Helps ensure that when an effective intervention is found, all caregivers will use the same approach with the patient. Promotes efficient use of nursing efforts: Specific, written instructions help to ensure that nurses do not waste time on ineffective approaches. Provides a guide for assessing and charting: Nursing orders and goals/expected outcomes on the care plan can help you plan your activities and ensure nothing is omitted from your documentation. Meets requirements of accrediting agencies: The Joint Commission and professional standards review organizations (PSROs) require a patient-specific plan of care

Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Evaluation When goals of the nursing care plan are met, the plan of care should be updated to reflect that.

The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient's family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Evaluation With the evaluation of the plan of care, constant reappraisal is required and alterations are made in the original plan to ensure its currency and relevance.

What are some other examples of dependent interventions?

Examples might include helping a client to ambulate (when there is a medical order for ambulation), starting an IV, advancing a client's diet when there is a medical order for "diet as tolerated," or administering medicines or treatments prescribed by the primary care provider.

Care plans that focus on diagnosis-related groups (DRGs) and are organized on a timeline to meet recommended lengths of stay are called standardized nursing care plans. True False

False Rationale: These types of care plans are called critical or clinical pathways (or critical pathways).

True or False: Nursing process phases must be used in order.

False. The steps may not be used in exact order, although they follow a logical progression. They may even occur at the same time (e.g., assessing while perform a nursing treatment—assessment and implementatio

Evaluation

Final phase of nursing process :You determine whether the desired outcomes have been achieved and assess whether your actions have successfully treated or prevented the client's health problems. This phase also includes modification of the care plan based on what has been achieved and what yet needs to be achieved

Critical-Thinking Model

Five step/category process -Contextual awareness -Inquiry -Considering alternatives -Analyzing assumptions -Reflecting skeptically and deciding what to do The critical-thinking model used throughout this book provides one way of making sense of critical thinking. This model organizes critical thinking into five major categories. This model is not meant to be all inclusive. Use it as a guide when faced with clinical decisions or unfamiliar situations. It should help you to achieve good outcomes for your patients

Focused assessment

Focused assessment: You will use a focused assessment to obtain data about an actual, potential, or possible problem that has been identified or is suspected. It focuses on a particular topic, body part, or functional ability rather than on overall health status. For example, focused assessments can relate pain, nutrition, spiritual health, social support, lifestyle, and family assessment. These specialized assessments add to the database created by the comprehensive initial assessment. An initial focused assessment is used to follow up on client-reported symptoms or unusual findings discovered during the first exam. An ongoing focused assessment is used to evaluate the status of existing problems and goals.

Computer-Generated Interventions

Generate a list of suggested interventions based upon a problem or outcome. Interventions are chosen according to the client's needs. Review each item and discuss with students which of these strategies provide the strongest evidence toward intervention identification and which would be the weakest. Most electronic care planning programs will generate a list of suggested interventions when you enter either a problem (nursing diagnosis, medical, collaborative) or an outcome (refer to Fig. 6-4). You then choose the interventions appropriate for the patient or type in nursing actions of your own. Computer prompts provide a wide range of interventions for your consideration. However, always look for other, perhaps more effective, strategies based on the patient data.

Problem irgency

High priority Life-threatening Medium priority Not a direct threat to life, but may cause destructive physical or emotional changes Low priority Requires minimal supportive nursing intervention

How do I go about getting the data I need? What sources should I use?

How do I go about getting the data I need? What sources should I use? Suggested response: There are many possible data sources: the patient, the patient's wife, the intake form, direct observation of the client and his wife, information gleaned from your interview, infor- mation gleaned from Mr. Nguyen's visit with the nurse practitioner, vital signs data, and exami- nation data. Nurses need to use all these data sources.

Identify data gaps and inconsistencies

Identify data gaps and inconsistencies: As you cluster and think about relationships among the cues, you will identify the need for data that were not apparent before and also look for inconsistencies in the data.

Identify problem etiologies

Identify problem etiologies: An etiology consists of the factors that are causing or contributing to the problem. Etiologies may be pathophysiological, treatment related, situational, social, spiritual, maturational, or environmental. It is important to correctly identify the etiology because it directs the nursing interventions. <<Key Point:>>An etiology is always an inference because you can never actually observe the "link" between etiology and problem.

Implementation overlaps with all of the steps in the process.

Implementation overlaps with assessment. Nurses use assessment data to individualize interventions. Implementation provides the opportunity to assess your patient at every contact. When performing an ongoing assessment, you are both implementing and assessing. Implementation overlaps with diagnosis. Nurses use data discovered during implementation to identify new diagnoses or to revise existing ones. Implementation overlaps with planning outcomes and interventions. As you care for a client, you begin to know her better, and her unique needs become more apparent. Implementation overlaps with evaluation. When evaluating patient health status and progress toward goals, you will compare the responses you observe during implementation with the existing goals (which were written in the planning outcomes phase).

Writing quality statements

In choosing a NANDA-I label, do not rely on the label definition alone. Always compare patient data to the defining characteristics of the label as well as to the definition. Include both problem and etiology. A quick check of this is to read your statement backwards: "Etiology causes problem," and see if it makes sense. Avoid using medical diagnoses and treatments as etiological factors. The nurse should be able to provide interventions to change or remove the etiological factors. Write the statement clearly. The statement should give a clear picture of the client's health status, and other health professionals should be able to understand it readily. Write the statement concisely. A wordy statement is likely to be unclear. Be descriptive and specific. A vaguely stated problem and/or etiology cannot provide guidance for formulating goals and nursing interventions. State the problem as a patient response. A problem is not a patient need. As a rule, avoid using the word "need" in a problem statement. A need may cause a problem, but it is not a human response. A problem is not a medical test, treatment, diagnosis, or equipment. A problem is not a nursing goal, a nursing problem, or a nursing action. Use nonjudgmental language. If you examined your biases during the diagnostic process, your statements will probably be neutral. Avoid legally questionable language. Be alert for legal implications. Look for phrases that seem to blame caregivers or patients or that refer negatively to patient care.

Types of assessments

Initial Ongoing Comprehensive Focused Special Needs

Initial and ongoing planning

Initial planning Begins with first client contact Is written as soon as possible after initial assessment Includes development of the initial comprehensive care plan Ongoing planning Causes changes to be made in the plan as you evaluate the client's responses to care

Basic physical assessment techniques

Inspection Palpation Percussion Auscultation

Preprinted, Standardized Plans: integrated plans of care (IPOC)

Integrated plans of care (IPOCs) Standardized plans designed to be both care plan and documentation form Integrated plans of care (IPOCs): -May have a different form or column for each day of care. -IPOCs do not necessarily: -Organize care according to diagnosis. -Describe minimal standards of care. -Specify a timeline for interventions and outcomes

The RN working in a hospital participates in the interdisciplinary care conference held daily on the nursing unit. In which type of evaluation is the nurse participating? Process Ongoing Terminal Intermittent

Intermittent; During the care conference, the RN is able to discuss the client's progress with the team and to alter the care plan as needed.

State whether each of the following represents a nursing diagnosis, medical diagnosis, or collabora- tive problem: A patient has signs and symptoms of appendicitis, which must be treated with surgery and antibiotics.

Medical diagnosis: appendicitis (actual problem; nurse cannot treat independently; requires surgery and antibiotics)

The most correct definition of critical thinking is A problem-solving process that enables one to show others they are wrong An examination of one's own beliefs in order to defend them intelligently Purposeful, analytical thinking that results in a reasoned decision Rational thinking that results in obtaining the one correct answer

Most definitions of critical thinking include the concept of it being purposeful and deliberate. It is more than just problem-solving and is not used exclusively to defend one's beliefs. Critical thinking enables a person to see that there may be more than one correct answer. The correct answer is C. The key words in the stem are purposeful and deliberate. Critical thinking is not used exclusively to defend one's beliefs, and it should enable a person to see that there may be more than one correct answer.

Patient states he is here to become established as a patient at the center and that he has not had a physical exam in more than 10 years. Wife accompanies. He is currently experiencing bilateral knee pain that is affecting his work performance. "I supervise construction workers. To check on things, I have to climb up and down ladders, lift things, and crawl around a lot." Has not missed any work but has been using increasing amounts of acetaminophen and ibuprofen "to get through the day." The medications provide only limited relief. States pain occurs daily even if not at work and is achy and dull. Feels best when he is off his feet. Desires pain relief and checkup. Explains that both parents have heart disease, his father had cancer, and his mother has diabetes. Wife expresses worry that he may be developing heart problems "because he's so tired after work and he gets short of breath easily." Review the opening scenario of Nam Nguyen in the front of your textbook. Imagine you are the clinic nurse at the Family Medicine Center. Based on the information presented in the scenario, work through the following questions: A. Patient Situation • Why is Mr. Nguyen at the clinic?

Mr. Nguyen has reported to the clinic for a checkup and to have his bilateral knee pain evaluated.

How Do I Write Goals for Groups?

NOC outcomes can be used for both individuals and groups. Home and community health nurses are especially likely to write goals for aggregates (groups), such as families and communities. Community health goals (public health goals) tend to emphasize health promotion, health maintenance, and disease prevention outcomes. The Clinical Care Classification (CCC) System was developed by Virginia Saba for use in home health nursing. In the CCC, you form goals by adding modifiers to the nursing diagnoses. This system has four nursing diagnoses that are clearly for family units: family coping impairment, compromised family coping, disabled family coping, and family processes alteration. The Omaha System was developed specifically for community health nursing and each nursing diagnosis must be labeled as individual, family, or group. You can write aggregate outcomes by specifying a family or group diagnosis and then creating a goal from it, by using terms in a problem rating scale for outcomes.

• Open-ended questions are most essential for which type of interview: directive or nondirective?

Nondirective interview

Give an example of a closed question.

Numerous answers are possible. "Are you having pain?" "Where does it hurt?"

Gordons functional health problems

Nursing models used to organize data Gordon's Functional Health Patterns: Describes common patterns of behavior that can be functional or dysfunctional. Gordon intended the model for nursing assessment. The functional health patterns are major model concepts.

Special needs assessment

Nutritional Pain Cultural Spiritual health Psychosocial Wellness Family Community Functional ability

During Sami's appointment at the women's clinic, she informs the nurse that her menstrual flow is very heavy and that she experiences severe abdominal cramping during menstruation. Sami's breast exam is normal. When the nurse sees the lab results (i.e., Pap smear result is normal, but hemoglobin level is low), she suspects that the heavy flow may be causing Sami's anemia. According to clinic protocol, birth control pills are prescribed to control Sami's heavy, painful periods and to provide contraception. Ongoing assessment will include visits every 6 months to evaluate Sami's response to hormone therapy and to monitor the anemia. State whether the following data are primary or secondary, subjective or objective: • You see in Sami's health record that her breast exam was normal.

Objective data (Someone other than Sami made the observation; it was not from Sami's perspective.)

Objective data

Objective data: What professionals observe; also called overt data, or signs data. This data are gathered by physical assessment and from laboratory or diagnostic tests and can be measured or observed by the nurse or other healthcare providers. May be used to validate (check) subjective data or to verify subjective information that seems accurate.

Nursing assessment skills

Observation Physical assessment Interviewing

One-part statement nursing diagnosis

One-part statement: Certain kinds of diagnostic statements need no etiology: -Syndrome diagnosis: A label that represents a collection of several nursing diagnoses. -Wellness diagnosis: As a rule, this is a one-part statement beginning with the phrase Readiness for Enhanced. A wellness label does not describe a problem, so there is no etiology. -Very specific NANDA-I labels: Some labels are so specific that they imply the etiology, or the only possible etiology is a medical diagnosis.

Ongoing assessment

Ongoing assessment: You will use data from ongoing assessments to identify new problems or to follow up on previously identified problems. In comparison to the initial assessment, ongoing assessment reflects the dynamic state of the client. For example, vital signs may change rapidly and serve as important indicators of developing or resolving health problems. An ongoing focused assessment is also used to evaluate the status of existing problems and goals.

Types of Evaluation: Frequency and Time of Evaluation

Ongoing: You will perform ongoing evaluation while implementing, immediately after an intervention, and at each patient contact. Intermittent: Performed at specified times. Terminal: Describes the client's health status and progress toward goals at the time of discharge. Most institutions have special discharge forms for terminal evaluation that also include instructions about medications, treatments, and follow-up care.

How does the model work? Patient situation

Patient data: Physical, psychosocial, spiritual. Patient preferences/context: Context for care, environment, relationships, culture, resources, supports

Perioperative Nursing Data Set (PNDS):

Perioperative Nursing Data Set (PNDS): This system is designed for use only in perioperative nursing.

Percussion

Physical part of assessment Percussion: Striking a body surface with the tip of a finger, which produces different vibrations and sounds depending on what is under the area that is tapped (air, fluid, or solid).

Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying patient needs. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Planning Interventions Intervention planning must include current best practices. Evidence-based policy will validate that the client is receiving research-based interventions in his or her plan of care.

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center." Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Planning Outcomes This statement documented in the client's record is a long-term goal, a part of planning outcomes. Care plan goals are both short-term and long-term. A short-term goal would be "no falls will occur in the next 24 hours" or "client will ask for assistance each time she gets out of bed."

What is planning

Planning can be formal or informal "Formal planning is a conscious, deliberate activity involving decision making, critical thinking, and creativity" (Wilkinson, 2012) Informal planning: Occurs while performing other nursing process steps

Potential nursing diagnosis

Potential (risk): Describes a problem response that is likely to develop if the nurse and patient do not intervene to prevent it.

Practice knowledge

Practical knowledge: Knowing what to do and how to do it. Consists of processes (e.g., the decision process and the nursing process) and procedures (e.g., how to give an injection) and is an aspect of nursing expertise.

