Podcast
Questions and Answers
What is the highest priority in the establishment of nursing diagnoses?
What is the highest priority in the establishment of nursing diagnoses?
What is the primary focus of the evaluation step in the nursing process?
What is the primary focus of the evaluation step in the nursing process?
Which of the following is NOT a component of planning in nursing diagnosis?
Which of the following is NOT a component of planning in nursing diagnosis?
Which type of evaluation assesses the immediate effects of the nursing care plan?
Which type of evaluation assesses the immediate effects of the nursing care plan?
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What should be included when writing an evaluative statement?
What should be included when writing an evaluative statement?
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In a collaborative diagnosis, what role does the nurse play?
In a collaborative diagnosis, what role does the nurse play?
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Which approach is essential when prioritizing nursing diagnoses according to Maslow's Hierarchy?
Which approach is essential when prioritizing nursing diagnoses according to Maslow's Hierarchy?
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What aspect of a client's status is not generally evaluated in the nursing process?
What aspect of a client's status is not generally evaluated in the nursing process?
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What should the evaluation methods in nursing care plans primarily focus on?
What should the evaluation methods in nursing care plans primarily focus on?
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In conducting an evaluation, which of the following methods would be appropriate?
In conducting an evaluation, which of the following methods would be appropriate?
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Which of the following represents a three-part nursing diagnostic statement?
Which of the following represents a three-part nursing diagnostic statement?
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What is the primary focus of a risk nursing diagnosis?
What is the primary focus of a risk nursing diagnosis?
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Which of the following is an example of a one-part statement in nursing diagnosis?
Which of the following is an example of a one-part statement in nursing diagnosis?
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In the PES format, what does 'E' represent?
In the PES format, what does 'E' represent?
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What would be an appropriate related factor in the nursing diagnosis 'Impaired memory'?
What would be an appropriate related factor in the nursing diagnosis 'Impaired memory'?
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Which of the following correctly identifies a defining characteristic for 'ineffective airway clearance'?
Which of the following correctly identifies a defining characteristic for 'ineffective airway clearance'?
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What is the correct structure of a two-part risk nursing diagnosis statement?
What is the correct structure of a two-part risk nursing diagnosis statement?
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Which is true about 'related factors' in a nursing diagnosis?
Which is true about 'related factors' in a nursing diagnosis?
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What is a key principle of ethical nursing intervention?
What is a key principle of ethical nursing intervention?
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Which of the following is NOT a component of a well-written outcome statement?
Which of the following is NOT a component of a well-written outcome statement?
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What action should follow an individualized and measurable outcome statement?
What action should follow an individualized and measurable outcome statement?
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In writing outcome statements, which modifier is important to specify?
In writing outcome statements, which modifier is important to specify?
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Which of the following is an essential characteristic of a measurable outcome?
Which of the following is an essential characteristic of a measurable outcome?
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What should be included in a nursing assessment during implementation?
What should be included in a nursing assessment during implementation?
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Which verb could be used in an expected outcome statement?
Which verb could be used in an expected outcome statement?
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What is the primary focus of the balance between cost and care in nursing interventions?
What is the primary focus of the balance between cost and care in nursing interventions?
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What is a characteristic of a nursing sensitive outcome?
What is a characteristic of a nursing sensitive outcome?
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Which component is NOT part of the SMART criteria when setting expected outcomes?
Which component is NOT part of the SMART criteria when setting expected outcomes?
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In the context of writing nursing orders, what is the correct structure of a nursing order?
In the context of writing nursing orders, what is the correct structure of a nursing order?
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Which type of nursing intervention relies on the nurse's judgment and knowledge?
Which type of nursing intervention relies on the nurse's judgment and knowledge?
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What is the purpose of problem-focused nursing diagnoses?
What is the purpose of problem-focused nursing diagnoses?
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Which type of goal is specifically measurable within a defined timeframe?
Which type of goal is specifically measurable within a defined timeframe?
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What type of nursing diagnosis aims to prevent possible health problems?
What type of nursing diagnosis aims to prevent possible health problems?
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Which of the following is a goal related to the nursing intervention of reducing acute pain?
Which of the following is a goal related to the nursing intervention of reducing acute pain?
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What indicates that an outcome is partially achieved?
What indicates that an outcome is partially achieved?
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Which of the following is NOT a cue when formulating accurate nursing diagnostic statements?
Which of the following is NOT a cue when formulating accurate nursing diagnostic statements?
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When evaluating the client's understanding of hospital routines, which response indicates the outcome was achieved?
When evaluating the client's understanding of hospital routines, which response indicates the outcome was achieved?
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Which nursing diagnostic statement correctly differentiates etiology and symptoms?
Which nursing diagnostic statement correctly differentiates etiology and symptoms?
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If a problem still exists post-evaluation, what should be the next step?
If a problem still exists post-evaluation, what should be the next step?
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Which statement is an example of a legally inadvisable nursing diagnosis statement?
Which statement is an example of a legally inadvisable nursing diagnosis statement?
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Which of these is an example of an achieved outcome in the context of nursing evaluation?
Which of these is an example of an achieved outcome in the context of nursing evaluation?
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What should a nurse do if desired outcomes have not been achieved?
