Nursing Interventions and Client Care

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Questions and Answers

Why is it essential for nurses to reassess the client before implementing an intervention?

To ensure the client is asleep and unaware of the procedures.

To choose a different intervention altogether.

To determine if the intervention is still necessary. (correct)

To prepare the client for discharge from care.

What is a potential reason for a nurse to seek assistance when implementing nursing activities?

The nurse feels uncertain about the procedure and needs help. (correct)

The nurse wants to have a colleague present for social support.

The nurse wishes to delegate all tasks to other personnel.

The nurse lacks the necessary time to complete the task alone.

What should a nurse explain to the client before implementing nursing interventions?

How to contact the nurse when in need.

The entire hospital policy on care.

What interventions will be done and what sensations to expect. (correct)

The history of the disease being treated.

What documentation procedure should the nurse ensure after delegating care to other personnel?

Other caregivers must document their activities on the client record. Signup and view all the answers

Which of the following best describes the evaluation phase in nursing?

An ongoing activity assessing progress towards goals and effectiveness of care. Signup and view all the answers

What does supervising delegated care require from the nurse?

Ensuring all delegated activities are documented and reported according to the care plan. Signup and view all the answers

What is a key reason for documenting nursing activities after implementation?

To record the interventions and client’s responses for future reference. Signup and view all the answers

When is it particularly important for a nurse to maintain client privacy during interventions?

When performing interventions that involve personal care. Signup and view all the answers

What type of pain is affected by psychological factors?

Psychogenic pain Signup and view all the answers

Which type of pain originates from internal organs?

Visceral pain Signup and view all the answers

Which of the following is a goal of non-pharmacological interventions?

To decrease fear and anxiety Signup and view all the answers

Which of the following is a psychological intervention for pain management?

Cognitive behavioral therapy Signup and view all the answers

What characterizes physical (sensory) interventions?

They inhibit nociceptive input and pain perception. Signup and view all the answers

Which is NOT a type of non-pharmacological intervention?

Acetaminophen Signup and view all the answers

What can continuous pain lead to in terms of psychological impact?

Increased distress and maladaptive behavior Signup and view all the answers

What type of pain is associated with nerve damage?

Neuropathic pain Signup and view all the answers

What is an essential aspect of social justice in nursing?

Equal treatment under the law Signup and view all the answers

Which behavior demonstrates the principle of social justice in nursing?

Advocating for vulnerable populations Signup and view all the answers

How should a nurse ensure patients make informed decisions about their healthcare?

By supplying complete and honest information Signup and view all the answers

What does culturally competent care entail for nurses?

Designing care plans sensitive to individual needs Signup and view all the answers

Which of the following is an expectation for nurses regarding privacy and confidentiality?

Documenting care in an accurate and honest manner Signup and view all the answers

What role does a nurse play in promoting fairness and nondiscrimination in healthcare?

Promoting universal access to healthcare services Signup and view all the answers

What is a common value conflict a nurse might encounter in their profession?

Balancing patient autonomy with safety concerns Signup and view all the answers

Which of the following actions exemplifies taking risks on behalf of patients in nursing?

Reporting unsafe working conditions Signup and view all the answers

What is pain primarily associated with?

Injury or the threat of injury Signup and view all the answers

Which process involves the transformation of a painful stimulus into a signal?

Transduction Signup and view all the answers

What is the role of a nociceptor in the pain experience?

To respond to potentially damaging stimuli Signup and view all the answers

Which of the following statements about pain is true?

Pain has both affective and sensory components. Signup and view all the answers

How does transmission occur after transduction is complete?

Nerve impulses travel along efferent nerve fibers. Signup and view all the answers

What does the term nociception refer to?

The detection of potential tissue damage Signup and view all the answers

What is the significance of recognizing pain as the fifth vital sign?

It highlights the importance of pain management in overall health. Signup and view all the answers

Which of the following is NOT a major process in the pain experience?

Circumvention Signup and view all the answers

Why should cow’s milk be avoided as a drink for babies under 12 months?

It may cause allergic reactions. Signup and view all the answers

What should be given to a baby experiencing diarrhea?