Safe, Effective Nursing Care and Nursing Orders: Thinking, Doing, Caring

Provide goal-directed, client-centered care. Establish mutual goals with client. Show respect for client values, religious beliefs, needs, and preferences. Implement interventions to promote client comfort. Validate evidence-based research to incorporate in practice. Incorporate evidence-based findings into client care . Provide safe, quality client care. Design a "Thinking, Caring, Doing" framework that incorporates a holistic approach to client care.

Evaluating and Quality Improvement in a Healthcare Setting

Quality improvement (QI) programs are specially designed programs to promote excellence in nursing. Variations of QI include quality assurance (QA), continuous quality improvement (CQI), total quality management (TQM), and persistent quality improvement (PQI). Whatever the approach, the goal is to evaluate and improve the care provided in an agency or for a group of patients. QI involves evaluation of structures, as well as outcomes and processes. All are important because structures and processes affect patient outcomes. Adequate structures (e.g., staffing, money) and processes (e.g., policies and procedures) do not guarantee desired patient outcomes; however, without them, it is very difficult to obtain good outcomes

Evaluating and Revising the Care Plan

Relate outcome to interventions. Draw conclusions about problem status. Revise the care plan. The following are variables that can affect the ability of an intervention to produce the desired outcome: -The client's ability and motivation to follow directions for treatment. -Availability and support from family and significant others. -Treatments and therapies performed by other healthcare team members. - Client failure to provide complete information during assessment. -Client's lack of experience, knowledge, or ability. -Staffing in the institution (ratio of licensed to unlicensed caregivers; number of patients for whom a nurse is responsible). -Nurse's physical and mental well-being. Draw conclusions about problem status: Goals met: If all goals for a nursing diagnosis have been met, you can discontinue the care plan for that diagnosis. Goals partially met: If some outcomes are met and others are not, you may revise the care plan for that problem, or you may continue with the same plan but allow more time for goal achievement. Goals not met: If goals are not met, you should examine the entire plan and review all steps of the nursing process to decide whether to revise the care plan. Revise the care plan: You must review each step of the nursing process to decide how to revise the plan. This includes the assessment, diagnosis, outcomes, interventions, and implementation.

NANDA-I Nursing Diagnosis: Components: related factors

Related factors: The cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem (label) are called related factors. They can be pathophysiological, psychological, social, treatment-related, situational, maturational, and so on.

The nurse is performing an assessment on a client. What should be included in this process? Ability to pay for hospital stay Who brought patient to the hospital Level of education Religious and spiritual needs

Religious and spiritual needs

Checklist for Evaluating the Care Plan

Review assessment: The data may have changed since the care plan was written, the client's condition may have changed, or new data may have been identified. Review diagnosis: You may need to revise or add new nursing diagnoses. Perhaps the nurse who wrote the diagnostic statement did not communicate the patient's condition clearly, or perhaps it was not validated with the patient. Review planning outcomes: You will probably need to revise the outcomes if you have added data or revised the nursing diagnosis. If assessment and diagnosis are satisfactory, perhaps the outcomes were unrealistic, written too broadly, or had unrealistic target times. Or perhaps the client's priorities have changed, or the outcomes did not address all aspects of the patient's problem. Review planning interventions: You will probably need to modify nursing orders 1) if you determine that interventions were not effective or 2) if you have revised nursing diagnoses or outcomes. Review implementation: It could be that goals were not met because of a failure to implement the nursing orders or because of the manner in which they were implemented. Get input from the client, significant others, other caregivers, and the client records to find out what went wrong

How Do I Evaluate Client Progress?

Review outcomes: Review the goals/outcomes on the patient's care plan. The goals and indicators you identified in the planning outcomes phase suggest the kind of assessments you need to make and provide criteria by which to judge the data. Collect reassessment data: Reassessments are always focused assessments and the care plan goals determine their focus. Judge goal achievement: Compare the reassessment data with the patient's goals and ask if the responses (actual outcomes) are the same as the expected or desired outcomes. If yes, the goal has been met. When some but not all of the desired behaviors are observed, or the desired response occurs only some of the time, it is considered partial achievement. When the desired response did not occur, the goal is labeled not achieved. Record the evaluative statement: It should include the conclusion about whether the goal was achieved and the reassessment data to support the judgment. Evaluate collaborative problems: Compare the reassessment data to established norms and determine whether data are within an acceptable range

Determine the type of nursing diagnosis for each of the following: d. Charles Oberfeldt has no symptoms of constipation. However, he reports that he does not include many fiber-rich foods in his diet and drinks few liquids. In addition, he is now fairly inactive because of a back injury. These are all risk factors for a diagnosis of Constipation.

Risk diagnosis

Suppose that on Todd's transfer from the ED (Meet Your Patient in your textbook), you made the following nursing diagnoses for him. Using prob- lem urgency as your criterion, assign each of these diagnoses a low, medium, or high priority. • Risk for Imbalanced Fluid Volume secondary to renal failure • Risk for Falls related to (r/t) decreased sensation and mobility in legs • Deficient Knowledge (renal disease process) r/t new diagnosis of renal involvement secondary to type 2 DM

Risk for Imbalanced Fluid Volume secondary to renal failure Suggested response: This is probably a high (or perhaps medium) priority; it's not an immediate threat to life because it is not an actual problem but rather a potential problem. • Risk for Falls related to (r/t) decreased sensation and mobility in legs Suggested response: Because Todd is in the hospital rather than at home, this could be assigned as a medium priority instead of high priority, because his activity will be limited while he is supervised when ambulating. If he were ambulating without supervision, it would be a high priority. • Deficient Knowledge (renal disease process) r/t new diagnosis of renal involvement secondary to type 2 DM Suggested response: This is a low priority for now. Todd may be too ill and anxious to learn at this time. At this point, an ongoing treatment regimen for the renal failure would not yet have been established. As he recovers, this will become a high priority problem because he will be transitioning to self-care

Secondary data

Secondary data: Data obtained secondhand; for example, from the medical record or from another caregiver

Secondary to nursing diagnosis format

Secondary to: When the defining characteristics are vague you may need to add a second part to the etiology, usually a disease or pathophysiology.

• What is a cue?

Significant data (also called cues) are data that influence your conclusions about the client's health status (or that influence your choice of nursing diagnoses). A cue should alert you to look for other cues that might form a cluster (pattern) representing a nursing diagnosis.

Significant data

Significant data (also called cues) are data that influence your conclusions about the client's health status. A cue should alert you to look for other cues that might be related to it (form a pattern).

Preprinted, Standardized Plans: standardized nursing care plans

Standardized nursing care plans Detailed nursing care for a particular nursing diagnosis; for all nursing diagnoses that commonly occur with a certain medical condition Standardized nursing care plans differ from unit standards of care in the following ways: -Provide more detailed interventions. -Are organized by nursing diagnosis and include specific patient goals and nursing orders. -Are a part of the patient's comprehensive care plan and become a part of the permanent record. -Describe ideal rather than minimum nursing care plans. -Allow you to incorporate addendum care plans. -Include checklists, blank lines, or empty spaces so that you can individualize goals and interventions.

Imagine you are the clinic nurse at the Family Medicine Center. Using the data presented in the opening scenario of Nam Nguyen in the front of the book, work through the following questions: A. What type of assessment, comprehensive or focused, is being performed at this clinic visit? Explain your thinking.

Suggested response: A comprehensive assessment is being performed because the nurse is not gathering data about a single problem but is gathering information about all aspects of Mr. Nguyen's situation.

E. The nurse has identified Acute Pain (knees) for Mr. Nguyen. If the pain were caused by a medical condition, osteoarthritis, how would you write a two-part diagnostic statement to describe this health status?

Suggested response: Acute Pain (knees) secondary to osteoarthritis If you write, "Acute pain [knees] related to osteoarthritis," remember that the etiology should suggest nursing interventions, and there is nothing the nurse can do to treat osteoarthritis. Therefore, using "secondary to" is preferred.

It's a pleasant Saturday afternoon, and you're meet- ing with an old friend whom you haven't seen in 2 years. She says, "I hear you've decided to become a nurse. What made you choose that? I don't think I could be around people who are sick and in pain. Hospitals are such sad places." To respond to her, you will need to consider your motivation for becoming a nurse and your beliefs about the profession. • How would you reply to her question?

Suggested response: Answers will vary. All answers are correct. You may respond, "I like working with people," or "I have always been interested in how the human body works," or even "I thought it would be a good way to have job security."

• Why would you not, at this point, be using the evaluation phase?

Suggested response: In the evaluation phase, nurses determine whether they have met the goals they developed with the patient. At this point, nurses are still gathering data and have not formulated goals.

4. Nursing Process: What kind of assessment will you, as the nurse, perform for Sami (e.g., comprehensive, focused, special needs, discharge)?

Suggested response: It will be an initial, comprehensive assessment. Some students might choose to conduct a special needs wellness assessment.

Are they similar to or different from his?

Suggested response: Mr. and Mrs. Nguyen have different expectations of the visit.

Give examples of each type of assessment (initial, ongoing, comprehensive, focused) using patients you have observed or cared for or your own personal experiences as a patient.

Suggested response: This answer should be similar to those provided in the discussion of initial, ongoing, comprehensive, and focused assessments in your textbook—with variations related to different clients and situations.

2. Critical Thinking (Inquiry Based on Credible Sources): a. What resources would you use to find out more about the pathophysiology of renal failure? How do you know the source is credible?

Suggested response: You may suggest pathophysiology and medical- surgical textbooks. If you mention Web sites, consider what type you would use and what you would need to know about the site in order to be comfortable with the information you find on it.

Suppose you are the triage nurse at the community clinic in the Meet Your Patient scenario [in your text- book]. What kind of assessment do you perform at Sami's first visit (initial, ongoing, comprehensive, focused)? What type will the care provider perform at the women's clinic?

Suggested response: • First visit: initial, comprehensive • Women's clinic: initial, focused (possibly comprehen- sive, if they do not have the data from the first visit)

Doing 3. Nursing Process (Diagnosis): a. Write one collaborative problem for Todd. If you do not know the potential complications of chronic renal failure, look them up in a medical- surgical or pathophysiology textbook. Explain why you would not use a nursing diagnosis to describe the problem

Suggested responses: Answers should include some of the following; you may think of others, as well: Anemia Cardiac tamponade Congestive heart failure Electrolyte imbalance Fluid overload GI bleeding Hyperparathyroidism Infections Medication toxicity Metabolic acidosis Pericarditis Pleural effusion Pulmonary edema Uremia

Critical Thinking: The nurse asks Sami, "If you can't afford healthcare, couldn't you get a roommate to save some money on rent?" What are some critical-thinking questions you should ask yourself when reflecting on this question later?

Suggested responses: • Why did I ask that question? What did I intend to do with the information that I got from it? • How did Sami respond to the question? • If she did not show her feelings, how did the question probably make her feel? • Should I have asked the question? • If I wanted to help Sami by making a suggestion, how might I have rephrased the question to make it more of a suggestion? • Was this a caring question? Did it respect Sami's dignity?

List at least three things you should do when pro- viding supervision to an unlicensed caregiver.

Supervisory activities should include the following: • Monitor the person's work to be sure it complies with agency policies and procedures and standards of practice. • Intervene, if necessary. Perhaps demonstrate care- giving activities. • Obtain feedback from and provide feedback to the worker. • Give positive, as well as negative, feedback often. • If the NAP's performance was not acceptable, communicate that privately with the NAP. • Evaluate client outcomes. • Ask the client for input after the care is given. • Ensure proper documentation.

Classification system used in nursing

Systems used in nursing The NANDA International (NANDA-I) The Clinical Care Classification (CCC) The Omaha System Perioperative Nursing Data Set (PNDS) International Classification for Nursing Practice (ICNP)

ANA on delegating assessment

The American Nurses Association (ANA) definitions of nursing and Scope and Standards of Practice (2015) guide decisions on who is ultimately responsible and qualified to collect assessment data.

The NANDA International (NANDA-I)

The NANDA International (NANDA-I) classification is based on identification of client problems and strengths obtained during assessment.

The Omaha System

The Omaha System consists of three interrelated components: the problem classification scheme, the intervention scheme, and the problem rating scale for outcomes.

Identify the long-term goal. Client's pulse oxygenation level will be greater than 92% on room air by tomorrow. Client will administer his own insulin using correct technique by discharge. Client's pressure ulcer will show presence of granulation tissue in 30 days. Client's urine output will be 400 mL per 8-hr shift within 72 hr.

The correct option is 3. Client's pressure ulcer will show presence of granulation tissue in 30 days. Rationale: A long-term goal indicates that the resolution to a problem is expected to occur over weeks to months or more.

Documentation

The final step of implementation Records the nursing activities and the client's response After giving care, you will record the nursing activities and the patient's responses. Documentation is a mode of communication among the members of the health team, and it provides the information you need to evaluate the patient's health status and the nursing care plan

List at least four things you could do to promote client participation in care or adherence to recommendations for treatment.

The following actions promote client participation: ● Assess the client's knowledge about her illness and the treatments, and provide the necessary information ● Assess the client's supports and resources ● Be sensitive to the client's cultural, spiritual, and other needs and viewpoints. ● Realize and accept that some attitudes cannot be changed. ● Determine the client's main concerns. ● Determine the client's priorities. ● Help the client to set realistic goals.

Which statement is correct about critical thinking and the nursing process? The nursing process is a critical-thinking, problem-solving model. When using the nursing process, critical thinking is not needed. Everything a nurse does requires critical thinking. Nursing process is the only form of critical thinking used in nursing.

The nursing process is a critical-thinking, problem-solving model.

How Nursing Diagnosis Relates to Outcomes and Interventions

The problem suggests the goal: The problem describes a health status that needs to be changed, and suggests the desired outcome (goal). From the problem, you can determine the patient outcomes for measuring this change. The etiology suggests interventions: The aim of the nursing interventions is to remove or alter the factors contributing to the problem

Explain how theory influences your choice of nursing interventions.

