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ULL nursing 204 Exam 2 `
purpose of nursing process correct answersis to diagnose and treat human responses to actual or potential health problems nursing process correct answersconsists of 5 phases: assessment, diagnosis, planning, implementation, evaluation ana scope and standards of practice correct answersStandard 1. Assessment "The RN collects pertinent data and information relative to the healthcare consumer's health or the situation." Standard 2. Diagnosis "The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues." Standard 3. Outcomes Identification "The RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation." Standard 4. Planning "The RN develops a plan that prescribes strategies to attain expected, measurable outcomes." Standard 5. Implementation "The RN implements the identified plan." 5A Coordination of Care
5B Health Teaching and Health Promotion Standard 6. Evaluation "The RN evaluates progress toward attainment of goals and outcomes." assessment correct answersfirst step. Collect data/ information assessment process correct answersBegins: initial meeting between nurse & client/family Next step: obtain info about the clients current and past problems. Analyze data: organize cluster behavior and make inference on S&O. Verify data: validate data and inferences with client. Types of info to collect from client for assessment correct answersHistory- past records and tests, other health care team members, family history. Physical exam- observation, current tests, measurements Assessment: data collection correct answerstwo types: Subjective (states) and Objective (observed)
Collaborative Problem: Risk for complications Problem - Focused ND correct answersHuman responses to health conditions/ life processes that can exist in an individual, family, or community. Supported by defining characteristics that clusters in patterns of related cues or inferences. -Major: must be present. -Minor: provide support, but may or may not be present. know diff bt major and minor correct answers Risk & High-Risk ND correct answersHuman response to health conditions that may develop in a vulnerable individual, family, or community. supported by risk factors that contribute to increased vulnerability. Risk & High-Risk Risk correct answersexpected or predictive diagnoses for all individuals who are undergoing some situation. High-Risk correct answersfor people with additional risk factors that may be vulnerable for the problem to occur. Possible ND correct answersDescribes suspected problem requiring additional data to confirm or rile out (r/o). Once additional data is collected the nurse can: -confirm presence of major s/s and label as problem-focused ND. -Confirm presence of potential risk actors and label as Risk ND. -R?O presence of diagnosis at this time.
Health-Promotion ND correct answersA clinical judgement of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in the readiness to enhance specific health behaviors, such as nutrition and exercise. To use health-promotion ND two cues should be present: correct answersA desire for increased wellness effective present status or function in specific health beahvior. Syndrome ND correct answersCompromise a cluster of predicted problem focused (actual) or high-risk ND relates to a certain event or situation. Are diagnostic statement with etiologic and contributing factors contained in the diagnostic label. Syndrome ND EX: correct answersRisk for Disuse Syndrome- has a cluster of ND related to inactivity. No need to write R/T - understood Collaborative Problems (CP) correct answersCertain physiological complications that nurses monitor to detect onset or changes in status. Nurses manage CPs using physician-prescribed and nursing-prescribed intervention to minimize the complications of the events. Three Components (parts) of ND correct answers1. Problem- label or "diagnostic label"
- Cause- etiology pr "relates to" factors (R/T) 3.Evidence - signs & symptoms- " as evidence by" (AEB) "defining characteristics"
love/belonging, safety, physiological example of each layer correct answers Avoid Errors in Diagnostic Statements correct answersDO NOT write diagnostic statements in terms of: -cues, inferences, goals, client needs, nursing needs. avoid legally inadvisable or judgmental statements Examples of Errors correct answersIncorrect- Risk for infection r/t Diabetes. Correct- Risk for infection r/t increased microorganisms actively with hyperglycemia Step 3. Planning correct answersNurse & client mutually decide on plan of care (POC) and anticipated outcomes. -Based on assessment data. -Specifies short-term goals (outcome criteria) -Includes action to support achievement of expected outcomes. .... Client-centered.... Identifying expected outcomes correct answersclient-centered, described in specific measurable terms, based on diagnoses, developed collaboratively with client and other healthcare (HC) providers, Realistic and achievable (attainable), Specify the action (behavior) client will demonstrate once HC problem is resolved.