Ample liquids. Signup and view all the answers

What type of foods should be limited if a young child is gaining inappropriate weight?

Energy-dense, nutrient-poor snack foods. Signup and view all the answers

Why is calcium intake particularly important for adolescent girls?

For bone growth. Signup and view all the answers

Which food type should older teenagers avoid to maintain a balanced diet?

Fast foods. Signup and view all the answers

What dietary recommendation is important for older adults to maintain muscle mass?

Be as active as possible. Signup and view all the answers

How can older people boost their vitamin D synthesis?

By spending time outside each day. Signup and view all the answers

What is a common challenge for young adults moving away from home regarding their diet?

Maintaining dietary variety. Signup and view all the answers

What is the primary component of urine?

95% water Signup and view all the answers

At what volume of urine in the bladder do adults typically begin to feel the need to urinate?

300-350 mL Signup and view all the answers

Which of the following is a common urinary elimination problem?

Urinary retention Signup and view all the answers

Nocturia is defined as which of the following?

Voiding two or three times at night Signup and view all the answers

What does dysuria refer to?

Painful or difficulty in voiding Signup and view all the answers

Which factors can affect voiding?

Muscle tone and activity Signup and view all the answers

What is the term for involuntary urination?

Enuresis Signup and view all the answers

What is urinary retention?

Accumulation of urine in the bladder Signup and view all the answers

Study Notes

Unit 1: Nursing Process

Nursing process is a dynamic and modified form of the scientific method used in nursing to assess client needs and create a course of action to address and solve patient problems.
It is an organized sequence of problem-solving steps for identifying and managing health problems of clients.
It is an accepted practice established by the American Nurses Association.

Objectives

Define nursing process
Describe purposes of nursing process
Identify components of the nursing process
Discuss requirements for effective use of the nursing process
Describe the functional health approach to the nursing process

Purpose Of Nursing Process

Identify a client's health status and actual or potential health care problems or needs
Establish plans to meet the identified needs
Deliver specific nursing interventions to meet those needs
Provide individualized, holistic, effective, and efficient client care

Components Of Nursing Process

Assessment (data collection)
Nursing diagnosis
Planning
Implementation
Evaluation

Components of Nursing Process (Diagram)

The nursing process utilizes the following steps
Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
Steps remain the same
Applications and results are different

Characteristics of Nursing Process

Cyclic
Dynamic nature
Client centeredness
Focus on problem solving and decision making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking and clinical reasoning

1. Assessment

It involves collection, organizing, validating, and documenting data (information).
Types of assessment are:
- Initial nursing assessment
- Problem-focused assessment
- Emergency assessment
- Time-lapsed reassessment
The ultimate purpose of assessment is data collection

1. Initial nursing assessment:

Performed within specified time after admission.
To establish a complete database for problem identification.
Example: Nursing admission assessment

2. Problem-focused assessment:

To determine the status of a specific problem identified in an earlier assessment.
Example: hourly checking of vital signs of a fever patient

3. Emergency assessment:

During emergency situation to identify any life-threatening situation.
Example: Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest.

4. Time-lapsed reassessment:

Several months after initial assessment.
To compare the client's current health status with the data previously obtained.

Components Of Assessment

Collection of data
Organize data
Validate data
Document data

1. Collection of data

The process of gathering information about a client's health status, including health history, physical examination, results of lab and diagnostic tests, and material contributed by other health personnel

1. Subjective data

Also referred to as symptoms or covert information.
Clear only to the person affected and can be described only by that person.
Examples: itching, pain, and feelings of worry

2. Objective data

Also referred to as signs or overt information.
Detectable by an observer or can be measured or tested against an accepted standard.
Obtained by observation or physical examination.
Examples: discoloration of skin or a blood pressure reading

Sources of Data

Primary: Direct source of information (client)
Secondary: Indirect source of information (family members, health professionals, records, lab/diagnostic results)

Methods Of Data Collection

Interview
Auscultation
Percussion
Palpation
Observation

2. Diagnosis

The process of defining a patient's response to health conditions/life processes, or to a vulnerability for a human response.
The official NANDA definition of a nursing diagnosis is: "a clinical judgment concerning a human response to health conditions, life processes, or a vulnerability for that response, by an individual, family, group, or community."
Diagnosing is to:
- Analyze data.
- Identify health problems, risks, and strengths
- Formulate diagnostic statement.