Theories influence your perspective: what you notice, what you consider to be a problem, how you define a problem, and what you choose to do about it.

List at least three ways to help ensure that the NAP will understand clearly what she needs to do when you delegate a task.

These actions help ensure that the NAP will understand a task: • Explain exactly what the task is, including what to do and what not to do. • Include specific times and methods for reporting. • Explain the purpose or objective of the task. • Describe the expected results or potential compli- cations to expect. • Be specific in your instructions.

b. Pain and limited range of motion in knees, uses walker, medical diagnosis of osteoarthritis

These are all symptoms of osteoarthritis. They probably best suggest a diagnosis of Impaired Walking. The cluster would probably need another cue or two to suggest Risk for Falls

How does the full spectrum nursing model work? Thinking

Thinking -Critical thinking -Theoretical knowledge Critical thinking: Enables you to fully use your knowledge and skills. Theoretical knowledge: Principles, facts, theories, what you have to think with

Review the opening scenario of Nam Nguyen in the front of the textbook. After the nurse practitioner completed the interview and physical examination of Mr. Nguyen, he listed the following diagnoses on the problem list: Hypertension Obesity Musculoskeletal pain Tobacco abuse Family history of prostate cancer Family history of cardiovascular disease Family history of diabetes mellitus (DM) A. What type of problem list does this one represent? How is it similar to or different from a problem list that you might generate?

This is a list of medical diagnoses. It is a list of pathophysiological conditions or diseases that Mr. Nguyen has or is at risk for. This is different from a problem list that a nurse would generate. A nursing problem list would focus on the patient's responses to these pathophysiological conditions.

The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. Which type of assessment is the nurse completing? Focused Initial Ongoing Special needs

This type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift. The correct answer is C. It is not a focused assessment because it is not a follow-up on an already identified client response or problem. It is not an initial assessment because the patient is already admitted and in the hospital. It is not a special needs assessment because it is head-to-toe rather than an in-depth assessment of one topic (e.g.pain)

C. How might you verify data that Mr. Nguyen provided on the intake sheet?

Through the interview and physical examination

To help you fix them in your mind, list at least 10 questions to ask yourself when evaluating your diagnostic reasoning.

To help you fix them in your mind, list at least 10 questions to ask yourself when evaluating your diagnostic reasoning. • Refer to Box 4-3 [in Chapter 4 of your book] if you need help preparing this list. Answer: Data Analysis • Did I identify all the significant data (cues)? • Did I omit any important cues from the cluster? • Did I include unnecessary cues that may have confused my interpretation? • Did I try more than one way of grouping the cues? • Did I consider the patient's social, cultural and spiritual beliefs and needs? • Did I identify all the data gaps and inconsistencies? Drawing Inferences and Interpretations of the Data • Did I consider all the possible explanations for the cue cluster? • Is this the best explanation for the cue cluster? • Did I have enough data to make that inference? When there are insufficient data, you should sus- pend judgment until you gather more data. • Did I look at patterns, not single cues? • Did I consider behavior over time, not just isolated incidents? • Did I jump to conclusions? Always take the time to carefully analyze and synthesize the data. Critiquing the Diagnostic Statement (Problem + Etiology) • Is the diagnosis relevant and does it reflect the data? • Does the diagnostic statement give a clear and ac- curate picture of the patient's problem or strength? • When identifying the problem and etiology, did I look beyond medical diagnoses and consider human responses? • Did I consider strengths and wellness diagnoses, as well as problems? • Can I explain how the etiology relates to the problem—that is, how it would produce the problem response? • Does the complete list of problems fully describe the patient's overall health status? Verifying the Diagnosis • Did the patient verify this diagnosis? • When I verified the diagnosis, did I explain clearly? Am I certain that the patient understood my description of his health status? • Did I obtain feedback from the patient, or did I just assume that he agreed? • Did I keep an open mind, realizing that all diag- noses are tentative and subject to change as I acquire more data? Prioritizing • Considering the whole situation, what are the most important problems? • What aspects of the situation require the most immediate attention? • Did I consider patient preferences when setting priorities? If not, was there a good reason?

Give at least two more examples of data you might obtain with each of your following senses. One example is provided for each

Touch (e.g., bladder distention) Answer: Numerous answers are possible, including the following: firmness or mobility of lesions 14, firmness of uterine fundus after childbirth, edema, skin temperature, pulse rate and rhythm, crepitus in joints, liver enlargement. • Vision (e.g., facial expression of pain) Answer: Numerous answers are possible, including the following: general appearance (e.g., height, weight, posture, grooming), skin color, condition of equip- ment, readings from monitors and pumps, gait. • Smell (e.g., fecal odor) Answer: Numerous answers are possible, including the follow- ing: body odor, smell of breath, and odor from wound secretions, drains, urine, or vaginal secretions. • Hearing (e.g., bowel sounds) Answer: Numerous answers are possible, including the fol- lowing: breath sounds, coughing, heart sounds, blood pressure, spoken words.

An example of an NIC intervention category for the nursing diagnosis of Anticipatory Grieving would be Coping Enhancement. True False

True Interventions in this category are designed to assist the patient to adapt to perceived stressors or threats.

College courses, such as microbiology and human growth and development, present content that is considered part of theoretical nursing knowledge. True False

True Knowledge gained in these courses helps the nurse develop a more holistic and complete plan of patient care.

Nutritional assessment

Type of special needs assessment Nutritional: The Joint Commission (2015) requires nutrition assessment for all patients. In addition to information about food intake, it includes information related to personal, psychosocial, and economic problems that may affect nutrition.

Wellness assessment

Type of special needs assessment Wellness: A wellness assessment includes data about spiritual health, social support, nutrition, physical fitness, health beliefs, and lifestyle, as well as a life-stress review.

Community assessment

Type of special needs assessment Community: A community assessment provides information about community demographics; health concerns; environmental risks; and community resources, norms and values, and points of referral.

Functional ability assessment

Type of special needs assessment Functional ability: Functional ability is especially important in discharge planning and home care. Future rehabilitation needs are derived from initial and ongoing functional ability assessments. The Joint Commission requires a functional ability assessment "based on the patient's condition."

Preprinted, Standardized Plans: unit standards of care

Unit standards of care General guides Describe the care that nurses are expected to provide for all clients in defined situations. Unit standards of care: Describe the minimum level of care the nurses are expected to achieve given the institution's goals and resources and the client population. Unit standards of care usually are not organized according to nursing diagnoses, and they usually resemble a list of "things to do."

Unknown etiology

Unknown etiology: The reason for the health problem is unknown.

What Are Complex Thinking Processes?

Use a combination of critical-thinking skills and attitudes -Problem-solving -Decision making -Clinical reasoning Complex thinking (reasoning) processes use a combination of critical-thinking skills and attitudes. This is a list of the processes most commonly used in nursing

Verify problems with the patient

Verify problems with the patient: After identifying problems and etiologies, verify them with the patient. A diagnostic statement is an interpretation of the data, and the patient's interpretations may differ from yours.

Wellness diagnosis

Wellness: Used when an individual, group, or community is in transition from one level of wellness to a higher level of wellness. Two conditions must be present to make a wellness diagnosis: 1) the client's present level of wellness is effective and 2) the client wants to move to a higher level of wellness.

Which of the following about the nursing process is correct? Works alongside an individualized plan of care Results in outcomes designed by the client Composed of a linear process with unique, distinct steps Includes only the care that the nurse will deliver

Works alongside an individualized plan of care

Delegation

You cannot delegate any intervention that requires independent, specialized, nursing knowledge, skill, or judgment.

What are the possible conclusions you can draw about a client's health status (e.g., that no problem exists)?

You might conclude that there is a patient strength, no problem, a wellness diagnosis, a possible problem, an actual nursing diagnosis, a risk (potential) nursing diagnosis, a collaborative problem, or a medical diagnosis.

Planning interventions

choose interventions to help client achieve stated goals Developing a list of possible interventions based on your nursing knowledge and then choosing those most likely to help the client achieve the stated goals. The best interventions are evidence based; that is, they are supported by sound research 4th phase of nursing interventions

Planning outcomes

decide goals you want to achieve with your nursing activities : Making decisions about goals for your care; that is, the client outcomes you want to achieve through your nursing activities. These outcomes will drive your choice of interventions 3rd phase of nursing process

• Which stage involves problem identification?

diagnosis

How Does Problem Status Influence Nursing Interventions? (cont'd): treatment interventions are used in

differences between the treatment interventions for the different types of nursing diagnoses. Suggested responses: Treatment interventions are used in: Actual nursing diagnoses: To relieve symptoms and resolve etiologies (contributing factors). Collaborative problems: To implement nursing and medical orders for relieving or eliminating the underlying condition for which complications may develop.

Preprinted, Standardized Plans

here are a variety of types of standardized, preprinted instructions for care. Types most commonly referred to include policies and procedures and protocols which cover specific actions usually required for a clinical problem unique to a subgroup of patients. Types Policies and procedures Protocols

How Does Problem Status Influence Nursing Interventions? (cont'd) 1. Observation/assessment interventions are used in

review Chapter 4. Observation/assessment interventions are used in: Actual nursing diagnoses: To detect change in status (improvement, exacerbation of problem). Potential nursing diagnoses: To detect 1) progression to an actual problem or 2) an increase or decrease in risk factors. Possible nursing diagnoses: To obtain more data to confirm or rule out a suspected nursing diagnosis. Collaborative problems: To detect onset of a complication for early physician notification. Wellness diagnosis: To assess and possibly potentiate a client's wellness practices

Types of Evaluation: What Is Being Evaluated?

structure, process, outcomes Structure focuses on the setting in which care is provided. It explores the effect of organizational characteristics on the quality of care. It requires standards and data about policies, procedures, fiscal resources, physical facilities and equipment, and number and qualifications of personnel. Process focuses on the manner in which care is given; the activities performed by nurses (and other personnel). It explores whether the care was relevant to patient needs, appropriate, complete, and timely. Outcomes focuses on observable or measurable changes in the patient's health status that result from the care given. Although structure and process are important to quality, the most important aspect is improvement in patient health status. The evaluation step of the nursing process uses outcomes evaluation

Nursing interventions

the differences between independent, dependent, and interdependent interventions. Independent intervention: One that registered nurses are licensed to prescribe, perform, or delegate based on their knowledge and skills. It does not require a provider's order. Knowing how, when, and why to perform an activity makes the action autonomous (independent). As a rule, nurses prescribe and perform independent interventions in response to a nursing diagnosis. Dependent intervention: One that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse. Dependent interventions are usually orders for diagnostic tests, medications, treatments, IV therapy, diet, and activity. In addition to carrying out medical prescriptions, you will be responsible for assessing the need for the prescription, explaining the activities to the patient, and evaluating the effectiveness of the order. Interdependent intervention: One that is carried out in collaboration with other health team members (e.g., physical therapists, dieticians, and physicians).

Individualized nursing care plan

used to address nursing diagnoses unique to a particular client

• What are some other examples of independent interventions?

xamples might include holding a client's hand during a procedure to relieve anxiety, helping a client to ambulate, giving a back rub, bathing a patient, or teaching a client about his healthcare problems and medicines.

Sami tells the nurse that she experiences cramping with her menstrual cycle.

• Primary data (The nurse obtained the information from Sami.) • Subjective data (This is Sami's perspective, told directly to the nurse practitioner by Sami.)

Name and describe three standardized intervention vocabularies recognized by the ANA.

● NIC. Consists of 542 interventions with associated activities. Can be used in all specialties. Does not include nursing diagnoses and patient outcomes. ● Clinical Care Classification (CCC). Designed for home healthcare. Has 198 interventions; also includes diagnoses and outcomes. ● Omaha System. Designed for community health. Includes diagnoses and outcomes. Has 63 "targets" for intervention that you combine with four "categories" to make the intervention statement.

Explain what is evaluated in each of the following types of evaluation (i.e., the focus of each type of evaluation): structure, process, and outcomes.

● Structure evaluation focuses on the setting in which care is provided. It explores the effect of organizational characteristics on the quality of care. It requires standards and data about policies, procedures, fiscal resources, physical facilities and equipment, and the number and qualification of personnel. ● Process evaluation focuses on the manner in which care is given—the activities performed by nurses (and other personnel). It explores whether the care was relevant to patient needs, appropriate, complete, and timely. ● Outcomes evaluation focuses on demonstrable ("measurable") changes in the patient's health status that result from the care given.

What Some Patients Have Said

-If caregivers listen to them, involve them in their own care, and allow them to make decisions about that care, they feel safe. -If their room is clean, their perception is that the whole organization is clean and they won't get an infection, so they feel safe.

Standardized nursing language

-Terms are carefully defined and mean the same thing to all who use them. -Clarify communication about nursing knowledge, thinking, and practice. Standardized nursing language is a comparatively recent attempt to bring such clarity to communication about nursing knowledge, thinking, and practice. A standardized nursing language: -Supports electronic health records. -Defines, communicates, and expands nursing knowledge. -Increases visibility and awareness of nursing interventions. -Facilitates research to demonstrate the contribution of nurses to healthcare and influence health policy decisions -Improves patient care by providing better communication between nurses and other healthcare providers and facilitating the testing of nursing interventions

Standardized Terminology for Outcomes

American Nurses Association (ANA) has approved several standardized vocabularies for describing client outcomes. The standardized vocabulary for describing client outcomes used in this textbook is the Nursing Outcomes Classification (NOC). In the NOC vocabulary, an outcome is "an individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing interventions" (Moorhead, Johnson, Maas et al., 2013).

Assessment

Assessment is the systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community Assessment: Although various definitions exist, all definitions of assessment include collecting data, categorizing data, recording data, and using a systematic and ongoing process Assessment includes Collecting data Using a systematic and ongoing process Categorizing data Recording data

Why does a clinical practice guideline provide better support for an intervention than does an agency's critical pathway?

