Nursing Diagnosis Assessment

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Questions and Answers

What is the primary purpose of the first nursing assessment?

To evaluate the effectiveness of previous interventions.

To establish a complete database for problem identification. (correct)

To perform focused evaluations on specific symptoms.

To identify ongoing care needs.

Which type of assessment is conducted during a physiologic or psychological crisis?

Emergency assessment (correct)

First assessment

Focused assessment

Time-lapsed assessment

In a focused assessment, which type of information is primarily gathered?

Family health history and social background.

Data about a specific problem already identified. (correct)

General health history and medications.

Comprehensive baseline data from previous assessments.

What is the purpose of a time-lapsed assessment?

To compare a patient’s current status to earlier baseline data. (A) Signup and view all the answers

Which of the following correctly describes the ongoing assessments performed by the nurse?

They establish a complete database for problem identification. (B) Signup and view all the answers

What type of questions would be pertinent during a focused assessment?

What are your symptoms and when did they start? (B) Signup and view all the answers

Why is systematic data collection necessary in nursing assessments?

To ensure that important information is not overlooked. (A) Signup and view all the answers

Which scenario best exemplifies when to conduct an emergency assessment?

An unresponsive patient is brought to a hospital. (D) Signup and view all the answers

What is the main purpose of applying prescribed wound dressings and monitoring for infection?

To ensure the wound shows signs of healing within one week. (A) Signup and view all the answers

Which guide is not mentioned as a helpful tool for prioritizing patient problems?

Rogers' Theory of Science. (D) Signup and view all the answers

In what order should basic human needs be prioritized according to Maslow's Hierarchy?

Physiologic needs, safety needs, love and belonging needs, self-esteem needs. (B) Signup and view all the answers

What category do non-life-threatening diagnoses fall into when establishing nursing priorities?

Medium priority. (D) Signup and view all the answers

What type of patient education is essential during discharge planning?

Self-care instructions and understanding of health issues. (B) Signup and view all the answers

What should be considered a low priority in nursing diagnoses?

Diagnoses not related to the current health problem. (B) Signup and view all the answers

Which of the following is not part of the Nursing Outcomes Classification (NOC)?

Patient demographic information. (A) Signup and view all the answers

Why is it important to account for patient preference when developing nursing priorities?

To ensure vital therapies are not compromised. (C) Signup and view all the answers

What is a key component of a nursing intervention?

It should enhance patient outcomes. (C) Signup and view all the answers

Which of the following is NOT a goal of nurse-initiated interventions?

Facilitate workforce training (D) Signup and view all the answers

What must be considered when identifying appropriate nurse-initiated interventions?

Patient outcomes and values (B) Signup and view all the answers

After teaching, what should a patient be able to do regarding coping strategies?

Identify two new coping strategies to try (B) Signup and view all the answers

What is a main purpose of using the Nursing Intervention Classification (NIC)?

To provide a comprehensive guide for interventions (D) Signup and view all the answers

What factor should NOT influence the selection of individualized evidence-based interventions?

Personal preferences of the nurse (B) Signup and view all the answers

Which of the following nursing actions helps to facilitate independence?

Assisting with activities of daily living (B) Signup and view all the answers

Which statement best describes nurse-initiated interventions?

They are based on clinical judgment and knowledge. (B) Signup and view all the answers

What is the primary difference between long-term and short-term outcomes?

Long-term outcomes usually require more than a week to be achieved, while short-term outcomes do not. (D) Signup and view all the answers

Why is involving patients and families in the development of outcomes important?

It increases the likelihood of achieving the established goals. (C) Signup and view all the answers

Which of the following is an example of a well-written patient outcome?

Mr. Smith will drink at least 500 mL of water daily. (B) Signup and view all the answers

What mistake is being made in the outcome: 'Patient will list dangers of smoking and stop smoking'?

It includes too many behaviors in the outcome. (A) Signup and view all the answers

Which verbs should be avoided when writing patient outcomes?

Understand (D) Signup and view all the answers

What is a common error when writing patient outcomes?

Having outcomes that are vague or unclear. (D) Signup and view all the answers

When identifying culturally appropriate outcomes, which factor is least important?

The healthcare provider's preferences. (C) Signup and view all the answers

What best describes the term 'discharge goals' in outcome setting?

Expectations for patients upon leaving a healthcare facility. (B) Signup and view all the answers

What is an example of an independent nursing intervention?

Educating a patient about medication importance (A) Signup and view all the answers

Which type of nursing intervention requires a physician's order?

Dependent intervention (D) Signup and view all the answers

What is a key responsibility of nurses when implementing a plan of care?

Identify the patient's need for nursing assistance (B) Signup and view all the answers

Which statement best describes interdependent nursing interventions?

They involve working with multiple members of the healthcare team. (B) Signup and view all the answers

In a chaotic healthcare environment, successful implementation of care requires what?