Status of the Nursing Diagnoses

Actual: Client problem is present at the time of assessment
Health Promotion: Client's readiness to improve health
Risk: Client is at risk of developing a problem unless nurses intervene.
Possible: Suspected problem for which data is insufficient to validate
Syndrome: Cluster of diagnoses

1. Actual Diagnosis Examples

Ineffective breathing pattern
Anxiety

2. Health Promotion Diagnosis Examples

Readiness for Enhanced Nutrition

3. Risk Nursing Diagnosis Examples

Risk for Infection

4. Wellness Nursing Diagnosis Examples

Family coping: potential for growth related to unexpected birth of twins.

Components of a Nursing Diagnosis

The problem statement (diagnostic label)
The etiology (related factors & risk factors)
Signs & Symptoms (defining characteristics)

1. Problem Statement (Diagnostic Label) Examples

Deficient Knowledge (Medications)
Deficient Knowledge (Dietary Adjustments)
Activity intolerance
Constipation

2. Etiology or Contributing Factors

Factors that influence client's response to a health problem
Example: Activity intolerance related to generalized weakness or obesity or sedentary lifestyle.

3. Defining Characteristics (S/S)

Cluster of signs and symptoms that indicate a particular health problem.
Example: Fluid volume deficit related to decreased oral intake ,manifested by dry skin and mucus membranes.

The Diagnostic Process

Analyzing data
Identifying health problems, risks and strengths
Formulating diagnostic statements

Formulating Diagnostic Statements

Basic two-part statements (PE format)
Problem (P) - statement of the patient's response
Etiology (E) - factors contributing to the response
Example: Activity intolerance related to generalized weakness or obesity
Basic three-part statements (PES format) Problem (P)- statement of the patient's response Etiology (E)- factors contributing to the response Signs & Symptoms (S)- evidence of the problem

Difference between Nursing Diagnosis & Medical Diagnosis

Nursing Diagnosis: Statement of nursing judgment; focused on patient responses; addresses conditions nurses are licensed to treat; describes patient's physical, sociocultural, psychological and spiritual responses to illness or a health problem;
Medical Diagnosis: Statement of medical judgment; focused on disease processes; addresses conditions only physicians can treat; describes a patient's response or specific patho-physiological responses to illness.

4.Planning

The nurse develops a detailed client care plan.
The nurse and client collaboratively develop goals/desired outcomes and nursing strategies to prevent, reduce, or alleviate health problems.

Types Of Planning

Initial Planning- occurs after initial assessment
Ongoing Planning- occurs during the beginning of a shift
Discharge Planning- anticipatory planning for needs after discharge

Planning process

Prioritize problems/diagnosis
Formulate goals/desired outcomes
Select nursing interventions
Write nursing interventions

1. Setting priorities

Deciding which nursing diagnosis requires attention first (Maslow's hierarchy of needs)
Examples: Air, food, water, security, and activity
Physiologic needs receive highest priority

2. Establishing Client Goals/ Desired Outcomes

Specific, measurable, attainable
Example: Client will raise right arm to shoulder height by Frida

Types Of Goals

Short-term goals
Long-term goals

3. Nursing interventions

Actions nurses take to achieve patient goals.
Types of interventions are: Independent, Dependent, and Collaborative

Types of Nursing Interventions

Independent- actions nurses are licensed to initiate
Dependent- actions carried out under orders or supervision of a healthcare professional.
Collaborative- actions carried out in collaboration with other health team members

4. Implementation

The action phase of the nursing process, where nurses perform the planned interventions. Processing implementing:
Reassessing the client
Determining the nurse's need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities

Evaluation

A planned, ongoing, purposeful activity in which the nurse determines the client's progress toward the achievement of goals and the effectiveness of the plan.

