Nursing Care Planning and Decision-Making

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Questions and Answers

Which approach should a nurse take to address personal biases in clinical decision-making?

Follow protocols without questioning

Trust only quantitative data

Keep an open mind and recognize biases (correct)

Rely on anecdotal evidence

What is a critical question to ask when identifying outcomes for a patient?

What are the unique needs of the patient?

Who is responsible for patient follow-up?

When is the next scheduled medication?

What must I observe based on nursing diagnoses? (correct)

During initial planning, what is a primary goal for the patient who reports shortness of breath and has leg swelling?

Monitor fluid balance and administer diuretics (correct)

Reduce pain and improve sleep quality

Educate the family about disease management

Facilitate communication between health professionals

What is the main objective of ongoing planning in patient care?

Keep the care plan current and effective Signup and view all the answers

In selecting evidence-based nursing interventions, what should a nurse prioritize?

Tailoring interventions to patient needs Signup and view all the answers

What is a potential consequence of failing to update a comprehensive nursing care plan?

Ineffective and inefficient patient care Signup and view all the answers

When prioritizing problems, which factor is crucial for a nurse to consider?

Which problems require immediate attention Signup and view all the answers

What new diagnosis might prompt ongoing planning adjustments?

Risk for Impaired Skin Integrity Signup and view all the answers

What are the four components of an actual nursing diagnosis?

Label, definition, defining characteristics, related factor Signup and view all the answers

Which type of nursing diagnosis indicates a higher vulnerability to develop a problem?

Risk nursing diagnoses Signup and view all the answers

What is the primary purpose of the problem statement within a nursing diagnosis?

To describe the patient's health state or problem clearly Signup and view all the answers

What defines defining characteristics in a nursing diagnosis?

Subjective and objective data indicating a health problem Signup and view all the answers

What does the etiology component of a nursing diagnosis identify?

The underlying factors related to the health problem Signup and view all the answers

Which type of nursing diagnosis comprises a cluster of actual or risk diagnoses?

Syndrome nursing diagnoses Signup and view all the answers

What is a possible nursing diagnosis?

A statement of a suspected problem needing further data Signup and view all the answers

Why is it important to correctly identify the etiology in a nursing diagnosis?

To prevent ineffective nursing interventions Signup and view all the answers

What is the primary purpose of nursing interventions in the patient care plan?

To assist the patient in achieving health-related goals Signup and view all the answers

Which of the following accurately describes nurse-initiated interventions?

Interventions developed based on patient preferences and needs Signup and view all the answers

Which intervention would likely be categorized as a collaborative intervention?

Implementing exercises as per the physical therapist's plan Signup and view all the answers

During the implementing step of the nursing process, what is essential for nurses to do?

Continuously think critically and adapt interventions as needed Signup and view all the answers

What is the primary focus of physician-initiated interventions?

Responses to medical diagnoses by providing prescribed actions Signup and view all the answers

Why are student plans of care typically more detailed than those in practice settings?

To help students understand each step of the nursing process Signup and view all the answers

Which of the following is NOT an aim of the implementation phase in nursing?

Documenting patient income Signup and view all the answers

What is a contributing factor to critical thinking during the implementation of nursing care?

Awareness of rapid changes in patient conditions Signup and view all the answers

What is the primary purpose of the evaluation step in the nursing process?

To allow the patient’s achievement of expected outcomes Signup and view all the answers

Which of the following actions does a nurse take if the expected outcomes are not achieved?

Modify the plan of care Signup and view all the answers

How can cognitive outcomes be evaluated effectively?

By asking patients to repeat information Signup and view all the answers

What type of outcome is evaluated by the patient demonstrating a new skill?

Psychomotor Outcomes Signup and view all the answers

Which method is used to evaluate physiologic outcomes?

Physical assessment skills to collect data Signup and view all the answers

When is the best time for a nurse to collect evaluative data?

At the designated time, in collaboration with the healthcare team Signup and view all the answers

What should a nurse do after collecting and interpreting data related to patient outcomes?

Document a judgment summarizing the findings Signup and view all the answers

What is an example of a specific time criterion for evaluating patient outcomes?

The patient will lose a specific weight by a set date Signup and view all the answers

What type of nursing intervention can a nurse perform independently?

Educating a patient on medication compliance Signup and view all the answers

Which nursing intervention type requires an order from a physician?

Ordering a prescription for a new medication Signup and view all the answers

Interdependent nursing interventions involve collaboration with which group?