Critical pathways may not always be evidence based, but clinical practice guidelines are always evidence based. Critical pathways are developed by the agency's practitioners, who may be reluctant to change some of the traditional practices that they believe to be effective. Some institutions may omit interventions they do not consider to be cost effective.

Implementation phase

Doing Delegating Documenting

Initial assessment

Initial assessment: You will first obtain data related to the person's reason for seeking nursing or medical assistance. Data gathered from the initial assessment provide guidance for care and determine the need for further assessment. Data are used to follow up on client-reported symptoms or unusual findings during the first exam (e.g., on admission to the hospital).

The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. What is most important for the nurse to do? Report this finding to the provider. Note this finding in the client's record. Revise the plan of care. Remove the nursing diagnosis from the plan.

Revise the plan of care It will be most important for the nurse to review all of the other steps of the nursing process to determine if errors were made that prevented the goal from being achieved.

NANDA-I Nursing Diagnosis: Components: risk factors

Risk factors: Events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem are called risk factors. They can be environmental, physiological, psychological, genetic, or chemical

Types of data

Subjective What the patient says Objective What can be observed or measured Primary Obtained directly from the client Secondary Obtained secondhand through the medical record or another person

The nurse teaches the client how to change his ostomy appliance. Of which type of intervention is this an example? Indirect care Independent Dependent Collaborative

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

The NANDA-International Nursing Diagnosis Taxonomy II:

The NANDA-International Nursing Diagnosis Taxonomy II: Consists of functional patterns and is a modified version of the Gordon model. Intended as a model for categorizing nursing diagnoses, not as a fully developed theory of nursing. Nursing models used to organize data

Identify the client outcome/goal that is written correctly. The client's urine output will be adequate by the end of the shift. The client's pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow. The client will drink more fluids than he did yesterday by 7:00 p.m. today.

The correct option is 3. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow. Rationale: This statement meets all of the criteria for a correctly written client outcome. "Adequate" is not measurable; clear breath sounds only would not be evidence of the resolution of pneumonia, and this is the medical diagnosis; "more fluids than yesterday" is vague and unclear.

As an RN, how could you establish that a NAP is competent to perform a task?

These actions would establish whether a NAP is competent to perform a task: ● Check facility records for documented proof that the person has demonstrated competence. ● Find out how often the NAP has performed the task. ● Find out whether the NAP has worked with patients with similar diagnoses. ● Observe and evaluate the NAP's performance.

Diagnosis

You will identify the client's health needs (usually stated in the form of a problem) based on careful review of your assessment data. You need to analyze all your data, synthesize and cluster information, and hypothesize about your client's health status Second phase of nursing process

Can I Delegate Assessments?

-A professional nurse must perform the assessment portion of the nursing process. -Nurse aides or other nursing assistive personnel (NAP) and licensed practical nurses (LPNs) collect information such as vital signs, pain reports, and fingerstick blood glucose levels. However, it is the responsibility of the professional nurse to assign those tasks, validate the data collected, conduct the interview, and complete the physical assessment.

Nursing diagnosis

-A statement of client health status that nurses can identify, prevent, or treat independently. -Stated in terms of human responses (reactions) to disease, injury, or other stressors. -A human response that can be biological, emotional, interpersonal, social, or spiritual, and can be either a problem or a strength. -In 1990, NANDA officially defined nursing diagnosis as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes." Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. The definition was approved at the 9th conference, and amended in 2013. This definition emphasizes the clinical judgment aspect of diagnosing

Reflecting on the Assessment

-Are my data complete, accurate, validated? -Did I record data, not conclusions? -Did I follow up with special needs assessment if indicated? -Think about the client interview -Review the physical assessment, observation, and examination

How is data collected from assessment used

-By other disciplines (collaboration) Collaboration is a process that allows a nurse to make referrals to other professionals with expertise in a particular area of healthcare. This helps ensure that clients receive the proper care by qualified individuals at the time it is needed -To plan for nursing care -To ensure clients receive The proper care By qualified individuals At the time it is needed

What is caring

-Caring is always specific and relational for each nurse-person encounter. -Caring is not an abstraction. -Caring involves thinking and acting in ways that preserve human dignity and humanity. Caring involves personal concern for people, events, projects, and things. It allows you to connect with others and to give help as well as receive it. One aspect of self-knowledge is to be aware of what and whom you care about. Knowing what the patient cares about reveals what is stressful for the patient, because only things that matter can create stress. Caring also enables the nurse to notice which interventions are effective

What are health problems?

-Conditions that require intervention to treat disease or illness -Treatment Independently Collaboratively A health problem is any condition that requires intervention to prevent or treat disease or illness. After you identify a health problem, you must decide how to treat it: independently or in collaboration with other health professionals. The answer determines whether it is a nursing diagnosis, a medical diagnosis, or a collaborative problem.

How Is the Nursing Process Related to Critical Thinking?

-Critical thinking and nursing process are interrelated but not identical. -Nursing decisions that require critical thinking may not be related to the nursing process. -Some nursing activities do not require reflective critical thinking, although they must be done skillfully. -Nursing process is a problem-solving process.

Student care plans

-Designed for learning -Contain detailed nursing orders -May include rationales and references -May be mind mapping Student care plans are designed to help you learn and apply concepts from the nursing process, physiology, and psychopathology. For this reason, they may contain more detailed nursing orders as well as other information the instructor may require. Some instructors may ask you to write rationales and cite references to support them. Rationales state the scientific principles or research that supports nursing interventions. Writing rationales helps ensure that you understand the reasons for your interventions. Mind mapping is a technique for showing relationships between ideas and concepts in a graphical, or pictorial, way. A mind-mapped care plan uses shapes and pictures to represent the steps of the nursing process, as well as the patient's pathophysiology and other pertinent information

Collaborative problems

-Physiological complications of diseases, medical treatments, or diagnostic studies -Clients with certain diseases or treatments are at risk for developing the same complications. -Always a potential problem If you can prevent the complication with independent nursing interventions alone, it is not a collaborative problem. Collaborative problems require both medical and independent nursing interventions to prevent them or minimize the complications

Computerized Care Plan

-Enter diagnosis or desired outcome. -The computer generates a list of suggested interventions. -Choose appropriate interventions. -Individualize by typing in own interventions as needed. It is important that when using computerized care plans that nurses resist the temptation to accept a "one size fits all" solution and look for creative approaches that might be more effective for a particular individual.

How Do Goals Relate to Nursing Diagnosis?

-Expected outcomes derive directly from the nursing diagnosis. -Problem statement describes the response/health status to be changed. -Desired outcome states the opposite of the problem response.

Analyzing data

-Identify significant data. -Cluster cues. -Identify data gaps and inconsistencies. -Draw conclusions about health status. -Make inferences. -Identify problem etiologies. -Verify problems with the patient.

How to choose NANDA-I label

-Identify the broad topic (or domain) that seems to fit the cue cluster. -Narrow your search (to the class or most likely labels). -Use a nursing diagnosis handbook; compare definitions and defining characteristics of the diagnostic labels with your cue cluster.

What Are Critical-Thinking Attitudes?

-Independent thinking -Intellectual curiosity -Intellectual humility -Intellectual empathy -Intellectual courage -Intellectual perseverance -Fair-mindedness Attitudes are not the same as intellectual skills. They are more like feelings and states of mind. Your attitudes and character determine whether you will use your thinking skills fairly and with an open mind. Without a critical attitude, people tend to use thinking skills to justify narrow-mindedness and prejudice and to benefit themselves rather than others

Preparing for interview

-Know the purpose of the interview and how the data will be used -Read the client's chart -Form some goals and opening questions -Schedule uninterrupted time -Have your forms and equipment ready -Compose yourself before entering the room

Prioritizing problems

-Places problems in order of importance -Does not mean that you must resolve one problem before attending to another -Determined by the theoretical framework you use -Maslow's hierarchy of needs often used to prioritize nursing problems Problem priority is largely determined by the theoretical framework you use; for example, whether your criteria are human needs, problem urgency, future consequences, or patient preference.

Discharge planning

-Planning for self-care and continuity of care after client leaves healthcare setting -Begins with initial assessment -Needed by all clients -Requires collaboration -Addresses the special needs of an older client Collaboration is ideally done with patient involvement to ensure achievement of desired outcomes. Older adults tend to have complex needs when discharged. Functional abilities, cognition, vision, hearing, social support, and psychological well-being must be a part of the initial assessment so that you can identify needed services at discharge

Safe, Effective Nursing Care: And What You Can Do as a Nurse...

-Provide patient-centered and best-practice care. -Employ best practices for fairness and inclusion. -Strive to enhance patient satisfaction ratings. -Ensure compliance with legal and accrediting agency requirements. Adapted from Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care. DOI: http://dx.doi.org/10.1093/intqhc/mzg081, and Vanderbilt University Medical Center. (2010). Nursing quality and performance improvement plan. Accessed August 2017 via the Web at http://www.mc.vanderbilt.edu/documents/Magnet%20Website/files/Nursing%20Quality%20Plan.pdf

Process for Writing Individualized Nursing Care Plans

-Make a working problem list: This will be a prioritized list of the patient's nursing diagnoses, collaborative problems, and strengths. Decide which problems can be managed with standardized care plans or critical pathways -Individualize the standardized plan as needed: You will cross out any instructions that do not apply to your patient and add or adapt nursing orders as appropriate. Transcribe medical orders to appropriate documents -Write ADLs and basic care needs in the patient care summary: This may be written on the Kardex. -Develop individualized care plans for problems not addressed by standardized documents

Why Is Critical Thinking Important for Nurses?

-Nurses are faced with complex situations. -Each client is unique. -Nurses apply knowledge to provide holistic care. -Nursing is an applied discipline. -Nursing uses knowledge from other fields. -Nursing is fast paced. -The scientific basis for patient care changes constantly. -Critical thinking is linked to evidence-based practice. Holistic care recognizes that each client is unique in terms of type of illness, culture, and age. Critical thinking enables the nurse to assess the client's and family's cultural beliefs and adapt care so that it is culturally sensitive and responsive to their needs. Nursing is an applied discipline. Nurses must apply their knowledge, not just memorize and regurgitate facts. Nursing uses knowledge from other fields. Nurses use information from chemistry, physiology, psychology, social sciences, and other disciplines to identify and plan interventions for patient problems. Nursing is fast paced. A patient's condition may change hour to hour or even minute to minute; thus, nurses need critical thinking in order to respond appropriately under stress.

What are critical thinking skills?

-Objectively gathering information on a problem or issue -Recognizing the need for more information -Evaluating the credibility and usefulness of sources of information -Recognizing gaps in one's own knowledge -Listening carefully; reading thoughtfully -Separating relevant from irrelevant data and important from unimportant data -Organizing or grouping information in meaningful ways -Making inferences (tentative conclusions) about the meaning of the information -Visualizing potential solutions to a problem -Exploring the advantages, disadvantages, and consequences of each potential action -Evaluating the credibility and usefulness of sources of information -Recognizing differences and similarities among things or situations -Prioritizing or ranking data as needed Skills in critical thinking refer to the cognitive (intellectual) processes used in complex thinking operations such as problem-solving and decision making. When planning nursing care, nurses gather information about the client and then draw tentative conclusions about the meaning of the information to identify the client's problems. Then they think of several different actions they might take to help solve or relieve the problem.

And What Other Patients Have Said

-Patients reported problems with lack of respect for patients' preferences and involvement of family and friends. -Patients asserted that risks of treatments or procedures were not explained or were only partly explained.

What Are Nursing Interventions?

-Purpose: To achieve client outcomes -Also called nursing actions, measures, strategies, activities -Based on clinical judgment and nursing knowledge -Reflect direct and indirect care example of both direct and indirect care: Suggested responses: Direct care interventions are performed through interaction with the client(s), such as physical care, emotional support, and patient teaching. Indirect care interventions are performed away from the client (but on behalf of a client or group of clients) and may include advocacy, managing the environment, consulting with other members of the healthcare team, and making referrals

Classification system

-Taxonomy: Classifies ideas or objects based on common characteristics -Systems used in healthcare: The American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) The International Statistical Classification of Diseases and Related Health Problems (ICD-10) (names and classifies medical conditions.) The Current Procedural Terminology (CPT) codes (used for reimbursement, name and define medical services and procedures,updated continuously)

Characteristics of the Nursing Process

-Useful in many settings -Goal directed and client centered -Involves both thinking and doing -Not linear but rather a cyclical process -Steps may be concurrent

"Does the client, family, or community value the outcome?" What does this question mean to you?

1 If the person or groups are personally invested in the goal, they are demonstrating that the goal has value for them. 2 Mutually established goals are more likely to be attained, especially if steps to achieve the goals are clearly delineated. 3 Value implies that communication, education, and collaborative coordination are involved. 4 Remember that someone may value something, but a determination must be made about if the goal is feasible and attainable, given client's circumstances, health status, and resources

Process Used for Generating and Selecting Interventions

1. Review the nursing diagnosis: The etiology of a nursing diagnosis describes the factors that contribute to the unhealthy response. Choose strategies you expect will reduce or remove the etiological factors of actual problems, or that will reduce or remove risk factors for potential problems. 2. Review the desired client outcomes: Desired outcomes (goals) suggest nursing strategies that are specific to the individual patient. "What intervention(s) will help to produce this patient response?" 3. Identify several interventions/actions: To get started, ask yourself: For this nursing diagnosis 1) What assessments/observations do I need to make? 2) What do I need to do for the patient? Include both dependent and independent activities as appropriate. 4. Choose the best interventions for this client: The best interventions are those you expect to be most effective in helping to achieve client goals. When possible, choose interventions based on research and scientific principles. 5. Individualize the standardized interventions: Always consider how an intervention can be used with this particular person.