High organization and efficiency (A) Signup and view all the answers

What should a nurse do if they doubt their ability to implement the plan of care?

Ask for help (B) Signup and view all the answers

Why is it essential to reassess a patient before initiating a nursing intervention?

To ensure the patient’s condition hasn't changed (A) Signup and view all the answers

Which of the following is NOT a specialized ability used by nurses in implementing a plan of care?

Making final medical diagnoses (C) Signup and view all the answers

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

To measure the patient's response to treatment (B) Signup and view all the answers

Which action should a nurse take if a patient is struggling to achieve planned outcomes?

Modify the plan of care as needed (B) Signup and view all the answers

How can cognitive outcomes be evaluated effectively?

Ask patients to recount information (D) Signup and view all the answers

What type of outcome focuses on a patient's ability to perform new skills?

Psychomotor outcomes (A) Signup and view all the answers

When should the nurse collect evaluative data?

At designated times in collaboration with the patient (A) Signup and view all the answers

What is a physiologic outcome evaluated by?

Conducting physical assessments and comparing data (A) Signup and view all the answers

What should the nurse do after collecting and interpreting data on patient outcomes?

Make and document a judgment summarizing the findings (B) Signup and view all the answers

What is the expected outcome for a patient demonstrating a weight loss of 3 kg per month?

Reaching a target weight of 135 kg (C) Signup and view all the answers

Study Notes

Assessment - Nursing Diagnosis

Nurses make ongoing assessments throughout the nursing process.
The assessment step establishes a database.
Nursing history details patient health status, strengths, problems, risks, and need for care.
A nursing physical examination may be conducted to gather data.
Assess priorities based on patient condition and assessment purpose.

Types of Nursing Assessments

First Assessment: Conducted after admission to a healthcare agency or service. Its purpose is to build a complete database for care planning. Data is collected on patient health and identified priorities for future assessments.
Focused Assessment: Concentrates on a specific problem already identified. Helpful questions include those about the symptom(s), when they started, and what makes them better or worse. A focused assessment is regularly used to monitor changes in ongoing data collection and to recognize new or overlooked problems
Emergency Assessment: Performed during a physiological or psychological crisis to identify life-threatening problems. Examples include choking, bleeding, or a patient in critical condition. Requires prompt action.

4- Time-Lapsed Assessment

This assessment is scheduled to compare a patient's current status to baseline data collected earlier. A common example is taking vital signs every 4 hours.

Data Collection

Data is collected to inform the assessment effectively.
Structuring data collection is necessary for systematic organization.
Guidelines facilitate effective patient focus during assessment.
The Gordon's functional health patterns framework categorizes patient data.
Maslow's hierarchy of five human needs provides another framework.

Types of Data: Subjective and Objective

Subjective Data: Information perceived only by the affected person (e.g., feelings of nervousness, nausea, chills, pain).
Objective Data: Observable and measurable data that can be seen, heard, or felt by someone else (e.g., elevated temperature, moist skin, refusal to eat).

Data Collection - Characteristics of Data

Purposeful: The nurse decides the assessment approach (comprehensive, focused, emergency, time-lapsed) and plans accordingly.
Complete: Collect all relevant data to understand the patient's health problems. consider if the weight loss is intentional or unintentional, and if there are related causes like eating or exercise changes or other health conditions.
Factual and Accurate: Describe behavior precisely (e.g., "patient lies with face to the wall", rather than "patient is depressed").

Sources of Data

Patient: Primary source; communication vital for appropriate care
Family and Significant Others: Valuable information about the patient.
Patient Record: Records compiled by various healthcare providers, helpful for understanding the patient's history and ongoing care.

Patient Record

Includes medical history, physical examination, and progress notes.
Includes reports of tests, therapies, consultations, and other observations by staff, helping to determine a treatment plan.

Nursing and Other Healthcare Literature

Consulting relevant nursing and related literature enhances patient understanding.
If the patient's issue is unfamiliar, thorough background knowledge ensures appropriate care.

Methods of Data Collection

Nursing History: Collected as soon as possible after the patient presents for care. Identifies strengths, weaknesses, health risks (e.g., heredity, environment), and problems.
Patient Interview: Planned communication; good interviewing skills are needed to establish a strong working partnership with the patient.
Nursing Physical Assessment: Examination of the patient for objective data. Helps to define the patient's condition for care planning

Data Reporting and Recording

Share collected data with other healthcare professionals.
Important to report any critical changes in the patient's condition.
Document the database on the designated forms on the date of admission.

Diagnosing

Involves a continuous process of gathering and analyzing data of the patient's problem.

History of Nursing Diagnoses

The first nursing diagnoses were identified in the 1950s, with a significant expansion in diagnoses in 1973
NANDA-I is a leading organization in further developing nursing diagnoses.

Nursing Diagnosis vs Medical Diagnosis

Medical diagnoses identify diseases.
Nursing diagnoses focus on patient responses to health issues.