Outcome statement components correct answersSubject: who is expected to achieve the outcome? Verb: what action must the subject take to achieve the outcome? Condition: under what circumstances is the subject the subject to perform the action? Performance criteria: how well is the subject to perform the action? Target Time: by when is the subject expected to perform the action? Example outcome statement correct answersClient recovering from surgery: "The client will consistently show no signs of infection AEB the incision being well-approximated and free of redness and swelling, normal temperature (98.6⁰ F), and WBC within normal limits (5,000- 10,000mm³) by 9/21/09". Step 4: Implementation correct answersTaking agreed-on action to alter client's status/symptoms. Consists of: Encouraging, supporting, and validating the client to achieve goals through integrated, therapeutic nursing interventions and communication strategies. Prescribing Nursing Interventions (NIs) correct answersNurse-prescribed (NP): Nurse formulates for self or other nursing staff to implement Physician-prescribed (delegated) (PP): Physician formulates for nursing staff to implement Focus of NIs correct answersProblem-Focused ND, Possible ND, Risk ND, Collaborative problems Problem- Focused ND correct answersReduce or eliminate contributing factors or the diagnosis Promote wellness Monitor & evaluate status Possible ND correct answersCollect additional data to rule out or confirm the diagnosis
Standardized language correct answersUse of standardized terminologies & taxonomies (coding systems) help: Classify nursing care & outcomes. Clearly communicate a common message. Compare & evaluate effectiveness of care. Describe care given, its effects, or to establish cost for nursing's contributions. Goals of standardized language correct answersGoals: improve communication, make nursing practice visible within the health information systems, and to assist in establishing evidence-based nursing practice. Taxonomy correct answersHierarchical method of classifying a vocabulary of terms according to certain rules. Used in nursing to communicate & compare across health care settings & providers, insurers, and payers, and policy makers who set priorities and allocate resources. Standardized language using nursing taxonomies correct answersNANDA, NIC, NOC NADA- North American Nursing Diagnosis Association correct answersFocus on Nursing Diagnoses Health problems that nurses can treat NIC- Nursing Interventions Classification correct answersFocus on Nursing Interventions Actions nurses perform NOC- Nursing Outcomes Classification correct answersFocus on Outcomes Client outcomes attained through nursing actions Critical Thinking (CT) correct answersa tool of inquiry, an analytical process, involves self-reflection, a cognitive process and affective component
Critical Thinking correct answersencompasses the steps in the nursing process... in a circular loop than the nursing process appears. allows the nurse to modify the care plan based on the clients's responses to his/her nursing interventions. Characteristics of a CT correct answersAttitude, thought process, actions Attitude in CT correct answersanalytical, inquisitive, systematic, open-minded, flexible thinking process Through process in CT correct answersreflective, transformational, logical, creative, persevere in seeking relevant information, discriminate, consider alternatives Actions in CT correct answersrecognize gaps & seek new input, revise actions, evaluate solutions and outcomes Patient-centered care correct answersempowering the client/family to be a full partner in providing compassionate, coordinated care. patient-centered care: correct answersknowledge, skills, attitudes Patient-centered care: Knowledge correct answersintegrates multiple dimensions of care, inc. communication to involve the client & family Patient-centered care: Skills correct answerselicit values& preference during your initial interview & care plan development to communicate client preferences to other HC members Patient-centered care: Attitudes correct answersvalue expressions of client values, as well as their expertise regarding their own health status Evidence- Based Practice (EBP) correct answersblending extensive clinical experience with sound clinical research and professional judgment in real-time client situations. Incorporating the best practices base on the newest evidence with our clinical expertise to deliver optimal care.
