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Foundations Test 1 - Nursing Process: Assessment, Diagnosis, & Clustering Notes
Terms in this set (33)
Nursing Process equals what?
Nursing process = Care planning
What are the 5 steps to the nursing process?
What are the 5 critical thinking activities that are linked to assessment?
1. Assess systematically and comprehensively to identify nursing and medical concerns. (Think head to toe assessment)
2. Detecting bias and determining the credibility of information sources.
3. Distinguishing normal from abnormal findings and identifying risks for abnormal findings.
4. Making judgments about the significance of data, distinguishing relevant from irrelevant data.
5. Identifying assumptions and inconsistencies, checking accuracy and reliability, and recognizing missing information.
During assessment, what is the nurse's primary source of information?
What is assessment?
The systematic and continuous collection, analysis, validation, and communication of patient data or information?
What are the 5 different methods of data collection?
1. Use of Assessment Forms
3. Nursing Health History
5. Labs/Other Tests
What are the 4 phases of a nursing interview?
1. Preparatory Phase
3. Working Phase
What are the 3 main purposes of a nursing physical assessment?
1. Appraisal of health status
2. Identification of health problems
3. Establishment of a database for nursing intervention
What happens if your assessment is incomplete or inaccurate?
It results in an incorrect nursing care plan and it will not provide a sufficient plan of care for the client.
During assessment phase, what are the 8 sources of data?
1. Patient, family, and significant others.
2. Physical assessment findings.
3. Medical history and progress notes.
5. Reports of labs and other diagnostic studies.
6. Reports of therapies by other health care professionals.
7. Medications, wounds, or dressings including the *location*, IV sites including
ions, wounds, or dressings including the *location*, IV sites including *location*, and other tubes, drains, or devices that the patient was not born with.
8. Nursing and other health care literature.
How should data be interpreted?
- Compare to norms
- Heart of critical thinking
How should data be clustered?
By the functional patterns or body systems.
What is a Nursing Diagnosis?
A statement that describes a patient's actual or potential response to a health problem that the nurse is licensed and competent to treat.
What is NANDA?
North American Nursing Diagnostic Association
What are the purposes of the nursing diagnosis?
- Identify how an individual, group, or community responds to actual or potential health and life processes.
- Identify factors that contribute to, or cause health problems. (etiologies)
- Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems.
What are the 3 parts of the nursing diagnosis?
1. Problem - Identifies what is unhealthy about the patient.
2. Etiology - Identifies factors maintaining the unhealthy state.
3. Defining Characteristics - Identifies the subjective and objective data that signal the existence of a problem.
What is the 1st step in determining the nursing diagnosis?
After data is analyzed and clustered, determining which nursing diagnosis seems appropriate. (you may choose a broad category like Respiratory)
What is the 2nd step in determining the nursing diagnosis?
Read the definition first to be sure it is the correct diagnosis. Look at the defining characteristics to see that you that these in your data cluster.
ex: ineffective breathing patterns vs gas exchange impariment
What is the 3rd step in determining the nursing diagnosis?
Determine if the diagnosis is an actual or potential problem.
Actual - Currently a problem.
Potential - A problem that could occur or that the pt is at risk for.
What is the "related to" statement?
The etiology, the WHY, or the pathophysiology behind the disease.
What is the purpose of the "related to" statement?
It allows for individualization of care plan
What is important regarding the "related to " statement?
- Medical diagnosis is not an etiology
- It must be in the domain of nursing
- It is supported by assessment data, but IS NOT data
- It is NOT a definition of the diagnosis
Example of a related to statement
Ineffective breathing pattern related to ineffective pumping action of the heart
A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario?
a. Lung Cancer
b. Test Results
c. Smoking Cigarettes
d. The subjective and objective data
c. Smoking Cigaretts
What is a secondary statement?
A statement that can be added which CAN be a medical diagnosis
Example of secondary statement
Ineffective breathing pattern related to ineffective pumping action of the heart secondary to CHF
ALWAYS USE SPECIFICATIONS: Here are some examples!
- Risk for Injury: hemorrhage
- Tissue Perfusion alteration: cerebral
- Tissue Perfusion alteration: cardiopulmonary
Nursing Diagnosis vs Medical Diagnosis:
- Nursing needs of patient's health or illness response
- Assist to adapt to illness or resolve health care problem
- Based on assessment
- Specific disease state
- Cure disease
- Based on assessment
What are the major sources of error when writing a nursing diagnosis?
- Making legally inadvisable statements
- Reversing the clauses
- Identifying environmental factors rather than patient factors as the problem
- Identifying as a patient response what is not necessarily unhealthful
- Having both clauses say the same thing
- Identifying as a patient problem what cannon be changed
Which of the following nursing diagnosis is written correctly?
a. Child abuse related to maternal hostility.
b. Breast Cancer related to family history.
c. Deficient Knowledge related to alteration in diet.
d. Imbalanced Nutrition related to insufficient funds in meal budget.
D. Imbalanced Nutrition related to insufficient funds in meal budget.
What are the advantages of nursing diagnosis?
1. Facilitates Communication
-- Prioritizes needs
-- Organized communication
-- Continuity of care
2. Quality Improvement
-- Correct care
-- Standard met
3. Individualized Care
What are the limitations of nursing diagnosis?
- "Labels" (non-compliant)
- Evolving taxonomy
Things to remember!
- The data drives the diagnosis, not vice versa.
- Data supports the diagnosis, not the related to statement.
- A nurse should incorporate critical thinking in the decision-making steps to determine which diagnosis is correct.
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