Podcast
Questions and Answers
What is one of the main purposes of a nursing care plan?
What is one of the main purposes of a nursing care plan?
A focused assessment is performed only during a patient's admission.
A focused assessment is performed only during a patient's admission.
False
List two sources of data used for nursing assessments.
List two sources of data used for nursing assessments.
Patient, Family & Significant others
Nursing diagnosis provides the basis for selection of patient outcomes and nursing __________.
Nursing diagnosis provides the basis for selection of patient outcomes and nursing __________.
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Match the type of assessment with its description:
Match the type of assessment with its description:
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Which of the following describes subjective data in nursing assessments?
Which of the following describes subjective data in nursing assessments?
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Accurate documentation of nursing assessments is not essential for continuity of care.
Accurate documentation of nursing assessments is not essential for continuity of care.
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What is the first step in the diagnostic process?
What is the first step in the diagnostic process?
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Which type of nursing diagnosis involves identifying the vulnerability of an individual to develop undesirable responses?
Which type of nursing diagnosis involves identifying the vulnerability of an individual to develop undesirable responses?
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A nursing diagnosis must include an etiology for all types.
A nursing diagnosis must include an etiology for all types.
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What is a three-part nursing diagnosis composed of?
What is a three-part nursing diagnosis composed of?
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An example of a risk diagnosis is 'Risk for ______ AEB previous history of falls.'
An example of a risk diagnosis is 'Risk for ______ AEB previous history of falls.'
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Match the nursing diagnoses with their descriptions:
Match the nursing diagnoses with their descriptions:
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Which of the following is a defining characteristic in a nursing diagnosis?
Which of the following is a defining characteristic in a nursing diagnosis?
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The nursing diagnosis is the same as the medical diagnosis.
The nursing diagnosis is the same as the medical diagnosis.
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What is the purpose of secondary etiology in nursing diagnoses?
What is the purpose of secondary etiology in nursing diagnoses?
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What does NANDA stand for?
What does NANDA stand for?
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Standardized Nursing Language helps to promote nursing research.
Standardized Nursing Language helps to promote nursing research.
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Name one component of the NGN Clinical Judgment Measurement Model.
Name one component of the NGN Clinical Judgment Measurement Model.
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In the nursing process, 'A' stands for __________.
In the nursing process, 'A' stands for __________.
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Match the following nursing process steps with their descriptions:
Match the following nursing process steps with their descriptions:
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Which of the following is NOT a step in recognizing cues?
Which of the following is NOT a step in recognizing cues?
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What is the purpose of transforming thinking into clinical judgment?
What is the purpose of transforming thinking into clinical judgment?
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Eliminating preconceived ideas is important when assessing patient information.
Eliminating preconceived ideas is important when assessing patient information.
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Study Notes
Nursing Care Plan
- Individualizes care to maximize outcomes
- Sets priorities for patient care
- Facilitates communication between nursing personnel and colleagues
- Promotes continuity of high-quality and cost-effective care
- Evaluates patient response to nursing care
- Creates a record used for evaluation, research, reimbursement, and legal reasons
Nursing Assessments
- Prioritized according to patient needs
- Comprehensive and thorough
- Systematic and follows a specific process
- Accurate and reflects the patient's condition
- Recorded in a standardized manner for clarity and consistency
Types of Assessments
- Initial Assessments - conducted upon admission or at the start of a shift
- Focused Assessments - target a specific problem or system
Sources of Assessment Data
- Patient - through observation, interviews, and physical exams
- Family and Significant Others - provide insights and history
- Patient Record - contains medical history, previous diagnoses, and medications
