Nursing Diagnosis

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Questions and Answers

What is the primary purpose of a nursing diagnosis in the nursing process?

  • To develop a treatment plan
  • To implement pharmacological interventions
  • To evaluate the effectiveness of treatment
  • To identify a patient's problem or need (correct)

Which of the following is a tertiary source of information during the assessment phase of the nursing process?

  • Drug reference books (correct)
  • Primary care provider's notes
  • Patient's medication list
  • Pharmacy records

During the implementation phase of the nursing process, what is the primary focus of the nurse?

  • Developing a treatment plan
  • Evaluating the effectiveness of treatment
  • Carrying out the planned interventions (correct)
  • Assessing the patient's response to treatment

What is the primary goal of patient education in the nursing process?

<p>To enhance the patient's independence (B)</p> Signup and view all the answers

During the evaluation phase of the nursing process, what is the primary focus of the nurse?

<p>Determining the effectiveness of the treatment plan (A)</p> Signup and view all the answers

What is the primary purpose of a nursing diagnosis?

<p>To provide a basis for nursing interventions (C)</p> Signup and view all the answers

What type of nursing diagnosis involves a 3-part statement?

<p>Actual diagnosis (B)</p> Signup and view all the answers

What is the primary goal of patient education in pharmacology?

<p>To ensure patient compliance with medication regimens (B)</p> Signup and view all the answers

What is the focus of the affective domain of learning?

<p>Feelings and beliefs about medication (C)</p> Signup and view all the answers

What is the purpose of the teach-back method in patient education?

<p>To assess patient knowledge (C)</p> Signup and view all the answers

What is the primary focus of implementation in nursing care?

<p>Carrying out the plan of care (A)</p> Signup and view all the answers

What is the purpose of ongoing assessment in pharmacology?

<p>To monitor for signs and symptoms of medication side effects (B)</p> Signup and view all the answers

What is the primary role of the family member in medication administration?

<p>To provide psychological support to the patient (B)</p> Signup and view all the answers

What is the purpose of evaluation in nursing care?

<p>To determine whether expected outcomes were met (A)</p> Signup and view all the answers

What is the primary goal of discharge planning and teaching?

<p>To ensure patient safety after discharge (D)</p> Signup and view all the answers

What is the purpose of the medication administration record?

<p>To record medication administration (B)</p> Signup and view all the answers

What is the legal implication of not documenting patient care?

<p>It is considered negligence (A)</p> Signup and view all the answers

What is the primary focus of the cognitive domain of learning?

<p>Thinking portion and incorporation of experiences (A)</p> Signup and view all the answers

What is the purpose of including a family member in medication administration?

<p>To provide psychological support to the patient (A)</p> Signup and view all the answers

What is the primary goal of health promotion and wellness diagnosis?

<p>To promote healthy lifestyle habits (C)</p> Signup and view all the answers

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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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