Review problem status (actual, potential, or possible nursing diagnosis; collaborative problem; or wellness diagnosis) in Chapter 4. For which type(s) of problem(s) would you write: • Preventive nursing orders?

Answer: Actual and potential nursing diagnoses and collaborative problems

• You check the result of the Pap smear in her electronic health record and see that it is normal.

Answer: • Objective data (This was observed by someone other than the patient.) • Secondary data (You did not get the information directly from the patient. It would be primary data for the pathologist.)

• Where do the four types of nursing knowledge fit into the full-spectrum model?

Answer: • Theoretical knowledge fits into thinking. • Practical knowledge fits into doing. • Self-knowledge and ethical knowledge fit into caring. • All types of knowledge are applied to the patient situation (context)

Refer to the Meet Your Patient scenario near the beginning of this chapter [in your textbook]. You have now admitted Todd from the ED. According to the ED report, Todd's admitting medical diagnosis is chronic renal failure. He is married, 58 years old, employed, and he has a longstanding history of type 2 diabetes mellitus (DM). During the past 3 days, he reports that he has developed swelling and decreased sensation in his legs and difficulty walking, which he describes as "slight loss of mobility." You have many questions concerning Todd's immediate and long-term needs, which include the following: • His medication regimen • His compliance with his diabetes treatment plan • The extent to which his family is involved • What laboratory tests have been completed • How severe his renal dysfunction has become • His safety needs After you obtain necessary data, you need to organize and analyze them to form some initial impressions about what they mean. For example: • Admitting diagnosis is chronic renal failure; anticipate a problem with fluid balance. • Decreased sensation in lower extremities; patient may have a mobility and a safety problem. • Diabetes; Todd is at risk for Impaired Skin and Tissue Integrity. • Diabetes and renal failure require complex treatment regimens and self-care: Is Todd managing his therapy effectively? If not, is it because he is not motivated to do so? When Todd and his family arrive on your unit, you begin gathering comprehensive data. From that, you then make a list of Todd's health problems in order of priority. These actions illustrate the diagnosis phase of the nursing process. Thinking 1. Theoretical Knowledge: What theoretical knowledge will you need to identify the collaborative problems and nursing diagnoses for Todd?

Answers should include pathophysiology and interventions for chronic renal failure and type 2 diabetes mellitus; information about effects of chronic renal failure and/or DM on sensation and mobility; information about actions and side effects of any medications Todd is taking; information about the usual medical regimen for chronic renal failure and DM; norms for whatever laboratory tests Todd has had

Assessment includes Collecting data Using a systematic and ongoing process Categorizing data Recording data

Collecting data: Examples of where you may find this data are in the patient's medical record, from interviewing the patient and/or his or her family, from your actual physical assessment, and from other interdisciplinary team members such as clergy or social workers. Using a systematic and ongoing process: Working in a systematic fashion allows you to stay organized and not miss important data; ongoing refers to process being constantly changing as new information is revealed. Categorizing data: This could include putting data into main categories such as physical, mental, spiritual, socioeconomic, and cultural. Recording data: You will record the data in order to have a patient database from which you can develop a plan of care.

How Does the Model Work? Doing

Doing -Practical knowledge -Nursing process Practical knowledge: Skills, procedures, and processes (including the nursing process). Nursing process: Assessment and evaluation: everything you know about the patient, including context. Planning and implementation: what you do for the patient

Draw conclusions about health states

Draw conclusions about health status: After clustering cues and collecting any missing data, the next step is to begin drawing conclusions about the patient's health status—strengths as well as problems.

For the following nursing diagnoses, write one intervention to address the problem and one intervention for the etiology of the problem. Ineffective Airway Clearance: Related to thick secretions and decreased chest expansion secondary to dehydration and pain Self-Care Deficit: Bathing, dressing, feeding, toileting r/t fatigue secondary to heart failure

Example for Ineffective Airway Clearance Examples of interventions for the problem: Suction to remove secretions, as needed. Monitor respiratory status hourly: rate, depth, effort, lung sounds, skin color, and amount and color of sputum. Teach breathing and coughing techniques. Examples of interventions for the etiology: Medicate for pain per order. Offer fluids hourly. Initiate and/or maintain IV fluids as ordered. Assess hydration level (e.g., skin turgor) every 8 hr. Monitor intake and output every 4 hr

• Can you think of an example of an indirect-care intervention?

Examples might include checking the Code Blue cart, calibrating a blood pressure machine, ordering supplies for the unit, lobbying for healthcare legislation, or meeting with a physical therapist to discuss a patient's care plan

2. Critical Thinking (Contextual Awareness): What details in the scenario represent "patient situation" or "context"?

Examples should include the following: She has family that apparently love and support her, and she cares about them. She is concerned about healthcare expenses, so if concerns are realistic, she must not have access to a large amount of money or insurance coverage. She is not expected to live more than a few months without chemotherapy and only a year or two more with it.

The nurse implements interventions from a single-study for client care however the outcomes are not favorable. What should the nurse do?

Find out if a clinical pathway is available for the health problem (keeping in mind that these may not be research-based). 1. Search for evidence reports; however, these reports are systematic reviews of clinical topics for the purpose of providing evidence for practice guidelines, quality improvement, and funding decisions. Evidence reports are usually developed by scientists rather than by clinicians, patients, and advocacy groups, so this approach may not be appropriate for the client's problems. 2. Identify clinical practice guidelines. These guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. They are typically developed by clinicians, patients, and advocacy groups and are published by specialty organizations, universities, and government agencies. They form the basis for nursing interventions and would be the most appropriate approach for this client situation

Reflecting Critically About Expected Outcomes/Goals

For each nursing diagnosis Is there at least one goal that, when met, would demonstrate problem resolution? Are the predicted outcomes adequate to completely address the nursing diagnosis? Is each expected outcome Appropriate for the nursing diagnosis? Derived from only one nursing diagnosis? Descriptive of only one client response/behavior? Stated as a client behavior, not a nurse activity? If an expected outcome is not deemed appropriate for the nursing diagnosis, a new nursing diagnosis should be written. Derived from only one nursing diagnosis: Does the outcome describe only one patient response? Is each expected outcome (cont'd) Stated in positive terms? Measurable or observable? Given specific and concrete performance criteria? State the outcome in terms of what you intend to occur, rather than what should not occur. Measurable or observable: Think: "What do I want to see, hear, feel, or smell?" Outcomes should be very specific and concrete in order to avoid being interpreted differently by different people Does each goal/outcome include all the necessary parts? Is there a subject (implied or actual), action verb, performance criterion, target time, and special condition (when needed)? Is each outcome/goal realistic and achievable? This involves considering the patient's support system, financial status, available community services, and physical and mental status as well as institutional resources. Is the goal not in conflict with the medical or other collaborative treatment plan? Does the client, family, or community value the outcome?If the client, family, or community values a care plan goal, it is more likely to be effective. If your goals conflict with the patient's you may need to explore the patient's thinking and try to find a compromise or alternative approach. Does the goal conflict with any religious or cultural values? If a patient is "noncompliant" the reason may be that he or she is complying with his or her cultural beliefs rather than the caregiver's plan of care.

Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Implementation The implementation phase of the nursing process is the "action" phase. The injection given by the nurse is the action performed to control Mr. Thompson's pain and allow him more comfort with activity.

Reflecting Critically About Evaluation: Thinking About Your Thinking

Inquiring, noticing content, analyzing assumptions, reflecting skeptically -Inquiring: Is my evaluation statement clearly stated? Were my information sources reliable? Did I jump to conclusions about goal achievement? Do I need any other data to validate my conclusion? - Noticing content: What was going on either before or during evaluation that might have influenced my ability to gather data or draw conclusions? What emotional responses influenced my conclusions about goal achievement? - Analyzing assumptions: What biases do I have that may have affected my ability to reassess or evaluate goal achievement? - Reflecting skeptically: Did I make evaluating a priority? Did I schedule time for it, the same as I do for interventions? Could I have done it better? What would I do differently next time?

Which statement is a priority nursing diagnosis? Impaired Verbal Communication related to Altered Central Nervous System Fluid Volume Excess related to Compromised Regulatory Mechanism Impaired Physical Mobility related to Discomfort Activity Intolerance related to Generalized Weakness

Maslow's Hierarchy of Human Needs places survival needs as a priority. Fluid volume excess can lead to pulmonary edema, impaired gas exchange, and respiratory failure. Fluid volume excess is therefore life-threatening and would be a high priority when ranking problems according to problem urgency.

Future consequences

May result in harmful future consequences and negatively impact the client's health When assigning priorities, also consider the possible future effects of a problem. Even if a problem is not life-threatening and even if the patient does not see the problem as a priority, it may result in harmful future consequences for the patient

Special Discharge or Teaching Plan

May use standardized plan for discharge planning and teaching or include as teaching in a nursing diagnosis care plan

Maslow's Hierarchy of Needs:

Non-nursing model used to organize data Maslow's Hierarchy of Needs: This model groups data according to human needs. It states that basic needs must be met before higher needs can be addressed. The categories of needs from most basic to highest are physiological, safety and security, love and belonging, esteem and self-esteem, cognitive, aesthetic, and self-actualization.

No directive interviewing

Nondirective interviewing Allows the client to control the subject matter; nurse's role is to clarify and summarize Nondirective interviewing: This type of interviewing is used to promote communication, build rapport, or help the patient to express feelings. You allow the patient to control the subject matter. Your role is to clarify, summarize, and ask mostly open-ended questions that facilitate thought and communication

The nurse, Linda, identifies some concerns about her patient's financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Drag and drop the step of the nursing process this represents. Assessment Diagnosis Planning Outcomes Planning Interventions Implementation Evaluation

Planning Outcomes Discharge planning should begin at admission. This process can often take days to coordinate and may prolong the client's hospital stay if not started right away. This identification of discharge needs is a part of planning patient outcomes

Primary data

Primary data: The subjective and objective information obtained directly from the client in what the client says or what you observe.

Think of some other defined situations for which unit standards of care might be useful.

Suggested responses: Responses should not include examples given in the textbook. Responses should be for standards that would (1) apply to every patient in the defined situation, rather than a subgroup; (2) not become part of the patient's care plan but be kept on file on the unit; and (3) not usually include specificmedical orders. Examples might include all children admitted to a pediatric unit, all patients being discharged from a hospital, all patients being admitted to the hospital, and all patients treated in the emergency.

• What is one possible explanation for what is hap- pening in this situation?

Suggested responses: There are many possible answers to this question. Below are a few possible explanations: • Mr. Nguyen may be afraid to report his fatigue and shortness of breath. • Mrs. Nguyen may be aware that her husband will not relay this information at the visit. • Mrs. Nguyen may want her husband to stop smoking. • Mr. Nguyen may believe his fatigue and shortness of breath are related to his knee pain.

Three functional assessment tools

These three functional assessment tools are commonly used: The Katz Index of ADL Scale (1963): This instrument is one of the best for assessing independent performance in very basic areas. It assigns one point for independence in each of the following areas: bathing, dressing, toileting, transfer, continence, and feeding. Lawton Instrumental Activities of Daily Living (IADLs) Scale (1969): This tool is particularly helpful in assessing a person's ability to independently perform the more sophisticated tasks of everyday life, such as shopping. Identifying early functional decline is important for discharge planning. The Lawton scale is especially useful for older adults who may begin to experience functional decline within 48 hr of hospital admission. The Karnofsky Performance Scale (Karnofsky & Burchenal, 1949): This tool is used primarily in palliative care settings to assess functional abilities at the end of life.

Three-part statement nursing diagnosis

Three-part statement: This is also called the PES format (problem, etiology, and symptom). The format is: Problem r/t etiology as manifested by (AMB) signs or symptoms. The connecting phrase can be either AEB (as evidenced by) or AMB (as manifested by

The nurse tells you that Sami is anemic.

• Objective data (This is observed by someone other than the patient; not told to you by the patient. It isn't the verbal reporting of data that makes them "subjective"; it is the verbal reporting by the pa- tient that does.) • Secondary data for you (You did not get the data from Sami.) Actually, anemia is a diagnostic con- clusion made by the nurse practitioner, not data. But when you receive the information, it is, for you, data.

• What are some other examples of interdependent interventions?

• What are some other examples of interdependent interventions? Suggested responses: Examples might include assisting with crutch walking after a patient has been taught by a physical therapist or assessing a patient's emotional status after the patient has been seen by a psychiatrist.

• What does the nurse do in the planning phases of the nursing process?

• What does the nurse do in the planning phases of the nursing process? Answer: In the planning phases, the nurse chooses outcomes/goals based on assessments and nursing diagnoses, chooses nursing interventions, and writes the plan of care.

What type of nursing knowledge (theoretical, practical, ethical, or self-knowledge) is needed to answer the following questions?

• What health concerns does Mr. Nguyen have that should be addressed by the healthcare team? Suggested response: You need theoretical and practical nursing knowledge encompassing many areas to answer to this question.

In the NIC system, what is the difference between interventions and activities?

● Interventions are broad, general, two- or three-word labels (names); they are the standardized part of the language. ● Activities are the more specific actions the nurse performs in carrying out the intervention; they are not standardized.

Guidelines for documenting data

-Document as soon as possible. -Write neatly, legibly, and in black ink or record data. -Document electronically. -Use proper spelling and grammar. -Use acronyms sparingly. -Write the patient's own words, when possible. -Record only the most important patient words. -Use concrete, specific information. -Record cues, not inferences. The ANA Nursing: Scope and Standards of Practice (2015) and The Joint Commission standards (2015) stress the importance of documenting patient information, including assessment data, in a retrievable format. Accurate, timely, and clear documentation of all assessment findings benefits patients by providing the basis for planning effective nursing care. The bulleted items on this slide are the key points that should be addressed when documenting data.

Why does a clinical practice guideline provide better support for an intervention than does a single study?

