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Terms Definitions
Which component of the nursing process?

Conducting initial interview
Assessing
Which component of the nursing process?

Collect nursing health history.
Assessing
Which component of the nursing process?

Perform physical assessment
Assessing
Which component of the nursing process?

Document assessment data.
Assessing
What is the primary purpose of assessing? To create a database for the client
When you make a clinical judgment, you are really performing which component of the nursing process? Diagnosing
Which component of the nursing process?

Analyze the data base.
Diagnosing
Which component of the nursing process?

Derive conclusions based on the analysis of the client's data base
Diagnosing
Which component of the nursing process?

Assign diagnostic labels
Diagnosing
Which component of the nursing process?

Determine causative factors
Diagnosing
Which component of the nursing process?

Formulate a diagnostic statement, including defining characteristics
Diagnosing
Which component of the nursing process?

Establish priorities
Planning
Which component of the nursing process?

Establish goals
Planning
Which component of the nursing process?

Formulate outcome criteria
Planning
Which component of the nursing process?

Identify nursing interventions
Planning
Which component of the nursing process?

Formulate a plan of care
Planning
Which component of the nursing process?

Organize interventions
Implementing
Which component of the nursing process?

Perform interventions
Implementing
Which component of the nursing process?

Review outcome criteria
Evaluating
Which component of the nursing process?

Collect data related to outcome criteria
Evaluating
Which component of the nursing process?

Compare data to outcome criteria and determine whether outcomes were attained
Evaluating
Which component of the nursing process?

Summarize inferences regarding evaluation outcome
Evaluating
Which component of the nursing process?

Take appropriate action based on the outcome of evaluations
Evaluating
(def)

a clinical judgment about an individual, family, or community
Nursing diagnosis
A nursing diagnosis is a clinical judgment that is a response to ________ and ________ health problems / life processes. Actual and Potential
A proper nursing diagnosis provides the basis for what? the selection of interventions that will achieve outcomes that the NURSE is accountable for
Describe what a "Wellness Nursing Diagnosis" is? a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness
What 2 cues must be present for an individual or group to have a wellness diagnosis? 1. a desire for a higher level of wellness
2. effective present status or function
A Wellness Nursing Diagnosis will begin with what specific label? "Readiness for Enhanced"
The following nursing diagnosis is an example of what type of diagnosis?

"Readiness for Enhanced Community Coping"
Wellness Nursing Diagnosis
What is the primary differences between a nursing diagnosis and a medical diagnosis? A nursing diagnosis describes a patient's response to a disease or a condition. It is dynamic (can change as the client's response changes).

A medical diagnosis describes a specific disease. It will remain constant throughout the duration of the illness.
What is the purpose of using standard terminology (NANDA definitions) when preparing a nursing diagnosis? To facilitate communication among nurses
A client's database is derived from both the health history and the physical examination. Why would you want to use both sources when determining your nursing diagnoses? To promote holistic care of the client
A nursing diagnosis provides direction for what? the planning of independent nursing interventions

(Nursing Diagnoses should be treated by nursing interventions, not medical interventions. A proper diagnosis should be able to be treated with a proper "nursing" intervention)
How do nursing diagnoses promote professional accountability and autonomy? they define and describe the independent area of the nursing practice

(there is an NANDA list of approved diagnoses that nurses can treat)
Diagnosing is a process of ________ and _________. analysis and synthesis
(def)

the portion of the diagnostic process that involves the separation of information into components
analysis
(def)

the portion of the diagnostic process that involves taking information and putting it together to form a whole
synthesis
What is the purpose of using Gordan's functional health patterns and a head-to-toe physical assessment? to gather and organize information