2. Diagnosis (cont)

Diagnosing is to:
Analyze data
Identify health problems, risks and strengths
Formulate diagnostic statements

2. Diagnosis (cont)

Status of nursing diagnosis:
Actual diagnosis: Client problem that exists when assessed.
Health promotion diagnosis, Risk diagnosis, Possible diagnosis, Syndrome diagnosis

3. Planning (cont)

Planning involves 3 stages:
Initial planning
Ongoing planning
Discharge planning

4.Implementation

Implementation is the action phase
Nurses are responsible to reassess the client, and determine whether the intervention needs assistance.

5. Evaluation

Evaluation determines client progress towards goals and effectiveness of the plan.

Concept Of Values And Belief

Values are important in nursing and healthcare as they under- pin all aspects of professional practice.
Belief - assumptions about self, others in the world and how we expect things to be.
Attitude- feelings toward a person, object or idea
Relevant terms:
Assumptions - beliefs considered obvious and correct.
Honesty- virtuous moral character (integrity, truthfulness, straightforwardness)
Code- system of principles
Conduct- manner of acting, personal deportment, mode of action.
Decision- choice or judgment.
Environment- surroundings and influences
Moral
Attitudes
Values transmission
Learned from observation, parents, teachers, and influential people
affected by family, sociocultural environment and peers.
examples ( honesty, courage, and patience)
Types of Beliefs:
Commendatory beliefs-e.g. "I am a good writer."
Existentialism-e.g. Belief in God
Monotheism, Polytheism, Atheistic
Types of Values
Religious values
Personal values
Cultural values
Humanistic Values
Optimistic Values
Democratic Values
Motivational Values
Rituals
A ritual is a formalized predetermined set of symbolic actions performed in a certain environment.
Factors influencing values:
Family, environment, peers, culture

1. Assessment (cont)

Examine the client from a physical perspective.

2. Planning (cont)

Implement plans in a way that achieves client's goals and is consistent with their values.

3. Implementation (cont)

Take into account their values and beliefs when implementing the plan.

Concept Of Pain

Pain is a complex experience consisting of physiological and psychological responses to a noxious stimulus.
A warning mechanism that protects organism against harmful stimulus or the threat of injury.
Is subjective and difficult to quantify.

Types of pain:

Acute pain - quickly appears, short duration (hours/days) associated with tissue damage
Chronic pain - lasts longer than expected (months/years) often related to long-term diseases.

Theories of pain:

Gate control theory - non-painful input closes "gates" to painful input (preventing it from getting to the brain)

Non-pharmacological interventions

Massage
Positioning
Hot and cold treatment
Transcutaneous Electrical Nerve Stimulation (TENS)
Acupuncture
Progressive muscle relaxation

Pharmacological Interventions

Nonopioids- Mild to moderate pain (NSAIDs, paracetamol, aspirin)
Compound analgesics- mild to moderate pain (combination of drugs with codeine + aspirin or paracetamol)
Opioids- severe pain (morphine, oxycodone, codeine, tramadol, buprenorphine, fentanyl, diamorphine)
Adjuvants- manage symptoms of neuropathic pain (tricyclic antidepressants, antiepileptic drugs)
Topical analgesics- localized pain relief (rubefacients, topical NSAIDs, local anesthetics)

Concept Of Nutrition and Dietary Pattern

Pattern of food and fluid consumption relative to metabolic need.
Includes all aspects of nutrition (digestion, absorption, metabolism) Dietary intake is essential for good health and is influenced throughout the lifespan.

Essential Nutrients (for body growth):

Protein
Fats
Carbohydrates

Concept of Sleep & Rest

Sleep is a basic human need and is a part of biological rhythms.
Rest is a state of decreased activity and free from stress.
Different stages and types of sleep can be identified.
Sleep needs can vary depending on a person's age/developmental stage.

