Questions and Answers
What is the primary purpose of a nursing diagnosis in the nursing process?
Which of the following is a tertiary source of information during the assessment phase of the nursing process?
During the implementation phase of the nursing process, what is the primary focus of the nurse?
What is the primary goal of patient education in the nursing process?
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During the evaluation phase of the nursing process, what is the primary focus of the nurse?
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What is the primary purpose of a nursing diagnosis?
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What type of nursing diagnosis involves a 3-part statement?
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What is the primary goal of patient education in pharmacology?
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What is the focus of the affective domain of learning?
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What is the purpose of the teach-back method in patient education?
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What is the primary focus of implementation in nursing care?
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What is the purpose of ongoing assessment in pharmacology?
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What is the primary role of the family member in medication administration?
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What is the purpose of evaluation in nursing care?
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What is the primary goal of discharge planning and teaching?
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What is the purpose of the medication administration record?
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What is the legal implication of not documenting patient care?
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What is the primary focus of the cognitive domain of learning?
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What is the purpose of including a family member in medication administration?
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What is the primary goal of health promotion and wellness diagnosis?
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Study Notes
Nursing Diagnosis
- A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes
- Provides basis for nursing interventions
- 4 types:
- Actual (3-part statement)
- Risk/High-risk
- Health promotion and wellness (readiness for enhanced)
- Syndrome
Common Nursing Diagnoses
- Pain related to hesitancy in taking prescribed pain medication because of fear of addiction
- Acute confusion related to adverse reaction to medication
- Ineffective health maintenance related to not receiving recommended preventive care
- Deficient knowledge related to effects of anticoagulant medication on clotting mechanism
- Noncompliance related to forgetfulness
- Risk for injury related to side effects of drug
- Ineffective self-health management related to lack of finances or health care coverage to purchase medications
- Readiness for enhanced knowledge related to medication schedule and medication side effects
Planning
- Formulated to meet patient’s needs
- Patient goals not nursing goals
- SMART
- Maslow’s Hierarchy of Needs
- NCP to critical pathways
- Standardized, automated care plan with standards, interventions, goals, and outcome
- Evidence-based medicine
Planning - Pharmacology
- Identification of therapeutic intent of medication
- Identification of common adverse effects that require education
- Identification of dosage and route of administration
- Scheduling of administration
- Teaching patient to keep written records
- Education as needed about techniques of self-administration
Implementation
- Carrying out plan of care
- Meeting the needs of the patient, providing safety, monitoring for complications, ongoing-assessment
- 3 actions:
- Dependent
- Interdependent
- Independent
Implementation - Pharmacology
- Selection of correct supplies
- Verification of aspects of the medication
- Premedication assessment
- Administration
- Education (noncompliance)
- Inclusion of a family member:
- Act as a psychological support
- Actually administer all or part of therapy
- Observe effectiveness and S/E
- Implement other changes or preparation
Evaluation
- Determining whether expected outcomes were met
- Involves patient and SO
- Provides means for input of new significant data
Evaluation - Pharmacology
- On-going assessment to patient’s response to medications, signs and symptoms, therapeutic effects
Patient Education
- Domains of learning:
- Cognitive domain
- Affective domain
- Psychomotor domain
Cognitive Domain
- Thinking portion and incorporation of experiences
- Formulating new meanings
Affective Domain
- Feelings and beliefs on what has been understood
- Value of medication
Psychomotor Domain
- Learning of new procedure or skill
- Demonstration of procedure
Patient Teaching
- General
- Side effects
- Self-administration
- Diet
- Cultural considerations
Principles of Teaching and Learning
- Carries legal implications
- Basic patient right
- Involves establishing goals with patient and family
- Focus the learning
- Consider learning styles
- Organize teaching sessions and materials (teach back)
- Motivates individual to learn
- Determine readiness to learn
- Space the content
- Use repetition to enhance learning
- Consider education level
- Incorporate culture and ethnic diversity
Strategies for Health Teaching
- Teach appropriate use of the internet
- Encourage adherence
- Communicate goals and expectations
Discharge Planning and Teaching
- Summary statement of patient’s unmet needs
- Explain proper method of taking prescribed medication
- Stress need of punctuality
- Teach storage of medication
- Provide written instructions (large bold letters)
- Identify anticipated therapeutic response
- Instruct how to monitor response to drugs
- Give list of signs and symptoms
Medication Administration and Safety
- Legal and ethical considerations
- A privilege, not a right which includes accountability
Patient Charts
- Chart or electronic medical record
- Primary source of information
- Communication link
- Legal document
- Content:
- Summary sheet/info
- Consent forms
- Medical order sheet
- History & physical examination
- Progress notes
- Nurses’ notes
- Laboratory tests record
- Graphic record
- Flow sheets
- Consultation reports
- Medication administration record/medication profile
- Patient education record
- “If you didn’t chart it, it didn’t happen”
- “If not documented, it is not done”
Nursing Process and Patient-Centered Care
- Foundation for nursing practice
- Problem-solving approach
- On-going cyclic process that responds to changing requirements of the patient
- Steps:
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
Assessment
- Admission until discharge
- Problem-identifying
- Collecting data
- Sources:
- Primary source
- Secondary source
- Tertiary source
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Description
Nursing Diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. It provides a basis for nursing interventions and has four levels: actual, risk/high-risk, health promotion, and syndrome.
