Nursing Diagnosis Practice Questions

• The nursing process is the organized sequence of steps used to identify and manage the health problems of clients, as defined on page 18.
• It's an accepted standard of clinical practice recognized by the American Nurses Association (ANA).
• Provides a framework for decision-making in client care.
• Used to determine if standards of care have been met.
• Includes decision making and critical thinking, guiding nurses' actions.
• Provides a structured plan for nurses to follow
• Benefits client care
• Provides a framework to evaluate care effectiveness.
• Used as a tool for data collection and research in patient care.

Characteristics of the Nursing Process

• It operates within the legal scope of nursing practice.
• It's based on knowledge and evidence.
• It's planned and systematic.
• It is client-centered, focusing on the individual's needs.
• It is goal-directed, aiming to achieve specific outcomes.
• Problems are prioritized based on importance.
• It is dynamic, adapting to changing circumstances.

Nursing Process Components

• Assessment involves collecting and organizing data.

Diagnosis

• Analyzes data
• Identifies nursing diagnoses and collaborative problems.

Planning

• Prioritizes problems
• Identifies measurable outcomes (goals)
• Selects nursing interventions
• Documents the plan of care.

Implementation

• Carries out nursing orders.
• Documents nursing care and client responses.

Evaluation

• Monitors client outcomes.
• Determines whether to resolve, continue, or revise the current plan of care.

Data Collection/Assessment

• This is the first critical step in the Nursing Process.

Sources of Data

• Primary sources come directly from the client.
• Secondary sources include information from others.

Types of Data

• Subjective data comes from the client's perspective.
• Objective data is measurable and observable.
• Database assessments are comprehensive.
• Focused assessments target specific problems.
• Functional assessments evaluate abilities.

Data Organization

• Data can be organized by clustering related information.
• Information can be captured on an Assessment Record.

Diagnosis/Priority Problem

• It is the second step in the nursing process.
• The diagnosis must be approved by NANDA.
• North American Nursing Diagnosis Association International is able to submit suggestions to NANDA.
• A diagnostic statement is a nursing diagnostic statement containing parts, according to page 23.
• A nursing diagnosis is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures.
• Diagnoses consist of four groups: problem-focused, risk, syndrome, and health promotion
• Nursing diagnosis differs from medical diagnosis.

Examples of Diagnostic Statements

• Disturbed sleep pattern related to excessive intake of coffee as evidenced by difficulty in falling asleep, feeling tired during the day, and irritability with others, drinking coffee until 8 pm
• Acute pain related to post-surgical inflammation as evidenced by facial grimacing and verbal reports of pain.
• Risk for aspiration related to decreased cough and gag reflexes.
• Dressing self-care deficit related to right-sided paralysis as evidenced by the inability to put clothing on the upper and lower body.

Collaborative Problems

• Potential complications can arise from a disorder, test, or treatment that the nurse cannot treat independently (pg. 24-25).
• Hemorrhage

Nursing priorities for Robert

• Ineffective airway clearance
• Impaired gas exchange
• Knowledge deficit
• Risk for falls

Planning Step

• Occurs after diagnosis.
• Involves setting priorities to promote outcomes or goals.
• Distinguishes between short-term versus long-term goals.
• Establishes goals for collaborative problems.
• Written from a nursing perspective.
• Focuses on what the nurse will monitor, report, record, or do to promote early detection and treatment.

Planning: Interventions

• Selection of Interventions is part of Planning
• Critical thinking is used to reach conclusions based on objectively analyzing, interpreting, and evaluating observations.
• Interventions must be safe, within the legal scope of practice, and compatible with medical orders.
• Example: Risk for falls - interventions to mitigate that risk.
• Nursing Rationale provides a scientific reason for an action.
• Involves explaining the intervention and using critical thinking skills as part of the planning process.

Care Plan Documentation

• Care plans can be written or computerized.
• Nursing orders provide specific instructions for performing interventions.
  • Example: Provide 100 mL of oral fluid every hour while awake

Communication of Care Plan

• Everyone involved with the patient's care should know about the care plan.
• The care plan is intended to be permanent.
• Implementation means carrying out the plan of care.

Evaluation of Care Plan

• Occurs a final step in the nursing process
• Throughout the process , the plan is ongoing and changing based on the clients needs and goal
• This process include evaluating all aspects related to patient care.
• Consider insights from care conferences
• Refer to the Nurse Practice Act guidelines.

Important notes

• Assessment involves data collection; planning follows.
• Implementation, evaluation, and documentation of all steps is done throughout.
• Prioritize goals based on patient needs and conditions.

Test your knowledge of nursing diagnoses. These questions cover the components of a nursing diagnostic statement, differentiating it from a medical diagnosis, and prioritizing diagnoses.