A clinical practice guideline provides better support because it includes more data and multiple studies. A single study may have included only a few patients and may not be reliable because of that or for other methodological reasons. Considering many studies removes some of the bias.

Taxonomy

A taxonomy is a system for classifying ideas or objects based on characteristics they have in common. This requires use of a specific (standardized) vocabulary of terms for a particular topic in accord with specific laws or principles

List the steps in the diagnostic process.

Answer: 1. Analyzing and interpreting data (this includes identifying significant data, clustering cues, and identifying data gaps and inconsistencies) 2. Drawing conclusions about health status (this includes making inferences and identifying problem etiologies) 3. Verifying problems with the patient 4. Prioritizing the problems 5. Recording the diagnostic statements (it could be argued that this is not really a part of the diagnostic process) You might also include "reflecting critically about your diagnostic reasoning," although it comes after the diagnostic process, strictly speaking

Briefly describe a process for creating a comprehen- sive, individualized care plan that incorporates collaborative care and standardized planning documents.

Answer: A process for creating such a care plan should include the following steps: • Perform a comprehensive patient assessment. • Make and prioritize a working problem list. • Decide which problems can be managed with standardized care plans or critical pathways. • Individualize the standardized plan as needed. Mark off any instructions that do not apply to the patient; add or adapt nursing orders as appropriate. • Transcribe medical orders to appropriate documents. Write activities of daily living (ADLs) and basic care needs in special sections of the Kardex, care plan, or computer. • Develop individualized care plans for problems not addressed by standardized documents. Write outcomes and nursing orders for each nursing diagnosis not addressed by standardized documents

Define critical thinking in your own words.

Answer: Because this is in your own words, it cannot be "wrong." However, you should have included some of the ideas discussed in the textbook. For example: thinking about your thinking, trying to make your thinking unbiased and fair, having a questioning/ inquiring attitude, not jumping to conclusions, reasoned thinking, reflective thinking, and problem-solving.

State whether each of the following represents a nursing diagnosis, medical diagnosis, or collabora- tive problem: • After giving birth, all women are at risk for develop- ing postpartum hemorrhage.

Answer: Collaborative problem (potential complication of childbirth: postpartum hemorrhage) Rationale: This is a potential problem that the nurse can help to prevent (e.g., by fundal massage); but if fundal massage is not effective, the physician must prescribe medication to prevent hemorrhage. This is a potential physiological complication associated with a medical diagnosis (childbirth).

What is the main disadvantage of computerized and standardized care plans?

Answer: Computerized and standardized care plans may cause you to lose some creativity, intuition, insight, or caring because it is tempting, when you are busy, to accept the "easy answer" provided by the computer and not go further to think about the unique needs of a particular patient.

How are critical pathways different from other stan- dardized care plans?

Answer: Critical pathways focus on care for a particular medical diagnosis or diagnosis-related group (DRG); they are organized on a timeline to meet recommended lengths of stay; instructions for nursing interventions are usually less specific/ detailed.

State whether each of the following represents a nursing diagnosis, medical diagnosis, or collabora- tive problem: • A client is at risk for constipation because he post- pones defecation and also does not consume enough dietary fiber and fluids.

Answer: Nursing diagnosis Rationale: The problem can usually be prevented by independent nursing interventions, such as patient teaching. Medication is sometimes prescribed, but not always.

Review problem status (actual, potential, or possible nursing diagnosis; collaborative problem; or wellness diagnosis) in Chapter 4. For which type(s) of problem(s) would you write: Nursing orders for treatments?

Answer: Primarily for actual nursing diagnoses and collaborative problems

n addition to care related to the patient's basic needs, what other types of information does a com- prehensive care plan contain?

Answer: The comprehensive care plan also contains information about the medical/multidisciplinary plan of care, information about care related to nursing diagnoses and collaborative problems, and information regarding special teaching and/or discharge planning needs.

• List all the characteristics of caring that you can remember.

Answer: The text mentions the following: • Sees each person as unique and valued • Is specific and relational for each nurse-person encounter • Includes compassion • Includes caring "in the moment" for "this" patient, even if you are busy or tired • Thinking and acting in ways that preserve human dignity and humanity • Does not treat people as objects • Is never routine or mechanical • Has at least five components: Knowing, being with, doing for, enabling, and maintaining belief

• What is the ultimate purpose of full-spectrum nursing?

Answer: The ultimate purpose of full-spectrum nursing is to achieve safe, effective care and to promote good patient outcomes.

When gathering admission assessment data, the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" What should the nurse do? Explain to the client how weight gain occurs. Check the calibration and re-weigh the client. Document the weight as 200 pounds. Instruct the NAP to re-weigh the client in 2 hr.

B It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.

Write an example of each of the following six diagnostic statement formats, using the three listed components—mix and match: Problem labels: Anxiety, Pain (lower back) Etiologies: Unknown outcome of surgery; muscle strain and tissue inflammation Cues: Exhibits physical manifestations of anxiety (e.g., hands shaking); states pain is 9 on a scale of 1 to 10 • Basic two-part statement • Basic three-part statement • Basic two-part statement, using "secondary to" (create your own disease/pathology) • Statement with unknown etiology • Possible nursing diagnosis • Risk nursing diagnosis

Basic two-part statement. Anxiety related to unknown outcome of surgery—or Pain (lower back) related to muscle strain and tissue inflammation. • Basic three-part statement. Pain (lower back) related to muscle strain and tissue inflammation A.M.B. states pain is 9 on a 1 to 10 scale. • Basic two-part statement, using "secondary to" (create your own disease/pathology). Pain (lower back) related to muscle strain and tissue inflammation secondary to lifting heavy object using poor body mechanics. • Statement with unknown etiology. Anxiety related to unknown etiology. Pain (abdominal) related to unknown etiology. • Possible nursing diagnosis. Possible Anxiety related to unknown outcome of surgery. • Risk nursing diagnosis. Risk for Anxiety related to unknown outcome of surgery

The client has reddened skin and an open abrasion on the elbow from prolonged bedrest. When examining the components of the nursing diagnosis Impaired Skin Integrity, what would be the reddened skin and open abrasion? Related factors Risk factors Defining characteristics Diagnostic label

C Defining characteristics are the signs and symptoms that allow the nurse to identify a client problem.

Planning for implementation phase

Check your knowledge and abilities: You must decide whether you are qualified to carry out the orders. You should ask for help when: 1 You do not have the knowledge or skill needed to implement an order (e.g., when administering an unfamiliar medication or when you have never performed an ordered procedure). 2 You cannot perform the activity safely alone (e.g., helping a heavy, weak patient to ambulate). 3 Performing the activity alone would cause undue stress for the patient (e.g., giving back care to a patient with multiple fractures). Organize your work: When organizing your work, identify points in each intervention where you want to pause for feedback. Gather all the supplies and equipment you need before you go to the patient's room. Prepare the client: 1) Check your assumptions, 2) Assess the patient's readiness, 3) Explain what you will do and what the patient will feel.

A nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence-based practice. Which critical thinking attitude is the nurse demonstrating? Independent thinking Intellectual humility Intellectual courage Fair-mindedness

Critical thinkers are not afraid to question things. They do not proceed with a questionable action simply because "that's the way it's always been done." The correct answer is A. The key point in the slide is that critical thinkers are not afraid to question things

NANDA-I Nursing Diagnosis: Components: diagnostic label

Diagnostic label: The diagnostic label (title or name) is a word or phrase that represents a pattern of related cues and describes a problem or wellness response.

Ethical knowledge

Ethical knowledge consists of information about moral principles and processes for making moral decisions. Ethical knowledge helps you to fulfill your ethical obligations to patients and colleagues.

How Does Problem Status Influence Nursing Interventions? (cont'd): health promotion interventions are used in

Health promotion interventions are used in: Wellness diagnoses: To support a client's health promotion efforts and achieve a higher level of wellness

List at least eight questions you could ask to critically evaluate the quality of your goal/outcome statements.

List at least eight questions you could ask to critically evaluate the quality of your goal/outcome statements. Answer: Questions to ask include the following: • For each nursing diagnosis: Is there at least one goal that, when met, would demonstrate problem resolution? That is, does at least one goal flow from the problem clause? • For each nursing diagnosis: Are the predicted out- comes adequate to completely address the nursing diagnosis? For each expected outcome: • Is the outcome appropriate for the nursing diagnosis? • Is each outcome derived from only one nursing diagnosis? • Does each outcome describe only one patient response or behavior? • Is the outcome stated as a patient behavior, not a nurse activity? • Is the outcome stated in positive, rather than negative, terms? • Is the outcome measurable or observable? • Are the performance criteria specific and concrete? Avoid words like normal, sufficient, enough, more, less, adequate, increased. • Does each goal include all the necessary parts? • Is the expected outcome realistic and achievable by this patient, given the available resources? • Does the outcome conflict with the medical or other collaborative treatment plan? • Does the patient, family, or community value the outcome? • Does the goal conflict with any religious or cultural values?

Difference between medical assessments and nursing assessment

Medical assessments focus on disease and pathology. Nursing assessments focus on the client's responses to illness and will initiate changes in the plan of care

Writing nursing orders

Nursing orders are instructions that describe how and when nursing interventions are to be implemented. Nursing orders are: 1. Instructions that describe how and when nursing interventions are to be implemented. 2. Usually written on a nursing care plan. 3. Possibly delegated to other nurses and nursing assistive personnel (NAP), who bear the responsibility for the delegated activity, skill, or procedure. 4. The responsibility of the RN who delegates the "responsibility" but maintains overall accountability for the patient

Observation

Observation refers to the deliberate use of all of your senses to gather and interpret patient and environmental data. The CROP mnemonic (memory aid) in Box 3-2 may help.

Orem's Self-Care Model:

Orem's Self-Care Model: Conceptualizes health as the ability to perform self-care. Using this model, you would gather data to identify the universal self-care deficits that require nursing assistance. Nursing models used to organize data

Components of a Nursing Outcomes Classification

Outcome label: This is a broadly stated neutral label (a variable), to allow for positive, negative, or no change in patient health status. -Indicators: The observable behaviors and states you can use to evaluate patient status. -Measurement scale: For each outcome, NOC has a five-point measurement scale for describing patient status for each indicator. As a rule, 1 is least desirable and 5 is most desirable. In your initial assessment, you assign the number that represents the patient's present health status. To form the "goal" you assign the scale number that the patient can realistically achieve after the interventions

Physical assessment

Physical assessment (or physical examination) produces mostly objective data and uses the techniques of inspection (visual examination), palpation (touch), percussion (tapping a body surface), direct auscultation (listening with the unaided ear), and indirect auscultation (listening with a stethoscope).

Auscultation

Physical part of assessment Auscultation: Listening with the unaided ear for sounds made by the client (direct auscultation) and listening with the use of a stethoscope (indirect auscultation) for normal and abnormal sounds within the body.

Catlett, S., & Lovan, S. (2011). Being a good nurse and doing the right thing: A replication study. Nursing Ethics, 18(1), 54-63. The purpose of this qualitative study was to examine nurses' perceptions of what it means to be a good nurse and to do the right thing. Researchers used open-ended questions to interview nurse subjects. They identified four categories that related to being a good nurse and doing the right thing: (1) personal traits and attributes; (2) technical skills and management of care; (3) work environment and coworkers; and (4) caring and caring behaviors. SUGGESTED RESPONSES 1. What examples of full-spectrum nursing can you see in the four categories identified?

Possible responses include the following: • Thinking (Critical thinking): Category 1, personal traits and attributes, may be referring to the criti- cal-thinking skills and attitudes described in Chapter 2 of your textbook (e.g., independent thinking, fair-mindedness, contextual awareness, considering alternatives, analyzing assumptions, reflecting skeptically, and deciding what to do). • Thinking (Nursing Knowledge): Category 2, tech- nical skills and management of care, most likely includes both theoretical knowledge and practical knowledge (e.g., of nursing skills). • Doing (Nursing Process): Category 2, under management of care, undoubtedly requires use of nursing process (data collection, diagnosing, planning, implementing, and evaluating care). • Caring (Self-Knowledge and Ethical Knowledge): Category 3, work environment and coworkers, involves self-knowledge and ethical knowledge inorder to interact in a caring manner. Category 4, caring and caring behaviors, specifically states that caring is necessary. • Patient situation (Context): Category 3, work en- vironment and coworkers, indicates that the good nurse considers the environment surrounding the care she gives to the patient.

Five rights of delegation

Right task: Examples of tasks you might assign to a nursing assistive personnel (NAP) are: bathing a stable patient, ambulating steady patients, obtaining routine vital signs, changing linens, assisting patients with meals, clerical duties, and transporting non-acute patients and specimens. Right circumstance: Before deciding to delegate, assess your patient to be certain that her needs match the abilities of the NAP or LPN. Right person: You must also be sure that the LPN or NAP is competent to perform the task and that his workload allows time to do the task properly. Consider the person's experience, training, and cultural competence. Right direction/communication: 1) Explain exactly what the task is, 2) Include specific times and methods for reporting, 3) Explain the purpose or objective of the task, 4) Describe the expected results or potential complications, 5) Be specific in your instructions. Right supervision: Supervision is the process of directing, guiding, and influencing the performance of the delegated task. When you delegate tasks to a NAP or LVN/LPN, you or another RN must be available to answer questions and provide help, if necessary. You are responsible for providing supervision and evaluating the outcomes

How Can You Show That Your Nursing Care Is Safe? Effective? Timely? Equitable (fair and equal for all)?