Multiple members of a healthcare team Signup and view all the answers

What is an example of a nursing intervention focused on patient education?

Instructing a patient on deep breathing techniques Signup and view all the answers

During the implementation of a care plan, what is a critical initial step a nurse should take?

Conduct a thorough assessment of the patient Signup and view all the answers

To ensure successful implementation of the care plan, what is essential for nurses?

Effective organization and efficiency Signup and view all the answers

Which action is primarily focused on promoting self-care in nursing practice?

Assessing a patient's understanding of their health condition Signup and view all the answers

What should a nurse do if they feel inadequate to implement a plan of care?

Ask for assistance or guidance Signup and view all the answers

Which of the following nurse variables can influence the implementation of the plan of care?

Level of expertise Signup and view all the answers

What is a crucial resource that affects the effectiveness of a well-designed plan of care?

Adequate staff and supplies Signup and view all the answers

How do nurses improve the quality of nursing care?

By using research findings Signup and view all the answers

What is important for a nurse to be knowledgeable about in order to practice good nursing?

Laws and regulations affecting healthcare Signup and view all the answers

What is a critical nursing intervention involving ongoing assessment?

Data collection and revision of the care plan Signup and view all the answers

Which of the following is NOT a common reason for a patient's noncompliance with the plan of care?

Dedicated support from healthcare staff Signup and view all the answers

What must nurses be alert to while monitoring patients' responses to planned interventions?

Identifying new problems and diagnoses Signup and view all the answers

Which of the following factors does NOT contribute to a lack of patient cooperation with the plan of care?

High-quality educational materials provided Signup and view all the answers

Study Notes

Assessment - Nursing Diagnosis

Nurses perform ongoing assessments throughout the nursing process to establish a database.
The nursing history gathers data on the patient's health status, strengths, problems, risks, and need for nursing care.
Nurses may also conduct a physical examination to collect objective data.

Types of Nursing Assessments

First Assessment: Conducted after admission to a healthcare agency, it creates a comprehensive database for problem identification and care planning. Data collection includes patient's health, priorities for ongoing assessments, and future comparison.
Focused Assessment: Gathers data about a specific identified problem. Helpful questions include those about symptoms, when they started, factors making symptoms better or worse, use of remedies. It's a routine part of ongoing data collection.
Emergency Assessment: Performed during a physiologic or psychological crisis to identify life-threatening problems. Examples include a patient choking or experiencing a bleeding episode, or an unresponsive patient.
Time-Lapsed Assessment: Scheduled to compare a patient's current status against earlier baseline data, often used for vital signs every 4 hours.

Data Collection

Data collection involves structured methods to gather patient information systematically.
Gordon's functional health patterns framework organizes patient data using a five-part framework.
Data types include subjective (e.g., symptoms, feelings) and objective (e.g., measurable signs, physical observations).

Data Collection - Subjective Data

Subjective data are personal perceptions only understood by the affected individual.
Examples include feeling nervous, nauseous, or chilly, experiencing pain.
Subjective data can also be referred to as symptoms or covert data.

Data Collection - Objective Data

Objective data are observable and measurable.
Examples include elevated body temperature, skin condition (e.g., moist), and refusal of food or fluids.
Objective data can also be referred to as signs or overt data.

Data Collection - Sources of Data

Patient is the primary source.
Family and significant others can provide crucial information, especially for children or those with limited capacity.
Patient Records are essential to care planning.
Medical history, physical exams, progress notes, reports of lab tests, and therapies from other professionals (nutritional, speech, physical therapy) are recorded within the patient's record.
Consultations with specialists help in establishing medical diagnosis or planning/executing treatment.
Healthcare literature on specific health problems can be consulted.

Data Collection - Characteristics of Data

Purposeful: The nurse identifies the reason for the assessment and gathers appropriate data.
Complete: Data to understand the patient's health problems and needs are collected.
Factual and accurate: Observed behavior is described objectively. Data should be reported accurately and factual.
Nurse should be aware that they need to carefully and precisely note what they observe. This is crucial for the record and to be able to explain what they are seeing.

Methods of Data Collection

Patient Interview: Gathering nursing history through planned communication with the patient.
Nursing Physical Assessment: Examining the patient, using senses to collect objective data, and verify data from history or yield new data.
Nursing History: Typically completed first, focusing on patient's strengths, weaknesses, health risks/problems (environmental and hereditary), past and present conditions. Should be carried out as soon as possible after patient presents for care.