Data Interpretation and Analysis

Experienced nurses analyze collected data promptly.
"Cues" represent significant data influencing analysis.
Significant data should raise concern for the nurse.

Recognizing Significant Data

Sort healthy responses from unhealthy ones; be clear on what is normal for that patient's specific circumstances.
Establish patient-specific norms.

Recognizing Patterns

Nursing diagnoses should come from clusters of significant data, not just one single datum.

Identifying Strengths and Problems

Identify patient strengths & how they affect well-being and illness.
Define the problems the patient is likely experiencing (or is at risk of experiencing).

Identifying Potential Complications

Observe for any developments that pose serious problems connected to the patient's current diagnosis and/or current plan of care.
Consider possible complications from medication, prior procedures and/or current treatments, as well as interactions with other illnesses or treatments

Reaching Conclusions

After comprehensively analyzing the data, the nurse concludes from four potential options: no problem; possible problem; actual or potential nursing diagnosis; or clinical problem aside from nursing diagnosis

Formulating and Validating Nursing Diagnoses

NANDA defines five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.

Possible Nursing Diagnoses

These diagnoses describe a suspected problem when more data are needed.

Syndrome Nursing Diagnoses

A collection of diagnoses predicted to arise from a particular event or situation.

Writing Nursing Diagnoses

Explain the problem clearly and concisely.
Use quantifiers or descriptors to delineate problem specifics.

Etiology of Nursing Diagnoses

Identify factors that contribute to the problem, whether as a cause or other contributing factor
Accurate identification is necessary for appropriate interventions.

Defining Characteristics (Nursing Diagnoses)

Subjective and objective data that clearly identify the presence of a problem, whether actual or potential

Nursing Diagnosis: A Critique

Nurses often manage a complex caseload of patients requiring individualized care

Planning Nursing Care

Outcome identification & planning is the third phase of the system.

Unique Focus of Nursing Outcome Identification and Planning

Care plans are designed to prevent, reduce, or resolve health problems.

Identifying and Writing Outcomes

Using established standards for creating relevant outcome-based plans.
Identify measurable outcomes.

Identifying Nursing Interventions

Interventions to help patients meet their outcomes.
Types of interventions (nurse-initiated, physician-initiated, collaborative)

Nurse-Initiated Interventions

Interventions under the nurse's authority.
Focus on monitoring health, reducing risks, resolving, preventing or managing problems.
Promoting self care, well being, etc

Physician-Initiated Interventions

Interventions initiated by the physician, but carried out by the nurse.

Collaborative Interventions

Interventions performed by the nursing team, multiple members of the health team.

Student Plans of Care

Formats can vary across different nursing programs or institutions.
Aims to assist nursing students in mastering the nursing process's five steps.

Implementing the Plan of Care

Nurse actions are carried out as part of the plan.

Implementing the Plan of Care—Determining The Patient's Need

Reassess the patient and review the plan of care.

Organizing Resources

Ensures patient is prepared/visitors aware
Determine if the nurse or other party should carry out the intervention.
Ensure necessary tools/equipment is readily available.
Evaluate the environment needed to meet the patient's privacy, dignity and safety needs

Implementing the Plan of Care—Promoting Self-Care

Important plan to promote patient's self care skills and enhance independence

Implementing the Plan of Care—Assisting Patients to Meet Health Outcomes

Nurse Variables: Expertise, creativity, time and willingness
Resource Variables: Adequate personnel, equipment, supplies
Research findings: The current research in the field.
Ethical and legal Considerations: Nurses should be familiar with their professional codes and laws to ensure they operate ethically and legally.

Continuing Data Collection and Risk Management

Ongoing data collection is necessary to determine if the interventions are effective.
Monitoring patient responses is critical in managing risk.

When a Patient Does Not Cooperate with the Plan of Care

Reasons for non-compliance, including a lack of support, understanding or ability to afford treatment, are frequently encountered
Nurses should understand these reasons and communicate appropriately.

Evaluating

Evaluate to determine success, based on patient responses.
If successful, the plan of care is terminated
If not met, the plan of care needs revision/modification.

Types of Outcomes

Evaluate different outcome types (cognitive, psychomotor, affective, and physiologic)
Evaluation methods differ depending on the outcome type (e.g., asking questions for cognitive).

Time Criteria

Use of appropriate time-based considerations during the evaluation and determining intervention effectiveness.

Documenting Judgment

The nurse documents the met, partially met, or unmet statuses of the patient outcomes.

Modifying the Plan of Care

Modifying the plan of care when the outcomes have not been met, based on factors affecting achievement.

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Description

This quiz covers the key concepts related to nursing diagnosis assessments within the nursing process. Explore the different types of assessments, including first assessments, focused assessments, and their significance in patient care. Test your knowledge on how assessments are critical for establishing a comprehensive healthcare database.