- Other Healthcare Professionals - contribute their expertise and perspectives
Types of Assessment Data
- Subjective Data: What the patient says or feels, such as pain level or symptoms
- Objective Data: Measurable and observable findings, such as vital signs, lab results, or physical examination findings
The Phases of Assessment Set the Stage for Diagnosis
- Assessment provides the foundation for developing nursing diagnoses
Nursing Diagnosis
- A clinical judgment about an individual's response to actual or potential health problems
- Serves as the basis for planning patient care and intervention
Steps in the Diagnostic Process
- Create a list of suspected problems
- Name actual and potential problems/diagnoses and identify their causes or contributing factors
- Determine risk factors that need to be managed for risk diagnoses
- Confirm defining characteristics for actual diagnoses
- Prioritize nursing diagnoses based on urgency and impact
The Nursing Process Framework
- A standardized approach to nursing practice that sets a standard of care
Standardized Nursing Language
- NANDA (North American Nursing Diagnosis Association)
- Defines nursing's contribution and impact in healthcare
- Provides a clear and concise language for describing nursing interventions and outcomes
- Promotes evidence-based practice and research
Think Like a Nurse to Develop Clinical Judgment
- Prepares for NCLEX (National Council Licensure Examination)
- Transforms thinking into practical clinical judgment
- Encourages self-directed learning and critical thinking
- Reduces errors in healthcare settings
NGN Clinical Judgment Measurement Model
- Recognize Cues: Gathering information and identifying relevant data
- Analyze Cues: Interpreting and understanding the gathered information
- Prioritize Hypotheses: Formulating potential diagnoses and prioritizing them
- Generate Solutions: Developing appropriate interventions for the identified problems
- Take Actions: Implementing the chosen interventions
- Evaluate Outcomes: Assessing the effectiveness of actions and adjusting the plan as needed
Recognizing Cues and Getting Information
- Determine the necessary information
- Utilize multiple sources for comprehensive data
- Eliminate preconceived notions and biases
- Observe the patient's environment and surroundings
- Identify signs and symptoms accurately
- Assess systematically and comprehensively
- Ensure the accuracy of collected information
Alignment of the Clinical Judgment Model and the Nursing Process
- CJM - Nursing Process
- Getting the Information - Assessment
- Making meaning of the information - Diagnosis
- Determine actions to take - Planning
- Take Action - Implementing
- Evaluate Outcomes and your thinking - Evaluating
ADPIE - The Nursing Process
- Assessment: Gathering information about the patient
- Diagnosis: Identifying the patient's health problems and nursing diagnoses
- Planning: Developing a plan of care to address the identified issues
- Implementation: Carrying out the planned interventions
- Evaluation: Assessing the effectiveness of the implemented interventions and making adjustments as needed
Types of Nursing Diagnoses
- No Problem: Absence of a health concern
- Problem-Focused Diagnosis: Describes an actual human response to health conditions
- Risk Diagnosis: Identifies the vulnerability of an individual to develop an undesirable human response
- Health Promotion Diagnosis: Reflects a client's motivation to increase well-being
- Syndrome Diagnosis: Identifies a cluster of nursing diagnoses that occur together
Actual Problem - 3-Part Nursing Diagnosis
- Problem: The actual health concern
- Related to (R/T): The cause or contributing factor
- As Evidenced by (AEB): The observed signs and symptoms
Etiologies
- Only problem-focused nursing diagnoses and syndromes require related factors
Adding Secondary to the Etiology
- Provides additional clarity and explanation of the contributing factor
At Risk Nursing Diagnosis
- A clinical judgment concerning the vulnerability of an individual to develop a health problem
- Problem statement: The potential issue
- As Evidenced by (AEB): Identifying risk factors that increase vulnerability
Nursing Diagnosis Versus Medical Diagnosis
- Medical DX: The underlying disease or condition
- Nursing DX: The patient's response to the medical diagnosis
NSG DX Versus Medical DX
- Nursing diagnoses focus on providing care to address the individual’s response to their medical condition.
Example: Impaired nutrition less than body requirement R/T decreased desire to eat AEB BMI 13, Pre-Albumin of 15 (norm 40 – 100), patient consumes only 5% of meals X 5 days
- This example demonstrates a 3-part nursing diagnosis:
- Impaired nutrition less than body requirement: The problem/diagnosis
- R/T decreased desire to eat: The related to (etiology) factor
- AEB BMI 13, Pre-Albumin of 15 (norm 40 – 100), patient consumes only 5% of meals X 5 days: The evidence, or defining characteristics.
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Description
Test your knowledge on nursing care plans and assessments to enhance patient outcomes. This quiz covers individualization of care, types of assessments, sources of assessment data, and prioritization techniques in nursing. Prepare to evaluate and apply your understanding of quality nursing practices.
