Nursing Diagnosis Assessment Quiz

Assessment in Nursing Diagnosis

• Nurses perform ongoing assessments throughout the nursing process.
• The assessment establishes a database.
• The patient's history provides information on health status, strengths, health problems, health risks, and need for care.
• A physical examination is also a data-gathering method.
• Assessment priorities should be identified based on the patient's condition and the purpose of the assessment.
• Patient data should include patient information, family members, and healthcare professional reports.

Types of Nursing Assessments

• First Assessment: Performed after the patient is admitted to establish a comprehensive database for problem identification and care planning. Data includes patient's health, priorities for ongoing focused assessments, and future comparison.
• Focused Assessment: Used for a specific problem already identified, including what symptoms are present, when they began, anything different at onset, and what makes the symptoms better or worse.
• Emergency Assessment: Performed when a physiologic or psychological crisis presents to identify life-threatening problems. Examples include choking, bleeding, stab wounds, and unresponsiveness.
• Time-Lapsed Assessment: Scheduled to compare a patient's current status to baseline data obtained earlier. Useful for tracking changes over time, often involving vital signs taken at regular intervals.

Data Collection

• Data collection must be structured systematically.
• Gordon's Functional Health Patterns framework organizes data into patterns for analysis.
• Maslow's Hierarchy of Needs provides a framework for analyzing basic human needs and ensuring those are met before prioritizing other needs.

Types of Data: Subjective and Objective

• Subjective data: Information perceived only by the affected person; symptoms, feelings.
• Objective data: Observable and measurable data; observable physical signs, lab results.

Data Collection - Characteristics

• Purposeful: Nurses must identify the purpose (comprehensive, focused, etc.) for the assessment.
• Complete: All necessary data relevant to current and potential problems.
• Factual and Accurate: Data must be precise and detailed, not subjective interpretations.

Data Collection - Sources

• Patient: The primary source of information.
• Family and Significant Others: Important, especially with children or individuals with limited communication abilities.
• Patient Records: Data collected by other healthcare providers.
• Medical History, Physical Examination, Progress Notes: Documentation for medical professionals.
• Consultations: Data from specialists related to the patient's care.
• Laboratory Records: Laboratory tests data.
• Diagnostic Studies, Radiographs, Therapies: Additional data collected or performed by healthcare teams.
• Nursing and Other Healthcare Literature: Background knowledge to understand patient and health related issues.

Methods of Data Collection

• Nursing History: Gathered as soon as possible after admission. Nurses should identify patient strengths, weaknesses, risk factors, and any existing health problems.
• Patient Interview: A planned communication strategy where the nurse gathers information from the patient.
• Nursing Physical Assessment: Physical exam that follows the nursing history. Nurses use their senses to gather objective data.

Data Reporting and Recording

• Timeliness is critical. Critical changes in patient health should be reported immediately.
• Documentation should be detailed using standard agency forms.

Diagnosing

• Identifying patient problems/diagnoses
• Ruling out similar issues/diagnoses
• Clarifying contributing factors to health issues
• Identifying risk factors that need management
• Identifying patient strengths and resources.

History of Nursing Diagnoses

• Origination of nursing diagnosis.
• Key events in the development of nursing diagnosis.
• Defining of nursing diagnoses.

Nursing Diagnosis vs. Medical Diagnosis

• Nursing Diagnosis: Focuses on unhealthy responses to illnesses and health problems.
• Medical Diagnosis: Focuses on diseases.

Data Interpretation and Analysis

• Experienced nurses begin interpreting data during the collection process.
• "Cue" is a term used to denote significant or relevant data.
• Significant data should "raise a red flag" to indicate a priority concern during the assessment.
• Interpretation should include identifying patterns in data for analysis and identifying possible contributing factors.

Recognizing Significant Data

• Distinguish healthy responses from unhealthy ones.
• Patient individual variation impacts normal readings. E.g: A healthy athlete may have a lower resting heart rate than a non-athlete.
• Consider COPD; normal for a COPD patient might be an abnormal reading for someone without COPD.
• Identify warning signs of problems.