Safety can be shown by: Patient surveys (see next slide). Absence of preventable complications, such as falls, pressure sores. Clean and comfortable environment with absence of preventable infections. Coordination and continuation of care as needed across the broader healthcare system, including specialty care, hospitals, home healthcare, community services, and supports. Effectiveness of nursing interventions can be shown by: Use of techniques/processes to avoid medical/nursing errors. Patient reports absence of pain as a result of nurse's use of pharmacological and nonpharmacological interventions for relief of pain. Patient report and nurse documentation of resolution of problem requiring nursing intervention. Patient is discharged with resolution of problem or progress toward its resolution. Patient is not readmitted in less than 30 days for the same problem. Timeliness can be shown by: Documentation of medications, treatments, and other nursing interventions delivered at allotted time. Ongoing nursing assessment of client's status that identifies early signs of an impending problem which might be prevented by timely intervention. Equitability can be shown by: Patient reports being respected as a human being and as a patient at the center of his or her planned healthcare interventions. Patient reports absence of discrimination in healthcare (e.g., being refused needed care, healthcare providers refusing to touch them or using excessive precautions, healthcare providers using harsh or abusive language, being blamed for their health status, etc.). Patient reports being provided teaching, information, and resources he or she needs to access or continue care.

List five skills or attitudes that reflect critical thinking

Skills. The following are examples of critical-thinking skills: -Objectively gathering information on a problem or issue -Recognizing the need for more information -Recognizing gaps in one's own knowledge -Listening carefully, reading thoughtfully -Separating relevant from irrelevant data, important from unimportant data -Organizing or grouping information in meaningful ways -Making inferences (tentative conclusions) about the meaning of the information -Integrating new information with prior knowledge -Visualizing potential solutions to a problem -Objectively evaluating the likelihood that each potential solution will work -Exploring the advantages, disadvantages, and consequences of each potential action -Evaluating the credibility and usefulness of sources of information • Recognizing differences and similarities among things or situations • Prioritizing or ranking data as needed Attitudes. The following are some critical-thinking attitudes (Paul, 1990): Attitudes. The following are some critical-thinking attitudes (Paul, 1990): • Independent thinking. Critical thinkers do not be- lieve everything they are told; they do not just go along with the crowd. They listen to what others think and they learn from new ideas. They do not accept or reject an idea before they understand it. Nurses should challenge actions and policies that have no logical support. • Intellectual curiosity. Critical thinkers love to learn new things. They are naturally inquisitive and fre- quently think or ask, "What if ...?" "How could we do this differently?"or "How does this work?" • Intellectual humility. Critical thinkers are aware that they do not know everything, and they are not embarrassed to ask for help when they don't know. They reevaluate their conclusions or chosen course of action in light of new information and are will- ing to admit when they are wrong. However, this trait does not imply ambivalence or apathy. • Intellectual empathy. Critical thinkers try to under- stand the feelings and perceptions of others and to expand their perspective toward a worldview. They try to view a situation as another person sees it. • Intellectual courage. Critical thinkers consider and examine their own values and beliefs, as well as viewpoints of others, even when this is uncomfort- able. They are willing to rethink, and even reject, previously held beliefs that are not well justified. Without intellectual courage, people become resistant to change. • Intellectual perseverance. Critical thinkers don't settle for the quick, obvious answer. They do not jump to conclusions. Important questions are usually complex; critical thinkers are willing to contemplate and consider alternate ideas. They investigate thoroughly, even when this takes a great deal of effort and time. • Fair-mindedness. Critical thinkers try to make impartial judgments. They consider various view- points fairly, realizing that personal biases, cus- toms, and social pressures can influence their thinking. They examine their own biases each time they make a decision

What do you think it means for a nurse to be "accountable" for an intervention? Do you think diagnosing ought to be limited to RNs only? Why do you hold your opinion?

Socratic reasoning is based on the idea that all thoughts can be pursued in four directions; that is, their origins, support, conflict with other ideas, and implications. The method is to ask a question, restate what the student answers ("I hear you saying that...") and then follow up the student's response with yet another question designed to pursue that thought further. For question 1, for example, when the student responds, you might say, "Can you give an example of a nurse being accountable for a particular intervention?" or "How does that conflict with the idea that the doctor is the captain of the ship?" You will need to think of follow-up questions ahead of time in order to be prepared for a good discussion. Remember, restate the student's response, then follow up with questions about: -Origin of the thinking (When did you begin to think that?) and clarification (What do you mean by...?) -Support (data, evidence) (What support do you have for your thinking? or Is there any reason to question that idea?) -Conflict with other ideas (differing perspectives) (What might the patient think about this? or What might the ANA think about the idea that...?) -Implications and consequences (What might happen, in that case, if the nurse makes an honest mistake?) >>

State nurse practice acts and delegating assessment

State nurse practice acts: Each state nurse practice act specifies which portions of the assessment can legally be completed by individuals with different credentials. Look for statements related to delegation. For example, the definitions in the National Council of State Boards of Nursing (NCSBN) Model Nursing Practice Act (2011) differentiate between assessments by RNs and LPNs/LVNs.

What Are the Components of a Goal Statement?

Subject: The subject is understood to be the client, but it can also be a function or part of the client. Action: Use an action verb to indicate the action the client will perform: What the client will learn, do, or say. Performance criteria: These need to be written in concrete, observable terms because they indicate what you need to measure in order to evaluate outcomes. Performance criteria specify: 1) how, what, when, or where something is to be done; 2) amount, quality, accuracy, speed, distance, and so forth. Target time: The realistic date or time by which the performance/behavior should be achieved. Special conditions: Amount of assistance or resources needed or the experiences/treatments the client should have to perform the behavior

Subjective data

Subjective data: What the patient says; also called covert data, or symptoms data. This consists of information communicated to the nurse by the client, family, or community.

Think about the following situation, and then answer the questions. Compare your ideas with those of other students; if you have any questions, consult your instructor. • Suppose you are a nurse in a healthcare setting where the policy states that nursing assistive person- nel (NAP) can take vital signs (blood pressure, pulse, temperature, and respirations). You have a patient who is critically ill and whose condition is changing rapidly. Would you measure the vital signs or dele- gate the task to the NAP? Why or why not?

Suggested response: Answers may vary. Consider the notion that policies are not absolute, so judgment is required. For example, you may say, "I would take the vital signs myself to be sure they were correct." Others might say, "If the patient is critically ill, the RN might have other tasks requiring more skill to do them, so she might work beside the NAP but still have the NAP take the vital signs." The scenario you imagine affects the answer you will give.

Self-Knowledge: In what ways are you similar to Sami? In what ways are you different?

Suggested response: Answers will vary depending on developmental level, gender, cultural heritage, and role.

D. Nursing Process • In what phase of the nursing process are you engaged when you are asking Mr. Nguyen about the reason for his visit?

Suggested response: Assessment phase • What activities are involved in the diagnosis phase? In planning outcomes? In planning interventions? Suggested response: • Diagnosis phase involves analyzing, synthesiz- ing, and evaluating the data gathered in the assessment phase. • Planning outcomes involves developing goals for your care of the patient. • Planning interventions involves developing a list of interventions to meet your goal for the patient.

c. Has hard, painful bowel movement about every 3 days; does not exercise regularly; eats very little dietary fiber; skin is dry.

Suggested response: Everything but dry skin is related. The bowel movement pattern represents symptoms of Constipation; the exercise and diet represent etiologies of that problem. Dry skin may be related in a way, because it is a symptom of Deficient Fluid Volume, which contributes to Constipation.

• How would your nursing interventions be different for the following diagnoses? a. Constipation related to lack of knowledge about laxative use b. Constipation related to weak abdominal muscles secondary to long-term immobility

Suggested response: For the first nursing diagnosis, nursing interventions should focus on teaching about the effects and side effects of laxatives and about normal bowel function. For (b), the nurse should suggest or assist with abdominal strengthening exercises, if that is feasible, and help the patient to move about as much as possible. If neither of those is feasible, medical interventions (e.g., laxatives or enemas) may be needed.

Prioritize the following nursing diagnosis labels (problems) based on the Maslow framework (see Fig. 4-6 in your textbook): (1) Assign each diagnosis a high, medium, or low priority. (2) Rank them in order of importance, with 1 being most important and 5 being least important. Ineffective Airway Clearance Ineffective Breathing Pattern Diarrhea Risk for Falls Impaired Memory

Suggested response: In addition to familiarizing you with the Maslow model, one purpose of this exercise is to demonstrate that it is not always easy to decide which problem is most important, especially when trying to rank them in order. There is some room for variation, especially when you do not have the etiologies for the problems. When assigning high, medium, or low priority, students might have chosen the following: • Ineffective Airway Clearance. This is high priority because it is a physiological need. • Ineffective Breathing Pattern. This is high priority because it is a physiological need. • Diarrhea. This is a physiological need; however, unless diarrhea is severe and prolonged, it probably would not interfere with survival. Therefore, nurses might rank this either high or medium priority. • Risk for Falls. This is medium priority because it is a safety/security need. However, if the risk is great or if a fall might be fatal for a particular person, nurses should assign a high priority. • Impaired Memory. It is difficult to prioritize this one without more information. A serious memory problem might be a threat to survival if a person lives alone. In that situation, it would at least be a threat to safety. For a hospitalized patient, it might be a low priority problem because (1) the person would probably have other physiological problems that would need more urgent attention and (2) nurses would probably be sure that the person's safety needs are met.

Most professional organizations identify assessment as a necessary skill for patient-centered care. In the full-spectrum model used in this book, the caring nurse is expected to use ethical knowledge to elicit patient values, preferences, and expressed needs as part of a clinical interview. Safe, effective care is an integral part of thinking, doing, and caring, as well. Where do you think these types of patient informa- tion fit into the preceding components of a nursing health history? Why?

Suggested response: One place to elicit these data would be in "Client's per- ception of health status and expectations for care," thinking that the patient's values, preferences, and needs would form his expectations for care. Family health history relates more to risk factors for illness, but would be another possibility. Social history includes information about family and other relationships, so logically might include values and preferences.

rewrite the nutrition statement as a three-part statement, including the phrase as evidenced by.

Suggested response: Overweight related to unknown etiology as evidenced by weight 165 lb and height 5 ́4"

• Imagine that you have been in an automobile acci- dent. You have internal injuries and broken bones and will be hospitalized for at least 2 weeks, right before your final exams. What human responses (physical, emotional, interpersonal, social, spiritual) would you have?

Suggested response: Responses might include fear, anxiety, pain, immobility, worry about missing work, concerns about taking an incomplete for the semester, worry about who will care for the family, worry about how far funds will stretch, boredom brought about by needing to stay in bed, loneliness (for family or friends), and so on

Rewrite the following diagnostic statement so it contains no legally questionable language. Use imagi- nary etiological factors if you need to. Risk for Falls r/t lack of staff to adequately supervise ambulation

Suggested response: Risk for Falls related to confusion and wandering secondary to dementia

After further assessment, you observe that Todd's skin is intact and without redness or lesions. Write a nursing diagnosis (problem and etiology) to describe your concerns about his skin.

Suggested response: Risk for Impaired Skin Integrity related to relative immobility and secondary to diabetes mellitus (DM) and chronic renal failure. This is not Impaired Skin Integrity because no defining characteristics are present.

When you are making your assessments of Todd, who is your best source of data? Why?

Suggested response: See Chapter 3, Assessment. The patient is the best source of information in most instances.

Practical Knowledge: What practical knowledge will you, as the nurse, use in this scenario?

Suggested response: The nurse will use the skills of interviewing and physical assessment, which usually include taking vital signs.

For each of the following cue clusters, decide whether the cues represent a pattern; that is, are all the cues related in some way? If so, explain how they are related. If not, state which cue does not fit. a. Dry skin, abnormal return of skin turgor (more than 4 seconds), thirst, and scanty, dark yellow urine

Suggested response: These are all related because each can be caused by Deficient Fluid Volume (dehydration). Together they suggest a fluid deficit problem, but they do not explain the etiology of the problem.

What is the role of Zach Miller on the healthcare team?

Suggested response: To answer this question, you need theoretical knowledge about the role of nurse practitioners. You also need practical knowledge about the role that nurse practitioners play at the Family Medical Center and their relationship with other healthcare providers.

B. Based on the data in the scenario, identify at least one actual, one potential, and one wellness diagnosis for Mr. Nguyen. Identify the NANDA-I labels and describe the cues that support your choices.

Suggested response: Use a nursing diagnosis handbook to look up defining characteristics to see whether their diagnoses are appropriate. Possible answers include the following, but they should not necessarily include all of the diagnoses. For example, you may identify Impaired Mobility related to pain in knees, whereas other classmates may identify the problem as Risk for Falls related to impaired mobility; you may identify Ineffective Health Maintenance, whereas other classmates may use Deficient Knowledge for that group of cues. • Diagnosis: Imbalanced Nutrition: More Than Body Requirements Cues: Weight 165 lb, too much for height of 5 ́4 ̋ • Diagnosis: Acute Pain (knees) Cue: He states that knee pain is his "chief complaint." • Diagnosis: Impaired Mobility secondary to bilat- eral knee pain Cue: He says that the pain is affecting his work performance: "I work in construction. I have to climb up and down ladders, lift things, and crawl around a lot." • Diagnosis: Risk for Falls related to impaired mobility secondary to knee pain Cue: He says that the pain is affecting his work performance: "I work in construction. I have to climb up and down ladders, lift things, and crawl around a lot." • Diagnosis: Ineffective Health Maintenance Cues: Even though Mr. Nguyen has hypertension, he continues to use tobacco and caffeine, he is overweight, and he reports a stressful life. He does not know whether he has had a pneumonia immunization, does not remember when he was immunized for tetanus, has not had a physical exam in more than 10 years, and has never had a colonoscopy. Despite some unhealthful behaviors, he has stated that he "might" like to stop smok- ing and would like a checkup. Some may identify this problem as Deficient Knowledge (lifestyle ad- justments needed for controlling hypertension, health promotion, and disease prevention measures).

Based on the data you have so far about Sami, con- sider the need to perform any of the special-purpose assessments. What is your rationale for using or not using a special needs assessment for her?