(to organize the data)
Inferences are made how? by comparing the data obtained to standards
When comparing the data you obtain to standards, you are essentially asking what basic question when looking at each piece of information? Is this normal or abnormal?
What are 5 examples of standards that you may compare data with? 1. normal health patterns
2. normal vital signs
3. laboratory values
4. growth and development
5. Erickson's developmental stages
The process of determining the relatedness of data and grouping the data is known as what? Clustering Data
Clustering data increases the accuracy of what? inferences
What are the 4 guidelines you should follow when clustering data? 1. search for abnormal cues
2. look for patterns in the database
3. use references to compare the client's cues with defining characteristics and etiologic factors of accepted nursing diagnoses
4. make an inference about the data cluster and label with a tentative diagnostic label
What is the next step in developing a diagnosis after you have developed a tentative diagnostic label? Verify the interpretation with the client.
Upon discussion of the tentative diagnostic label with the patient, the nurse and patient can make what (4) possible conclusions? 1. No problem exists
2. No problem exists, but a potential problem is present
3. A problem exists that the nurse can treat
4. A problem exists that the nurse cannot treat and must be referred.
After discussing your interpretation of data with the client and determining a conclusion based off of your interaction with the client, what is your next step? Finalizing the diagnostic statement
(def)

the part of the nursing diagnosis statement which is a description of the client's health problem (actual or risk) for which nursing therapy is given
diagnostic label
(def)

the part of a nursing diagnosis statement which refers to the etiology or contributing factors
Related factors
What are the 3 purposes of "related factors" within the diagnostic statement? 1. identify one or more probable causes of the health problems/diagnostic label
2. give direction to the nursing intervention
3. individualize the nursing diagnosis
(def)

cluster of signs and symptoms/clinical criteria that support the presence of the diagnostic category label
Defining characteristics
In formulating a nursing diagnosis, what is the next step after you have determined your related factors and defining characteristics? You complete your nursing diagnosis
When completing your nursing diagnosis, what determines if you will use a two-part or three-part statement? You will use a two-part statement for risk diagnosis. (PE - will consist of the problems/diagnostic label and the etiology/related-to factors)

You will use a three-part statement for actual diagnoses. (PES- will consist of Problem/diagnostic label, Etiology/Related-to factors, and Signs and symptoms/defining characteristics)
Correct the following diagnostic label and explain the reasoning for the correction:

"needs suctioning"
"Risk for aspiration"

- "needs suctioning" would be an intervention, not a diagnostic label. Diagnostic labels must come from the NANDA approved list
Correct the following Nursing Diagnosis:

Risk for injury due to change in mental status
Risk for injury R/T change in mental status

(never use the term due to)
Correct the following diagnostic label and explain the reasoning for the correction:

Impaired skin integrity R/T infrequent turning.
Impaired skin integrity R/T immobility.

(Never imply negligence or blame in a nursing diagnosis)
Correct the following diagnostic label and explain the reasoning for the correction:

Spiritual distress R/T strict rules necessitating church attendance.
Spiritual distress R/T inability to attend services.

(Never write a diagnosis with a value judgment, which means including your personal values and beliefs)
Correct the following diagnostic label and explain the reasoning for the correction:

Rapid respirations R/T increased airway secretions.
Ineffective Breathing Pattern R/T increased airway secretions.

(Never use a sign/symptom as your diagnostic statement. Use the NANDA list of diagnostic statements)
Correct the following diagnostic label and explain the reasoning for the correction:

Risk for ineffective airway clearance R/T Emphysema
Risk for ineffective airway clearance R/T accumulation of lung secretions.

(a medical diagnosis is never used UNLESS it is secondary to. Your R/T should always be something that can be treated by a nursing intervention.)
Correct the following diagnostic label and explain the reasoning for the correction:

Anxiety R/T cardiac monitoring.
Deficient knowledge: purposes and need for cardiac monitoring R/T lack of exposure to information.

(identify the client's response to equipment or treatment, not the equipment or treatment itself)
Correct the following diagnostic label and explain the reasoning for the correction:

Offer bedpan frequently R/T of diarrhea.
Diarrhea R/T intolerance to milk-based foods.

(your statement should never include your interventions.)
Correct the following diagnostic label and explain the reasoning for the correction:

Pain and anxiety R/T difficulty ambulating.
- Anxiety R/T difficulty in ambulating.
- Impaired physical mobility R/T discomfort in (R) knee.