Data Reporting and Recording

The nurse should share patient data with other healthcare professionals.
Critical changes in a patient's health status (e.g., change in body temperature, vital signs) should be reported promptly.
Initial data should be recorded in the designated agency format on the day of admission.

Diagnosing

Summarize data from the assessment phase.
Determine potential problems.
Identify actual or potential problems.
Identify risk factors.
Determine if a problem exists.
Provide resources/strengths/weaknesses for health promotion.

History of Nursing Diagnoses

Nursing diagnoses emerged in the 1950s.
Initial definitions/classifications evolved over the years.
The number of identified diagnoses continues to grow.

Nursing vs. Medical Diagnosis

Medial diagnoses identify diseases.
Nursing diagnoses focus on unhealthy responses to health and illness.
Nursing diagnoses are used to describe issues that nurses can independently treat.
Medical diagnoses often remain steady until the end of the disease process, but nursing diagnoses can change from day-to-day.

Data Interpretation and Analysis

Experienced nurses analyze data while collecting it.
Significant data (cues) are noted to denote important or influential data for analysis.
Significant data should raise a red flag to the nurse for potentially problematic situations.
Significant data is usually a collection of observed phenomena and should be analyzed through comparisons.
The analysis should highlight patient strength(s) and problem(s).
Identify potential complications early.
Reach conclusion from analysis.

Formulating and Validating Nursing Diagnoses

NANDA defines five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.
Actual diagnoses describe existing problems with major defining characteristics, such as anxiety.
Risk diagnoses describe vulnerability to potential problems, such as risk for falls.
Possible diagnoses represent suspected problems requiring further data collection, such as a suspected infection.
Syndromes are clusters of actual or risk diagnoses related to a specific event or situation, such as self-care deficiency syndrome.
A nursing diagnosis should clearly identify the problem and related factors (etiology).

Parts of Nursing Diagnosis Statements

The Purpose of a problem statement is used to accurately describe the health state (or health problem) of the patient.
NANDA recommends using quantifiers or descriptors to specify the meaning of the problem statement.

Outcome Identification and Planning

Identifying patient-centered goals and outcomes.
Set priorities.
Prescribe individualized nursing interventions.
Collaborative approach with patients, families, and the care team through communication and ongoing consultation.
The care plan can be dynamic as patient needs change.

Types of Nursing Interventions

Nurse-initiated: Actions a nurse performs independently, such as patient education, monitoring, and supporting self-care abilities.
Physician-initiated: Actions based on a physician's order to treat, such as administering medications or ordering tests.
Collaborative: Actions performed by multiple health care team members in collaboration, such as nursing, therapy, and other medical professionals.

Implementing the Plan of Care

Carrying out nurse-initiated, physician-initiated, and collaborative interventions.
Evaluate patient response to nursing interventions during implementation.
Nurses need to organize resources to ensure an effective plan of care.
Factors impacting the successful implementation of care can include patient and/or nurse limitations (developmental stage, resources). Nurse should check with the patient before performing procedures.

Evaluating

Determining whether the patient has reached established outcomes.
Based on the patient's responses, decide to terminate, modify, or continue the plan of care if necessary.
Document the evaluation and modify the plan as needed.

Types of Outcomes

Cognitive Outcomes: Focus on increased knowledge, evaluated by asking patients to recall or repeat information.
Psychomotor Outcomes: Involve the achievement of physical skills evaluated through demonstrating those skills
Affective Outcomes: Focus on changes in feelings or attitudes, evaluated by checking the patient's attitudes and feelings.
Physiologic Outcomes: Involve measurements of body processes, evaluated using physical assessment skills and comparing them to earlier data.

Time Criteria for Outcomes

Follow the designated time frames and evaluate the patient's attainment of the outcome.

Documentation of Outcomes

Summarize findings and results of the evaluation. Nurses have three options: met, partially met, or not met.
- Explain why outcomes were not met if not met to adjust/modify the plan of care.

Modifying the Plan of Care

If outcomes were not met, modify the plan of care.
Options include: adjusting diagnosis, refining the desired outcomes, altering time criteria, or changing the intervention methods.

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Description

This quiz focuses on clinical decision-making and care planning in nursing practice. It covers key concepts such as addressing personal biases, setting patient goals, and prioritizing care interventions. Test your understanding of evidence-based nursing strategies and planning for patient outcomes.