Recognizing Patterns

• Nursing diagnoses are derived from a cluster of significant data, not a single cue.
• Patterns in data may show a problematic trend.

Identifying Strengths and Problems

• Identifying patient strengths and possible problems; to inform care plan options.

Identifying Potential Complications

• Potential medical complications or issues based on the diagnosis and treatment are identified.

Reaching Conclusions

• Determining: (1) No Problem (2) Possible Problem (3) Actual or Potential Nursing Diagnosis (4) Clinical Problem Other Than Nursing Diagnosis

Formulating and Validating Nursing Diagnoses

• Actual Diagnoses: Represent clearly identified problems, have defining characteristics.
• Risk Diagnoses: Vulnerability to develop a problem.
• Possible Diagnoses: Statements about a suspected problem requiring further data.
• Syndrome Diagnoses: Clusters of actual or risk diagnoses linked to a significant event or situation.

Parts of Nursing Diagnosis Statements

• Problem/Diagnosis: Clearly describes the patient's health state or condition.
• Etiology: Identifies factors related to the problem.
• Defining Characteristics: Subjective and objective data indicating the problem's existence.

Planning Nursing Care

• Outcome identification and planning for patient outcomes.
• Outcomes set priorities, goals, and interventions.
• Collaboration with patients and families is crucial for patient-centered care.

Unique Focus of Nursing Outcome Identification and Planning

• Create a plan of care to manage, reduce, or prevent patient problems.
• Focused on patient outcomes.

Identifying and Writing Outcomes

• Outcome criteria to achieve the nursing goals.
• Identifying culturally appropriate outcomes for the patient in relation to their cultural background.
• Avoid making outcomes as a Nursing intervention.

Identifying Nursing Interventions

• Nurse-initiated Interventions: Actions performed without physician order.
• Physician-initiated Interventions: Actions based on physician orders.
• Collaborative Interventions: Actions performed by multiple healthcare team members.

Implementing The Plan of Care

• Determining patient needs.
• Organizing resources (equipment, environment, personnel).
• Promoting self-care (Education/Counseling/Advocacy).
• Assessing patient's response to interventions.

Critical Thinking and Implementing

• Critical thinking regarding patient response to treatment and adjustments to the plan if necessary.
• Evaluating if the plan of care is working based on the patient's response.
• Adapting the intervention if patient shows different response to the implemented plan.
• Knowing when to ask for help.

Types of Nursing Interventions

• Independent: Nurse performs actions without physician input.
• Dependent: Nurse carries out interventions based on physician or other provider orders.
• Interdependent: Actions by the multidisciplinary team/care team.

Student Plans of Care

• Provide more detailed plans than practice settings.
• Used to assist students in understanding each step in the nursing process.

Implementing The Plan of Care-Determine The Patient's Need

• Reassess the patient and the care plan regularly.
• Organize resources for implementation.
• Prioritize and promote patient's self-care.

Evaluating

• Evaluating successful or unsuccessful outcomes based on measurable data.
• Determining if outcomes are met.
• Modify the care plan based on the results of the outcome evaluations.

Types of Outcomes

• Cognitive outcomes: Involve increases in patient knowledge (e.g., teaching).
• Psychomotor outcomes: Describe the patient's achievement of new skills.
• Affective outcomes: Evaluate changes in feelings, emotions, or attitudes.
• Physiologic Outcomes: Observable changes in the patient's physical state or function.

Time Criteria

• Criteria, including the specific amount of time, is needed for achieving the outcome.

Documenting Judgement

• Making a judgment about how outcomes were met.
• Options include: "Met," "Partially met," or "Not met."

Modifying The Plan of Care

• Revising the care plan based on evaluation results and to improve patient outcomes. This might involve changing diagnoses, outcomes or interventions if they are failing to meet the goals.

This quiz covers the essential aspects of assessment in nursing diagnosis, including the types of assessments and data collection methods. It focuses on how nurses gather information to establish a patient database for effective care planning and problem identification. Test your knowledge on the priorities and techniques used in nursing assessments.