(There should only be one problem in a diagnostic statement. Write out each separately)
True/False:

There should only be one related factor in a diagnostic statement.
False- Although you can only have one problem, you can have one or more related factors.

For Example:

Impaired Nutrition: more than body requirements R/T limited physical activity and increase in fat and calories in diet.
When planning your care, the diagnoses you have identified are ranked by order of what? importance - higher priority items are placed at the top
What framework is often used to help determine priority of diagnoses? Maslow's hierarchy of needs
Would the following have a high, intermediate, or low priority:

Ineffective airway clearance
High Priority
Needs that required immediate attention are ranked a ______ priority. High
Needs that involve non-emergency, non-life threatening situations would be ranked a ______ priority. Intermediate
Needs that may not be directly related to a specific illness or prognosis, but may affect their future well-being would be ranked a _____ priority. low
When establishing your client's Expected Outcome, you will include both goals and outcome criteria. Describe each. Goals = broad statements reflecting resolution of the diagnostic label/problem

Outcome criteria = specific, measurable, observable statements that reflect the resolution of the defining characteristics
True/False:

An expected outcome is realistic in relation to the client's present and potential capabilities.
True
True/False:

An expected outcome is attainable in relation to the resources available to the client.
True
True/False:

An expected outcome is vague and may explain positive and negative outcomes.
False-

An expected outcome is clear, concise, and in positive terms
True/False:

An expected outcome should include a time estimate for attainment.
True
Who should formulate the expected outcome? When possible, both the nurse and client should formulate the expected outcome.
What is the overall purpose of an expected outcome? It is used to provide direction to nursing interventions and measure the validity of the interventions.
True/False:

An expected outcome is essentially a nursing intervention.
False- an expected outcome would be the result of a nursing intervention. They are not one in the same.
(def)

specific actions the nurse takes that are designed to assist the client to achieve expected client outcomes
Nursing interventions
Nursing interventions are individually tailored to meet the specific needs of a client. They should be designed to resolve what? the "related factors"
True/False:

Nursing interventions should only include your actions (care), never assessing, assisting, or teaching
False-

Include nursing interventions that are assessing, assisting, and teaching
Nursing interventions reflect the prescribed care that is required to do what (3) things? - monitor a problem (assessing)
- prevention of a problem
- treatment/resolution of a problem
What is the goal of nursing interventions if the nursing diagnosis is "Risk for..."? They should provide protection or precautionary measures
The verbs used in a nursing intervention are specific ones that direct what? They direct the nurse's actions (for example, assess, instruct, place, observe, etc.)
How would YOU guarantee that others are able to follow your care plan when you are not available? Make sure that your nursing interventions are specific! Use specific times, frequencies, amounts, etc.
Nursing interventions can be what (3) types? 1. Physician-Initiated
2. Nurse-Initiated
3. Collaborative
What is wrong with the following nursing intervention:

Provide hydrogen peroxide mouthwash for client.
It is not specific. A correctly stated nursing intervention would be -

Provide 50mL of hydrogen peroxide mouthwash for the client every 2 hours while awake.
True/False:

As a student, it is not important to understand the rationale behind a nursing intervention as long as you implement it properly.
False- you should be able to identify rationales for all nursing interventions. You can find rationales in your text books, notes, care plan books, etc.
What are critical pathways and computerized care plans? standard plans of care developed to set daily care priorities for specific diagnoses, promote timely achievement of outcomes, and reduce the length of hospital stays.
(def)

a system of organizing client information to develop a comprehensive plan of care
Care Map
_________ is simply carrying out the plan of care. Implementing
What are the 4 components of evaluating the plan of care? 1. Review outcome criteria
2. collect data related to the outcome
3. compare data collected with the outcome to determine if they were attained
4. Make inferences and take appropriate action if needed.
(def)

nursing interventions performed when implementing the medical regimen, such as giving medications and treatments
Physician-Initiated interventions
(def)

nursing interventions that evolve form the nursing diagnosis and do not require a physician's order
Nurse-Initiated interventions
(def)

Nursing orders that are performed by nurses in collaboration with other members of the health team
Collaborative interventions
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