Common Sleep Disorders

Insomnia (trouble falling asleep)
Excessive daytime sleepiness - hypersomnia
Narcolepsy (sleep attacks)
Sleep apnea (inability to breathe while sleeping)
Parasomnias (sleep-related behaviors such as bruxism, sleepwalking, and nightmares)

Factors affecting sleep:

Age
Illness
Environment
Lifestyle and habits
Emotional stress
Stimulants and Alcohol
Diet

Nursing Process for promoting sleep:

Assessment - Sleep history, physical examination, sleep diary and questionnaires
Interventions - Provide safe and supportive environment to promote sleep, educate about behaviors that promote sleep
Evaluation - Determine client's progress towards achieving sleep goals

Concept of Sexuality

A range of thoughts, feelings, behaviors, and roles regarding sexual attraction and gratification.
Affected by biological, social, psychological and cultural influences.
Important for relationships, family, and society.
Can be affected by various factors in the individual's lifespan.

Factors affecting sexuality

Quality of relationship, cognition, culture, values, beliefs, self-concept, previous experience, environment, pregnancy, illness, disease, and other critical life events.

Types of sexual problems

Sexual dysfunction, sexual abuse, impairment
related to age/developmental stage, medical conditions.
Other potential issues influence sexuality- cultural/historical/social values/attitudes

Stages of Sexual Development (some models)

Freud's psychosexual stages (Oral, Anal, Phallic, Latency, Genital)

Nursing implications for working with clients concerning sexuality

Establish a trustworthy, respectful relationship
Maintaining privacy
Active listening
Clarify that sexuality encompasses more than intercourse
Discuss alternative approaches

Nursing Diagnosis for Sexual Issues

Ineffective sexual pattern
Sexual dysfunction
Rape trauma syndrome

Human responses to illness

Definition of Health: A complete state of physical, mental and social well-being.
Wellness: A dynamic process involving attitudes and behaviors directed at maximizing an individual's potential and meeting standards of functioning.

Dimensions of Wellness

Physical: Ability to carry out daily tasks
Social: Able to interact
Emotional: Ability to manage stress, expressing emotions apropiately and accepting shortcomings
Intellectual: Learn and use information to develop personally
Environmental: Promote health in a community
Spiritual: Belief in a force greater than self (morals, values,ethics)
Occupational: Achieving balance between personal and work time

Concepts of illness and disease

Disease: An alteration in body functions resulting from an identifiable condition, e.g., cancer.
Illness: The individual response of a person to a disease. (emotional, subjective, and personal)
Variables affecting illness behavior:
Internal- perception, nature of illness, individual characteristics
External- visibility, social group, culture, economic status, accessibility to care

Types of Illness:

Acute illness: relatively short duration of symptoms
Chronic illness: lasts longer than 6 months, may result in permanent changes

Illness Behavior

How a person recognizes, evaluates, and reacts to symptoms. Includes seeking or avoiding help, coping mechanisms, and compliance with medical advice.
Stages:
Symptom experience
Assumption of sick role
Medical care contact
Dependent stage
Recovery/rehabilitation

Emotional responses to illness

Fear
Over-dependence/ Helplessness
Anxiety
Hope
Anger/Hostility

Effect of illness

Impact on client: physical, psychological, spiritual, and social
Impact on family: emotional, financial, and social

Support during illness:

Family support
Health care providers support
Complementary and alternative medicine
Faith healing
Homeopathy

Models of Health and Illness

Agent-host-environment: Factors such as agents (bacteria, viruses), Host (who they impact and have factors to support them), and environment (lack of sleep, cold temperatures, etc.)
Health-illness Continuum: Moving away from peak wellness to critical illness or death.
High-level wellness model: Health-environmental axis to measure health and wellness levels
Heath belief model: Addresses how individual perceptions affect responses to the threat of disease
Health Promotion model: Looks at individual, social and experiences related to health behaviors to attain the best outcomes

Loss & Grieving

Loss: Something valued that is changed or removed
Types
- Actual
- Perceived
- Anticipated
Grief: The emotional process related to loss
Stages of grief:
- Denial.
- Anger.
- Bargaining.
- Depression.
- Acceptance
Nursing implications: Understand the patient's experience, provide comfort and support

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Description

This quiz explores the critical aspects of nursing interventions, including the importance of client reassessment, documentation procedures, and maintaining client privacy. It further addresses the evaluation phase in nursing and the supervision of delegated care. Enhance your understanding of effective nursing practices through this assessment.