Accessible to all providers across all settings Should harmonize data requirements for home care, long-term care, acute & post-acute care patient- centered LPC. Using the NP in Nurse-Patient Relationships correct answersOrientation Phase > Working Phase> Termination Phase Orientation Phase correct answers1. Assessment (data)
- Diagnosis ( Problem ID) Working Phase correct answers3. Planning (Develop Action)
- Implementation (Take Action) Termination Phase correct answers5. Evaluation (Success or not) Family correct answersis who they say they are Nuclear family correct answersa father and mother, with one or more children, living together as a single family unit Extended family correct answersnuclear family unit's combination of second-and third-generation members related by blood or marriage but not living together Three-generational family correct answersany combination of first-, second-, and third-generational members living within a household Dyad family correct answershusband and wife or other couple living alone without children single-parent family correct answersdivorced, never married, separated, or widowed male or female and at least one child; most single-parented families are headed by women
stepfamily correct answersfamily in one or both spouses are divorced or widowed with one or more children from previous marriages who may not live with newly reconstituted family blended or reconstituted family correct answersa combination of two families with children from one or both families with children and sometimes children of newly married couple common law family correct answersan unmarried couple living together with or without children not legal in louisiana No kin correct answersa group of a least two people sharing a nonsexual relationship and exchanging support who have no legal, blood,or strong emotional tie to each other polygamous family correct answersone man (or woman) with several spouses same-sex family correct answersa homosexual or lesbian couple living together with or without children commune family correct answersgroups of individuals (may or may not be related) living together with or without children group marriage correct answersall individuals are " married" to one another are considered parents of all the children biological families correct answers- created without loss
- shared family traditions
- one set of family rules
- children one at a time
- biological parents live together blended families correct answers-born of loss
morphogenesis: how the family grow to change feed back loop: describes pattern that moves toward morphogenesis or morphostasis Bowen 8 interlocking concepts to explain his theoretical construct of the family system correct answers- Differentiation of self
- multi-generational transmission -nuclear family emotional system
- triangle -family-project process -sibling position -emotional cutoff -societal emotional process pa 220- Other Family Theories correct answers-structural family theory -developmental family theory
- family stress theory pa 221 Structural family theory correct answersStructures: subsystems, hierarchies, & boundaries Function: instrumental & expressive Developmental family theory correct answersDevelopmental tasks from childless families to retirement Family stress theory correct answersFamily response to & coping with stressful events
made by bowan 8 interlocking parts once anxiety enters system an emotional process starts Family-Centered Care correct answersGives health care providers (HCPs) a more uniform understanding of client & family's knowledge, preferences, & values Helps HCPs to give consistent information to all involved in client's care Health of 1 family member affects the whole family Some challenges to the nurse for family-centered care correct answers- To understand the impact of medical crisis on family functioning and dynamics etc.. Family Assessments correct answersDefine the family- who is capable & willing to provide family-type support Family Assessment Tools correct answers-Genograms -Ecomaps -Family Time Lines Genograms correct answersuses a standardized set of connections to graphically record basic information about family members and their relationships over three generations. Three parts - mapping family structure, recording family information, and describing the nature of family relationships. pa 224-
Note: Family participation in the process can enhance the therapeutic relationship & completeness of the data. Problem ID/Nursing Diagnosis correct answersIdentify problems r/t family communication and function. Be alert for cues of potential problem Make referrals as indicated Decide on potential nursing diagnoses (coping, therapeutic regimen, readiness) Planning AHRQ has developed "The guide to patient and family engagement in hospital quality and safety" correct answersStrategy 1. Working with patients and families as advisors.
- Communicating to improve quality
- Nurse bedside shift report
- IDEAL discharge planning planning 2 types of questions correct answerslinear circular Interventive questioning used to correct answersIdentify family strengths Help family members sort out personal fears, concerns, & challenges in health care Explore alternative options linear questions correct answersfacilitate understanding of a situation by both the nurse and family members.
circular questions correct answerslet to introspection, greater understanding, and behavior change. Implementation correct answers-Encouraging Family Narratives
tell their story -Incorporating Family Strengths resources, ability to cope -Giving Commendations recognizing capabilities, a pattern of behavior -Informational Support empower & engage Implementation: Meeting needs of families with critically ill clients correct answersProximity to the patient Breaking bad news to families Providing information Caring for families in Pediatric Intensive Care Unit Review Box 12-5, p. 234 Implementation:
