Podcast
Questions and Answers
A patient presents with laboured breathing, persistent cough, and decreasing oxygen saturation. The nurse correlates these findings as indicative of 'Impaired Gas Exchange'. Considering the nuances of NANDA-I taxonomy and diagnostic reasoning, which element is most crucial for differentiating this diagnosis from similar respiratory diagnoses, such as 'Ineffective Airway Clearance' or 'Ineffective Breathing Pattern'?
A patient presents with laboured breathing, persistent cough, and decreasing oxygen saturation. The nurse correlates these findings as indicative of 'Impaired Gas Exchange'. Considering the nuances of NANDA-I taxonomy and diagnostic reasoning, which element is most crucial for differentiating this diagnosis from similar respiratory diagnoses, such as 'Ineffective Airway Clearance' or 'Ineffective Breathing Pattern'?
- The patient's subjective reporting of dyspnea, as this is the most reliable indicator of impaired gas exchange.
- The nurse's intuition and prior experience with similar cases, which allows for a more holistic understanding of the patient's condition beyond objective data.
- The specific clustering of defining characteristics that clearly delineate gas exchange abnormalities at the alveolar-capillary level, beyond mere mechanical issues of airway patency or ventilatory effort. (correct)
- The explicit etiology of the condition, whether it is pneumonia, COPD exacerbation, or pulmonary embolism, according to the medical diagnosis.
In the context of formulating a 'Risk for Infection' nursing diagnosis, a patient exhibits a surgical incision site with localized erythema, a history of methicillin-resistant Staphylococcus aureus (MRSA) colonization, and recent administration of broad-spectrum antibiotics. Which component represents the MOST critical and specific risk factor to include in the diagnostic statement, ensuring targeted preventive interventions?
In the context of formulating a 'Risk for Infection' nursing diagnosis, a patient exhibits a surgical incision site with localized erythema, a history of methicillin-resistant Staphylococcus aureus (MRSA) colonization, and recent administration of broad-spectrum antibiotics. Which component represents the MOST critical and specific risk factor to include in the diagnostic statement, ensuring targeted preventive interventions?
- The synergistic effect of the surgical incision, MRSA colonization, and antibiotic use, creating an opportunistic environment for infection. (correct)
- A history of MRSA colonization, creating an inherent reservoir for potential infection.
- Alteration in intestinal flora related to broad-spectrum antibiotic therapy, disrupting the body's natural defenses.
- Compromised integumentary system, related to the surgical incision, which universally elevates infection risk.
A palliative care patient expresses a desire to deepen their spiritual connection and find meaning in their suffering. Which nursing diagnosis best reflects this patient's needs, aligning with NANDA-I classifications and promoting holistic well-being?
A palliative care patient expresses a desire to deepen their spiritual connection and find meaning in their suffering. Which nursing diagnosis best reflects this patient's needs, aligning with NANDA-I classifications and promoting holistic well-being?
- Ineffective Coping related to spiritual needs, as evidenced by seeking spiritual guidance.
- Spiritual Distress related to chronic illness and existential questioning, as evidenced by expressed lack of meaning.
- Anxiety related to uncertain prognosis, as evidenced by spiritual questioning.
- Readiness for Enhanced Spiritual Well-Being, as evidenced by the desire to deepen spiritual connection and find meaning during palliative care. (correct)
An elderly patient with a history of multiple falls, cognitive impairment, and decreased bone density lives alone. The nurse identifies 'Risk for Falls' as a primary nursing diagnosis. Considering contributing factors, which intervention demonstrates the MOST comprehensive approach to mitigating this risk, addressing the complex interplay of physiological and environmental determinants?
An elderly patient with a history of multiple falls, cognitive impairment, and decreased bone density lives alone. The nurse identifies 'Risk for Falls' as a primary nursing diagnosis. Considering contributing factors, which intervention demonstrates the MOST comprehensive approach to mitigating this risk, addressing the complex interplay of physiological and environmental determinants?
Following a complex spinal fusion surgery, a patient reports excruciating pain despite receiving the prescribed opioid analgesics. The nurse documents 'Chronic Pain related to nerve compression secondary to surgical intervention'. Given the intricacies of pain management, which additional assessment parameter is MOST critical for refining this diagnosis and guiding individualized interventions?
Following a complex spinal fusion surgery, a patient reports excruciating pain despite receiving the prescribed opioid analgesics. The nurse documents 'Chronic Pain related to nerve compression secondary to surgical intervention'. Given the intricacies of pain management, which additional assessment parameter is MOST critical for refining this diagnosis and guiding individualized interventions?
A patient with chronic obstructive pulmonary disease (COPD) is admitted with acute respiratory distress. Considering the principles of goal and outcome statement formulation, which of the following outcome statements demonstrates the MOST appropriate application of SMART criteria, while also acknowledging the complexities of managing a chronic condition?
A patient with chronic obstructive pulmonary disease (COPD) is admitted with acute respiratory distress. Considering the principles of goal and outcome statement formulation, which of the following outcome statements demonstrates the MOST appropriate application of SMART criteria, while also acknowledging the complexities of managing a chronic condition?
In the context of collaborative interventions for a patient recovering from a stroke with residual dysphagia, which outcome statement BEST reflects interprofessional collaboration and acknowledges the limitations of short-term interventions, focusing on long-term improvement?
In the context of collaborative interventions for a patient recovering from a stroke with residual dysphagia, which outcome statement BEST reflects interprofessional collaboration and acknowledges the limitations of short-term interventions, focusing on long-term improvement?
A patient is admitted with heart failure exacerbation. Considering the guidelines for formulating effective goal and outcome statements, which of the following options exemplifies the MOST appropriate approach to addressing the patient's fluid volume overload while avoiding common pitfalls in outcome statement construction?
A patient is admitted with heart failure exacerbation. Considering the guidelines for formulating effective goal and outcome statements, which of the following options exemplifies the MOST appropriate approach to addressing the patient's fluid volume overload while avoiding common pitfalls in outcome statement construction?
In planning care for a patient with a new diagnosis of type 2 diabetes mellitus, which outcome statement demonstrates the MOST effective application of SMART criteria, while also integrating patient education and self-management strategies?
In planning care for a patient with a new diagnosis of type 2 diabetes mellitus, which outcome statement demonstrates the MOST effective application of SMART criteria, while also integrating patient education and self-management strategies?
A patient recovering from a hip replacement is experiencing significant pain and limited mobility. Considering the principles of effective goal and outcome statement formulation, which of the following options BEST reflects an appropriate and realistic outcome, recognizing the complexities of postoperative pain management and rehabilitation?
A patient recovering from a hip replacement is experiencing significant pain and limited mobility. Considering the principles of effective goal and outcome statement formulation, which of the following options BEST reflects an appropriate and realistic outcome, recognizing the complexities of postoperative pain management and rehabilitation?
For a patient newly diagnosed with generalized anxiety disorder, which outcome statement best encompasses the principles of SMART goals while also acknowledging the chronic nature of anxiety and emphasizing adaptive coping mechanisms:
For a patient newly diagnosed with generalized anxiety disorder, which outcome statement best encompasses the principles of SMART goals while also acknowledging the chronic nature of anxiety and emphasizing adaptive coping mechanisms:
A patient is admitted with a stage III pressure ulcer on their sacrum. Considering the established guidelines for outcome statement formulation, which option exemplifies the MOST appropriate statement that incorporates SMART principles, while recognizing the challenges of wound healing and the potential for collaborative interventions?
A patient is admitted with a stage III pressure ulcer on their sacrum. Considering the established guidelines for outcome statement formulation, which option exemplifies the MOST appropriate statement that incorporates SMART principles, while recognizing the challenges of wound healing and the potential for collaborative interventions?
Within the framework of complex patient care scenarios, how does the application of Orlando's nursing process theory interface with contemporary models of clinical decision support systems that utilize Bayesian networks for probabilistic reasoning?
Within the framework of complex patient care scenarios, how does the application of Orlando's nursing process theory interface with contemporary models of clinical decision support systems that utilize Bayesian networks for probabilistic reasoning?
Considering the cyclical nature of the nursing process, what are the implications of prematurely terminating the evaluation phase due to resource constraints or perceived clinical stability, and how might this impact long-term patient outcomes and the ethical obligations of healthcare providers?
Considering the cyclical nature of the nursing process, what are the implications of prematurely terminating the evaluation phase due to resource constraints or perceived clinical stability, and how might this impact long-term patient outcomes and the ethical obligations of healthcare providers?
In the context of interprofessional collaborative practice, how can the nursing process be leveraged to facilitate shared decision-making and optimize patient-centered care across diverse healthcare disciplines with varied epistemological perspectives?
In the context of interprofessional collaborative practice, how can the nursing process be leveraged to facilitate shared decision-making and optimize patient-centered care across diverse healthcare disciplines with varied epistemological perspectives?
Considering the increasing prevalence of chronic diseases and the growing emphasis on preventive care, how can the nursing process be adapted to promote patient empowerment, self-management, and long-term adherence to therapeutic regimens within community-based settings?
Considering the increasing prevalence of chronic diseases and the growing emphasis on preventive care, how can the nursing process be adapted to promote patient empowerment, self-management, and long-term adherence to therapeutic regimens within community-based settings?
In light of emerging technologies such as artificial intelligence and machine learning, how might the traditional phases of the nursing process be augmented or transformed to enhance diagnostic accuracy, personalize treatment plans, and optimize resource allocation within complex healthcare systems?
In light of emerging technologies such as artificial intelligence and machine learning, how might the traditional phases of the nursing process be augmented or transformed to enhance diagnostic accuracy, personalize treatment plans, and optimize resource allocation within complex healthcare systems?
A patient with chronic kidney disease presents with peripheral edema, dyspnea, and elevated BNP. Which nursing diagnosis formulation best reflects the etiology compliant with NANDA-I guidelines?
A patient with chronic kidney disease presents with peripheral edema, dyspnea, and elevated BNP. Which nursing diagnosis formulation best reflects the etiology compliant with NANDA-I guidelines?
A patient is admitted with a sacral pressure ulcer, Stage III, complicated by MRSA infection and malnutrition. Considering the NANDA-I guidelines for related factors, which of the following nursing diagnoses is most accurately formulated?
A patient is admitted with a sacral pressure ulcer, Stage III, complicated by MRSA infection and malnutrition. Considering the NANDA-I guidelines for related factors, which of the following nursing diagnoses is most accurately formulated?
A patient post-stroke exhibits unilateral neglect. Which formulation of the nursing diagnosis 'Unilateral Neglect' adheres most closely to NANDA-I guidelines regarding etiology?
A patient post-stroke exhibits unilateral neglect. Which formulation of the nursing diagnosis 'Unilateral Neglect' adheres most closely to NANDA-I guidelines regarding etiology?
A patient undergoing chemotherapy exhibits persistent nausea and vomiting, leading to significant weight loss and electrolyte imbalance. Which nursing diagnosis statement is most appropriate given NANDA-I guidelines?
A patient undergoing chemotherapy exhibits persistent nausea and vomiting, leading to significant weight loss and electrolyte imbalance. Which nursing diagnosis statement is most appropriate given NANDA-I guidelines?
An elderly patient with a history of falls and impaired mobility resides in a cluttered home with poor lighting. Which nursing diagnosis related to fall risk is most appropriately phrased according to NANDA-I guidelines?
An elderly patient with a history of falls and impaired mobility resides in a cluttered home with poor lighting. Which nursing diagnosis related to fall risk is most appropriately phrased according to NANDA-I guidelines?
A patient with heart failure is prescribed a sodium-restricted diet but frequently consumes high-sodium foods. Which nursing diagnosis concerning non-adherence is most consistent with NANDA-I standards?
A patient with heart failure is prescribed a sodium-restricted diet but frequently consumes high-sodium foods. Which nursing diagnosis concerning non-adherence is most consistent with NANDA-I standards?
A patient in the ICU develops ventilator-associated pneumonia (VAP). Considering NANDA-I guidelines, which nursing diagnosis is most appropriately formulated for this patient?
A patient in the ICU develops ventilator-associated pneumonia (VAP). Considering NANDA-I guidelines, which nursing diagnosis is most appropriately formulated for this patient?
A patient with a long history of opioid abuse is being treated for acute pancreatitis. Which nursing diagnosis best addresses the ethical considerations and NANDA-I guidelines in managing this patient's pain?
A patient with a long history of opioid abuse is being treated for acute pancreatitis. Which nursing diagnosis best addresses the ethical considerations and NANDA-I guidelines in managing this patient's pain?
During the assessment phase of the nursing process, a patient reports experiencing persistent abdominal pain. To effectively validate this subjective data, which action should the nurse prioritize, considering the complexities of pain perception and reporting?
During the assessment phase of the nursing process, a patient reports experiencing persistent abdominal pain. To effectively validate this subjective data, which action should the nurse prioritize, considering the complexities of pain perception and reporting?
A nurse is caring for a patient who has undergone a total hip arthroplasty. The nurse identifies 'Risk for Infection related to surgical wound and presence of a foreign body' as a relevant nursing diagnosis. Which intervention reflects the most comprehensive approach to minimizing infection risk, integrating evidence-based practices and addressing the interplay of intrinsic and extrinsic risk factors?
A nurse is caring for a patient who has undergone a total hip arthroplasty. The nurse identifies 'Risk for Infection related to surgical wound and presence of a foreign body' as a relevant nursing diagnosis. Which intervention reflects the most comprehensive approach to minimizing infection risk, integrating evidence-based practices and addressing the interplay of intrinsic and extrinsic risk factors?
A patient with end-stage heart failure expresses feelings of hopelessness and isolation due to their declining health and limited social interactions. Which nursing diagnosis most accurately captures the patient's psychosocial distress, aligning with NANDA-I classifications and promoting holistic care?
A patient with end-stage heart failure expresses feelings of hopelessness and isolation due to their declining health and limited social interactions. Which nursing diagnosis most accurately captures the patient's psychosocial distress, aligning with NANDA-I classifications and promoting holistic care?
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) who is experiencing increased dyspnea and fatigue. The nurse formulates the nursing diagnosis 'Activity Intolerance related to imbalance between oxygen supply and demand'. Which goal statement is the MOST appropriately written for this patient?
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) who is experiencing increased dyspnea and fatigue. The nurse formulates the nursing diagnosis 'Activity Intolerance related to imbalance between oxygen supply and demand'. Which goal statement is the MOST appropriately written for this patient?
When formulating a nursing diagnosis for a patient with a confirmed diagnosis of pneumonia, which component is essential for differentiating a 'Problem-Focused' diagnosis from a 'Risk' diagnosis, according to NANDA-I guidelines?
When formulating a nursing diagnosis for a patient with a confirmed diagnosis of pneumonia, which component is essential for differentiating a 'Problem-Focused' diagnosis from a 'Risk' diagnosis, according to NANDA-I guidelines?
A patient with a history of poorly managed diabetes presents with a new non-healing ulcer on their foot. Blood glucose levels have consistently ranged between 300-400 mg/dL for the past several weeks. Which nursing diagnosis related factor is MOST appropriate, aligning with NANDA-I guidelines, for 'Impaired Tissue Integrity' in this scenario, considering the nurse's scope of practice?
A patient with a history of poorly managed diabetes presents with a new non-healing ulcer on their foot. Blood glucose levels have consistently ranged between 300-400 mg/dL for the past several weeks. Which nursing diagnosis related factor is MOST appropriate, aligning with NANDA-I guidelines, for 'Impaired Tissue Integrity' in this scenario, considering the nurse's scope of practice?
A patient is scheduled for an elective surgery and verbalizes significant anxiety and fear about the potential outcome, stating, “I just know something will go wrong, and I won’t be able to handle it.” The patient has a history of avoiding stressful situations. Considering the principles of identifying accurate and actionable related factors, which component would be MOST appropriate for the nursing diagnosis 'Anxiety'?
A patient is scheduled for an elective surgery and verbalizes significant anxiety and fear about the potential outcome, stating, “I just know something will go wrong, and I won’t be able to handle it.” The patient has a history of avoiding stressful situations. Considering the principles of identifying accurate and actionable related factors, which component would be MOST appropriate for the nursing diagnosis 'Anxiety'?
A patient with a known hypersensitivity to latex is scheduled for a surgical procedure. Upon review of the patient's chart, the nurse notes that the surgical team is unaware of this allergy and plans to use latex gloves during the procedure. Considering the components of the 'Risk for Allergic Reaction' nursing diagnosis, what is the MOST critical and specific risk factor that should be communicated to the surgical team?
A patient with a known hypersensitivity to latex is scheduled for a surgical procedure. Upon review of the patient's chart, the nurse notes that the surgical team is unaware of this allergy and plans to use latex gloves during the procedure. Considering the components of the 'Risk for Allergic Reaction' nursing diagnosis, what is the MOST critical and specific risk factor that should be communicated to the surgical team?
A patient is admitted with community-acquired pneumonia and has a productive cough, thick secretions, and decreased breath sounds in the lower lobes. The nurse is determining between 'Ineffective Airway Clearance' and 'Ineffective Breathing Pattern'. What assessment finding would be MOST indicative of 'Ineffective Airway Clearance' rather than 'Ineffective Breathing Pattern'?
A patient is admitted with community-acquired pneumonia and has a productive cough, thick secretions, and decreased breath sounds in the lower lobes. The nurse is determining between 'Ineffective Airway Clearance' and 'Ineffective Breathing Pattern'. What assessment finding would be MOST indicative of 'Ineffective Airway Clearance' rather than 'Ineffective Breathing Pattern'?
A patient recovering from a stroke exhibits right-sided weakness, difficulty with expressive language, and emotional lability. The care team is deciding on the most appropriate primary safety-related nursing diagnosis. Which nursing diagnosis is MOST appropriate, given the patient's complex presentation?
A patient recovering from a stroke exhibits right-sided weakness, difficulty with expressive language, and emotional lability. The care team is deciding on the most appropriate primary safety-related nursing diagnosis. Which nursing diagnosis is MOST appropriate, given the patient's complex presentation?
In complex healthcare scenarios, how do the traditional steps of the problem-solving method, such as identifying and analyzing a problem, differ from the nursing process when addressing a patient's multifaceted needs?
In complex healthcare scenarios, how do the traditional steps of the problem-solving method, such as identifying and analyzing a problem, differ from the nursing process when addressing a patient's multifaceted needs?
Considering the dynamic nature of patient care, how does the validation of data during the assessment phase of the nursing process affect subsequent stages, particularly when managing patients with rapidly changing conditions?
Considering the dynamic nature of patient care, how does the validation of data during the assessment phase of the nursing process affect subsequent stages, particularly when managing patients with rapidly changing conditions?
In what way does Orlando's development of the nursing process in the late 1950s represent a paradigm shift in healthcare, particularly regarding patient-centered care and evidence-based practice?
In what way does Orlando's development of the nursing process in the late 1950s represent a paradigm shift in healthcare, particularly regarding patient-centered care and evidence-based practice?
Given the interconnectedness of the nursing process phases, how might an incomplete or superficial assessment phase impact the subsequent diagnostic and planning phases, especially in complex cases involving multiple comorbidities?
Given the interconnectedness of the nursing process phases, how might an incomplete or superficial assessment phase impact the subsequent diagnostic and planning phases, especially in complex cases involving multiple comorbidities?
Considering the integration of technology in modern healthcare, how can electronic health record (EHR) systems be leveraged to enhance the accuracy, efficiency, and comprehensiveness of data collection during the assessment phase of the nursing process?
Considering the integration of technology in modern healthcare, how can electronic health record (EHR) systems be leveraged to enhance the accuracy, efficiency, and comprehensiveness of data collection during the assessment phase of the nursing process?
Match the steps of the traditional problem-solving method with their corresponding descriptions:
Match the steps of the traditional problem-solving method with their corresponding descriptions:
Match the phases of the nursing process with their primary activities:
Match the phases of the nursing process with their primary activities:
Match each data collection activity with its role in the assessment phase of the nursing process:
Match each data collection activity with its role in the assessment phase of the nursing process:
Match each step of planning nursing care with its correct description:
Match each step of planning nursing care with its correct description:
Match the following concepts with their appropriate descriptions regarding the nursing process:
Match the following concepts with their appropriate descriptions regarding the nursing process:
The problem-solving method, as described, involves a linear process where each step must be fully completed before moving to the next, with no iteration or feedback loops considered.
The problem-solving method, as described, involves a linear process where each step must be fully completed before moving to the next, with no iteration or feedback loops considered.
The nursing process, developed by Ida Jean Orlando $circa$ 1950, is designed to be a rigid framework, intentionally limiting creative and intuitive approaches to patient care to ensure consistency.
The nursing process, developed by Ida Jean Orlando $circa$ 1950, is designed to be a rigid framework, intentionally limiting creative and intuitive approaches to patient care to ensure consistency.
In the assessment phase of the nursing process, the primary goal is to efficiently collect data, prioritizing speed over thoroughness to minimize patient discomfort and streamline the process.
In the assessment phase of the nursing process, the primary goal is to efficiently collect data, prioritizing speed over thoroughness to minimize patient discomfort and streamline the process.
The problem-solving method and the nursing process are entirely distinct frameworks with no overlapping principles or shared goals in patient care.
The problem-solving method and the nursing process are entirely distinct frameworks with no overlapping principles or shared goals in patient care.
In the assessment phase, once data is collected and documented, further validation is unnecessary as the initial data is presumed accurate.
In the assessment phase, once data is collected and documented, further validation is unnecessary as the initial data is presumed accurate.
Flashcards
Assessment Phase
Assessment Phase
Organizing and differentiating data to identify abnormal findings and potential clusters to determine if more data is needed.
Validating Data
Validating Data
Verifying unclear data by comparing it with other sources to ensure accuracy and avoid incorrect assumptions.
Nursing Diagnoses
Nursing Diagnoses
Utilizing standardized language (NANDA-I) to identify actual problems, potential problems, and opportunities for health promotion. Focus is on nursing, not medical, diagnoses.
Problem-Focused Diagnosis
Problem-Focused Diagnosis
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Risk Diagnosis
Risk Diagnosis
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Enhanced Health Literacy Readiness
Enhanced Health Literacy Readiness
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Related Factor (Cause)
Related Factor (Cause)
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Related Factor (Connector)
Related Factor (Connector)
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Risk for Infection
Risk for Infection
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Impaired Tissue Integrity
Impaired Tissue Integrity
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Impaired Tissue Integrity
Impaired Tissue Integrity
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Maladaptive Coping
Maladaptive Coping
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Problem Solving
Problem Solving
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Problem Solving Steps
Problem Solving Steps
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Nursing Process
Nursing Process
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5 Phases of Nursing process
5 Phases of Nursing process
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SMART Goals
SMART Goals
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Outcome Criteria
Outcome Criteria
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Goal/Outcome Subject
Goal/Outcome Subject
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Vague Terms to Avoid
Vague Terms to Avoid
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Goal Focus
Goal Focus
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Realistic Goal Setting
Realistic Goal Setting
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Intervention Clarity
Intervention Clarity
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Problem Solving Method
Problem Solving Method
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Collecting Data
Collecting Data
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Thorough Data
Thorough Data
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Documenting Data
Documenting Data
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Problem-Focused Diagnosis: Related Factor
Problem-Focused Diagnosis: Related Factor
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Related Factors
Related Factors
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Challenge: Identifying The Cause
Challenge: Identifying The Cause
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Challenge: Phrasing the Cause
Challenge: Phrasing the Cause
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NANDA-I Guidelines for Related Factors
NANDA-I Guidelines for Related Factors
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Steps in Problem Solving
Steps in Problem Solving
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Study Notes
Nursing Diagnoses (cont.)
- Risk for infection can originate from broken skin continuity and a low white blood cell count (3000 cells per microliter) that is coupled with a history of frequent viral infections.
- An example of impaired tissue integrity is related to insufficient oxygen delivery to tissues due to chronic hyperglycemia, as evidenced by a pressure ulcer to the right heal, and blood glucose levels elevated at 300-450mg/dl over the past 2/52.
- An example of recognizing readiness for enhanced health literacy can be taken from the patient's expression of wanting to learn more about managing her critical illness.
Identifying Part 2 (Related Factor)
- One challenge is identifying the cause and appropriately phrasing the cause.
- NANDA-I suggests related factors should not simply be related to a medical procedure or diagnosis
- The related factor must be modifiable by a nurse.
- Poor tissue integrity can be related to an insufficient oxygen delivery to the tissues because of chronic hyperglycemia, as evidenced by a pressure ulcer that will not heal accompanied by blood glucose levels between 300-450mg/dl for the past 2/52.
- Maladaptive coping can be related to inadequate confidence in the ability to deal with a situation, as evidenced by refusing to eat while repeating "I can't deal with this on my own" and ruminating over upcoming surgery.
Goal Setting with Expected Outcomes
- Mr. Lawson can achieve pain relief by the day of discharge as Mr. Lawson is projected to report his pain is at a level of 3 or below by discharge and will walk to the chair without increased pain in 24 hours.
- As a goal, Mr. Lawson will express understanding of how to minimize postoperative risks by discharge, alongside descriptive activity restrictions to follow by discharge in 48 hours, demonstrate how to cleanse the surgical wound by discharge day, and describe three risks for infection in 24 hours.
- It as a goal, Mr. Lawson will remain infection-free by discharge, and Mr. Lawson will remain afebrile, will show no purulent drainage, and his wound will close at the site of incision separation by discharge.
Implementation Process
- Implementations require skills; specifically, congitive (critical thinking and decision making), interpersonal, and psychomotor skills.
Goals and Expected Outcomes (cont.)
- A goal is a broad statement while expected outcomes are the measurable criteria for the goal
- An overall goal statement should have words from the diagnostic statement to ensure relatedeness.
- Over the course of 8 hours with independent and dependent interventions, the patient will remain free from infection, as determined by a temperature within normal range (35.8-37.0°C), the absence of infection signs (such as redness and swelling), and no changes to wound size or drainage.
- The patient is the subject, remaining free from infection is the verb, over 8 hours of independent and dependent interventions are the condition, and specific criteria include temperature and other indications.
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Description
The nursing process is a problem-solving approach involving assessment, diagnosis, planning, implementation, and evaluation. It utilizes critical thinking to address patient needs through systematic data collection and analysis. This process helps nurses in making informed decisions and providing effective care.