Suggested response: • Based on the data that have been provided thus far in the chapter, there is nothing to suggest a need for in-depth information about nu- trition, pain, psychosocial health, functional abil- ity, family, or community. There are no abnormal cues or risk factors in those areas. Although the in- formation might be nice to have, it is probably not important enough to allocate time to it. • A cultural assessment might be helpful, especially if data show that she is sexually active and in need of birth control or safe-sex measures. • Because Sami is basically healthy and has not come to the clinic because of a health problem, health promotion measures seem appropriate. Therefore, a wellness assessment, including social supports, physical fitness, life stress review, health beliefs re- view, and lifestyle assessment would be helpful. • Your answers might also relate to reasons for not doing special assessments, such as the following: no readily available assessment form available, lack of time, lack of knowledge at this point in your education, and not appropriate for this client at this time and in this setting.

D. Based on what you know about Mr. Nguyen, what follow-up assessments would provide useful data to help with the care of Mr. Nguyen? Why would you make these assessments?

Suggested response: • Pain assessment to evaluate his knee pain • Nutritional assessment because he is overweight • Cultural assessment to evaluate his beliefs related to health, illness, and healthcare • Family assessment to learn more about his family structure and health • Psychosocial assessment to evaluate his lifestyle and coping patterns • Wellness assessment to identify health promotion activities

B. Identify the types of data (e.g., subjective/objective, primary/secondary) that have been gathered so far. Give an example of each type.

Suggested response: • Subjective data—patient statements, information Mr. Nguyen supplied on the intake form • Objective data—vital signs, observations made by healthcare providers • Primary data—combination of the subjective and objective data focused on Mr. Nguyen • Secondary data—Mrs. Nguyen's comments

Suggested response: One place to elicit these data would be in "Client's per- ception of health status and expectations for care," thinking that the patient's values, preferences, and needs would form his expectations for care. Family health history relates more to risk factors for illness, but would be another possibility. Social history includes information about family and other relationships, so logically might include values and preferences.

Suggested responses: Answers will vary according to knowledge they already believe they have. The supplied will depend on answers given. You might mention that you need to learn about young adult health and wellness needs, or what is involved in clinic services for general healthcare, or about Cuban American culture. You might want to know what is involved in the work of a fitness trainer. You might want to know what, exactly, a poverty-level income is.

Can you think of an example of a direct-care intervention?

Suggested responses: Examples might include administering a medication, performing range-of-motion exercises, or bathing a patient.

Review the opening scenario of Nam Nguyen at the front of this textbook. As the clinic nurse, you have written the following nursing diagnostic statement: Overweight r/t inappropriate food choices and serving size as evidenced by body mass index (BMI) of 28.5. Write at least two short-term and two long-term goals for Mr. Nguyen based on this diagnostic statement. Remember that your goals must be realistic and take into account Mr. Nguyen's other health problems

Suggested responses: Many answers are possible. However, you should write goals that are realistic and take into account Mr. Nguyen's hypertension, musculoskeletal pain, and smoking history. Short-term goals might be as follows: • By 9/26, client will attend one counseling session with the clinic nutrition staff. • By 10/1, client will be able to state food choices that are balanced in carbohydrates, proteins, and fat and low in salt. • By (date approximately 1 month from now), patient will lose 3 to 5 pounds. Examples of long-term goals include the following: • By (date 3 months from now), client will participate in aerobic exercise for at least 30 minutes, 3 times per week on a regular basis. • By (date 6 months from now), client will lose 15 pounds. • By (date 1 year from now), client will have BMI of 25.7.

Mrs. Castillo has late-stage cancer and is not expected to live more than a few months. With chemotherapy, she could live perhaps a year or two more. She cannot decide what to do. She knows that the chemotherapy will have unpleasant side effects and will be very expensive, and she wants to protect her family from the emotional and financial hardships of a lingering illness. She is showing physical signs of anxiety and distress (e.g., increased heart rate, restlessness, tearfulness). You want to provide support for her decision, whatever it may be Thinking 1. Theoretical Knowledge: What theoretical knowledge do you need to help Mrs. Castillo?

Suggested responses: Responses might include the following: theoretical knowledge of pathophysiology of cancer, stages of cancer, side effects and actions of chemotherapy, anxiety and coping.

Suggest some other subgroups for which a protocol might be appropriate.

Suggested responses: Responses should include subgroups that require specific actions for a clinical problem unique to that group of patients. Unlike traditional standing orders, protocols may include both medical and nursing orders. Examples in the textbook are risk for falls, seizure, administering oxytocin to induce labor, and barium enema. Protocols often contain medical and nursing orders. Your response might include administration of whole blood, allergic reaction to a medication, computed tomography (CT) scan of the head, cardiac catheterization, bedside administration of epidural anesthesia, insertion of central venous line, colonoscopy, and upper gastrointestinal (GI) examination.

4. Ethical Knowledge: Depending on Mrs. Castillo's decision, can you think of one ethical issue that might arise for you or members of her family later on?

Suggested responses: You may think of issues such as the following: • Mrs. Castillo might decide not to have the treat- ment. Does she have the right to do that? Would it be wrong of me, as a nurse, to try to convince her to have the treatment? • Whatever she decides, what if the family doesn't agree? What should we do then? • If Mrs. Castillo decides to have the treatment, and it turns out to be poorly for her, or ruins the family financially, I might feel guilty.

3. Practical Knowledge: a. What practical knowledge do you need to helpMrs. Castillo? Which skills can you already perform? Which skills would you need to learn or review before caring for this patient?

Suggested responses: a. Responses should include the following possibilities: how to administer chemotherapy (or medication), vital signs, help with activities of daily living (e.g., bathing, feeding, toileting). Or responses might be more general, such as practical knowledge of interview and communication techniques and processes. b. Responses will depend on what skills you already have, so responses will vary among students.

2. order to interact in a caring manner. Category 4, caring and caring behaviors, specifically states that caring is necessary. • Patient situation (Context): Category 3, work en- vironment and coworkers, indicates that the good nurse considers the environment surrounding the care she gives to the patient. Based on this abstract, which of the following questions might this study answer satisfactorily for you? Explain your reasoning. a. What is a good nurse? b. Did the nurse subjects demonstrate critical thinking? c. How did the nurse subjects describe a good nurse?

Suggested responses: • The best answer is answer option c, How did the nurse subjects describe a good nurse? It is not answer option a, What is a good nurse? The stated purpose of the study was to examine nurses' perceptions of what a good nurse is—it made no attempt to de- scribe definitively what a good nurse is. The authors did find out what nurses thought about being a good nurse and doing the right thing, but nurses' thoughts and ideas do not, by themselves, define "good nurse" and "doing the right thing." • The answer is not answer option b, Did the nurse subjects demonstrate critical thinking? The study intended to, and did, find out what nurses were thinking, but it did not apply any criteria to meas- ure the quality of their thinking (e.g., whether it was unbiased, based on principles, based on credi- ble sources, included critical reflection).

In addition to organizing your work, what other prepa- rations should you make before implementing care?

The following preparations should be made before implementing care: • Establish feedback points. • Check your knowledge/skill to see whether you are qualified to perform the intervention. • Organize/prepare supplies and equipment. • Prepare the patient (e.g., assure that the interven- tion is still needed, check for readiness, tell the patient what she will experience and what she is expected to do, and provide privacy).

Type of research based support

The types of research-based support include: Single studies: These are individual studies that are published in nursing journals. These kinds of studies have limitations, such as not including all types of interventions, limited studies about an intervention, or the use of a small sample of clients. Critical pathways and protocols: Standardized plans of care for specific situations, such as frequently occurring conditions where the outcomes and interventions are appropriate for all patients who have the health problem. These pathways and protocols are tools developed by an organization for its own use. They guide best practice at the local level and may not be based on research. Evidence reports: Systematic reviews of clinical topics for the purpose of providing evidence for practice guidelines, quality improvement, and funding decisions. Evidence reports are usually developed by scientists rather than by clinicians, patients, and advocacy groups. Clinical practice guidelines: Systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. They are typically developed by clinicians, patients, and advocacy groups and are published by specialty organizations, universities, and government agencies

Theoretical knowledge

Theoretical knowledge: Consists of information, facts, principles, and evidence-based theories in nursing and related disciplines (e.g., physiology and psychology). It includes research findings and rationally constructed explanations of phenomena. "This is the type of knowledge you will use to describe your patients, understand their health status, rationalize which interventions you choose, and it allows you to predict patient responses to interventions and treatments."

Evidence based practice

There are 12 ANA-recognized standardized languages. Currently, these three are the most frequently used in electronic health records (EHRs). Clinical Care Classification (CCC): Developed for use in home healthcare. In addition to terminology for nursing diagnoses and outcomes, the CCC has 198 interventions. The Omaha System: Developed for community health nurses to use in caring for individuals, families, and aggregates (community groups or entire communities) (Martin, 2005). It includes terminology for diagnoses, outcomes, and interventions Clinical Care Classification (CCC): Developed for use in home healthcare. In addition to terminology for nursing diagnoses and outcomes, the CCC has 198 interventions. The Omaha System: Developed for community health nurses to use in caring for individuals, families, and aggregates (community groups or entire communities) (Martin, 2005). It includes terminology for diagnoses, outcomes, and interventions Clinical Care Classification (CCC) The OMAHA System Nursing Interventions Classification (NIC) Clinical Care Classification (CCC): Developed for use in home healthcare. In addition to terminology for nursing diagnoses and outcomes, the CCC has 198 interventions. The Omaha System: Developed for community health nurses to use in caring for individuals, families, and aggregates (community groups or entire communities) (Martin, 2005). It includes terminology for diagnoses, outcomes, and interventions

Standardized Language for Interventions

There are 12 ANA-recognized standardized languages. Currently, these three are the most frequently used in electronic health records (EHRs). Clinical Care Classification (CCC): Developed for use in home healthcare. In addition to terminology for nursing diagnoses and outcomes, the CCC has 198 interventions. The Omaha System: Developed for community health nurses to use in caring for individuals, families, and aggregates (community groups or entire communities) (Martin, 2005). It includes terminology for diagnoses, outcomes, and interventions Nursing Interventions Classification (NIC) Consists of a label, a definition, and a list of specific activities NIC interventions are linked to NANDA-I diagnoses and NOC outcome labels. NIC includes interventions applicable to all settings. the difference between a label and a definition Label: Usually consisting of two or three words, is the standardized terminology. Definition: Explains the meaning of the label. In this book, you can look up a nursing diagnosis to see the list of outcomes suggested for it and the interventions for achieving each outcome

Pain assessment

Type of special needs assessment Pain: Some accrediting agency (The Joint Commission) standards require pain screening for all patients during initial and ongoing assessments. A comprehensive pain assessment may be required for ongoing, unrelieved, or severe pain.

Spiritual health assessment

Type of special needs assessment Spiritual health: For ill persons, spirituality can be a problem or a source of support. Spiritual health assessment provides insight into how a client's spirituality is affected by current life events and health status—far more than merely asking about the client's religious preference.

Diagnostic reasoning

Use critical thinking to: Analyze and interpret data Draw conclusions about the client's health status Verify problems with the client Prioritize the problems Record the diagnostic statements

Reflecting Critically About Nursing Orders

What makes a set of orders complete? That is, do they address all aspects of the problem, such as etiology or symptoms? Do they address the client's physical, emotional, interpersonal, spiritual, and cultural needs? What makes an order technically complete? That is, does it contain all the required components? What does that mean? How can you increase the clarity of an order and make it more specific and less prone to misinterpretation? Is the order individualized for this particular client? Includes patient likes and dislikes. Is it tailored for patient's particular needs, problems, circumstances, and goals? Are the orders concise? Keep the orders as brief as possible without sacrificing clarity and specificity. Which orders have priority? Decide which orders must be implemented immediately, which ones must be done on this shift, and which ones must be done today. You may use Maslow's Hierarchy, problem urgency, future consequences, and patient preference to establish your priorities.

Not all of the defining characteristics need to be present for a diagnosis, but recall that the more data you have when you make an inference, the more certain you can be that your inference is correct. For example, NANDA-I lists 15 defining characteristics for IneffectiveThermoregulation, including the following: • Fluctuations in body temperature above and below normal range • Cyanotic nailbeds • Pallor • Slow capillary refill • Tachycardia • In the preceding example, what if the first defining characteristic (temperature fluctuations) was not present and you had only cyanotic nailbeds, pallor, and slow capillary refill as cues? Could you conclude that Ineffective Thermoregulation is causing those signs? What other explanations might there be for cyanotic nailbeds, pallor, and slow capillary refill?

You may be very general or very specific with these answers, depending on your level of knowledge of pathophysiology. Some causes for this cue cluster might be respiratory disorders, cardiac disorders, circulatory disorders, or possibly anemia. Not all of the defining characteristics need to be present to make a diagnosis, but recall that the more data you have when you make an inference, the more certain you can be that your inference is correct

Choosing nursing interventions

examples of each of these approaches to choosing nursing interventions. Professional standards: The American Nurses Association Standards of Nursing Practice (ANA 2015, Standard 5, p. 61) states that the registered nurse "uses evidence-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem or need." Theories: A theory is a set of interrelated concepts (ideas) that describes or explains something; nursing, for example. A theory, like a lens, influences your perspective. Nursing research: Standard 13 of the ANA Scope and Standards of Practice, Nursing (ANA, 2015, p. 77), states that the registered nurse "uses current evidence-based knowledge, including research findings, to guide practice." Institute of Medicine: The purpose of the IOM core competencies is to employ evidence-based practice. This includes integrating clinical expertise with knowledge of current research. SENC competencies: These competencies used in this text are similar to the IOM competencies. They require that the nurse validate evidence-based research to incorporate it into client care and evaluate client outcomes using evidence-based research tools. QSEN competencies: State that when you graduate from your nursing program, you should be able to differentiate clinical opinion from research and evidence summaries