What should a nurse do if desired outcomes have not been achieved?
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Flashcards
SOAP/SOAPIER
SOAP/SOAPIER
A structured method for organizing client information and care plans in nursing.
Evaluation in Nursing
Evaluation in Nursing
The assessment of a client's health status and effectiveness of the nursing care plan.
Types of Evaluation
Types of Evaluation
Includes process, impact, and outcome evaluations to assess care effectiveness.
Area of Evaluation
Area of Evaluation
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Evaluative Statement
Evaluative Statement
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SMART goals
SMART goals
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Nursing sensitive outcomes
Nursing sensitive outcomes
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Short-term goal
Short-term goal
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Long-term goal
Long-term goal
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Independent interventions
Independent interventions
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Dependent interventions
Dependent interventions
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Collaborative problems
Collaborative problems
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Components of nursing orders
Components of nursing orders
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Nursing Diagnosis
Nursing Diagnosis
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P.E.S. Format
P.E.S. Format
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Risk Nursing Diagnosis
Risk Nursing Diagnosis
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Health-Promotion Nursing Diagnosis
Health-Promotion Nursing Diagnosis
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Defining Characteristics
Defining Characteristics
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Related Factors
Related Factors
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Diagnostic Label
Diagnostic Label
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Example Diagnostic Statement
Example Diagnostic Statement
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Complications of Haemorrhage
Complications of Haemorrhage
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Priority Diagnosis
Priority Diagnosis
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Maslow's Hierarchy
Maslow's Hierarchy
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Goal Setting in Nursing
Goal Setting in Nursing
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Autonomy
Autonomy
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Accountable
Accountable
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Outcome Statements
Outcome Statements
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Components of Outcome Statements
Components of Outcome Statements
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Implementation in Nursing
Implementation in Nursing
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Health Teaching
Health Teaching
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Referral
Referral
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Outcome Achieved
Outcome Achieved
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Outcome Partially Achieved
Outcome Partially Achieved
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Outcome Not Achieved
Outcome Not Achieved
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Desired Outcomes
Desired Outcomes
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Actual Outcomes
Actual Outcomes
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Etiology in Nursing
Etiology in Nursing
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Signs vs. Symptoms
Signs vs. Symptoms
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Study Notes
Nursing Process Overview
- The nursing process is a systematic problem-solving approach for identifying and managing client health problems.
- It employs a five-phase cyclical process: assessment, diagnosis, planning, implementation, and evaluation.
- The process is client-centered, continuous, and evidence-based.
- A holistic approach is emphasized, incorporating client perspectives and incorporating research-based knowledge and skills, caring, communication, and ethical principles
Learning Outcomes
- Students will be able to describe the five phases of the nursing process.
- Students will understand the differences between nursing diagnoses and collaborative problems.
- Students will comprehend the importance of nursing diagnoses and the nursing process in informing nursing care.
- Students will be proficient in formulating appropriate nursing diagnostic statements.
- Students will know how to apply the nursing process to develop a nursing care plan.
- Students will be familiar with recent research on nursing diagnoses and care plans, and their applications.
Nursing Process: Five Phases
- Assessment: Collecting data (including subjective and objective information).
- Diagnosis: Identifying patterns in collected data.
- Includes significant cues, data gaps, conclusions on health status, etiologies, verifying and labeling diagnoses.
- Planning : Establishing priorities, creating goals, expected outcomes, and interventions.
- Implementation : Putting the plan into action.
- Evaluation: Evaluating if goals were met and making necessary adjustments.
Assessment: Details
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Assessment is the initial step where nurses gather comprehensive data on patients.
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Phases of assessment: initial comprehensive assessment, and ongoing assessment
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Data Sources: nursing history/interview, physical exam, patient observation, medical records, and information from colleagues.
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Data Collection Methods: Interviews, physical assessment (head-to-toe), inspection, auscultation, percussion, palpation, vital signs, observation, diagnostic test results, and clinical records.
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Data Types:
- Subjective data (symptoms, patient experience).
- Objective data (observable/measurable signs).
- Primary data (collected directly from patient).
- Secondary data (information from other sources like records).
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Types of Assessment
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Initial/baseline/screening: pre-determined data collection & initial problem identification (e.g., Gordon's Functional Health Patterns).
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Ongoing: continuous, dynamic assessment to evaluate changes in condition.
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Focus assessment: addressing specific issues
Data organization
- Organize data using models and frameworks like Gordon's Functional Health Patterns, body systems examination, and Maslow's Hierarchy of Needs.
- Avoid vague language, ensuring clear and detailed documentation.
Cues VS Inferences
- Cues are specific factual data.
- Inferences are conclusions based on data.
- Accurate documentation differentiates between cues and inferences.
Types of Nursing Diagnoses
- Problem-focused diagnosis: addressing actual or potential health problems
- Risk diagnosis: identifying vulnerabilities to developing problems.
- Health promotion diagnosis: identifying strengths and promoting wellness.
- Syndrome diagnosis: identifying a pattern of diagnoses.
Writing Diagnostic Statements
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Use the P.E.S. (Problem, Etiology, Signs/Symptoms) format: (Problem r/t Etiology a.e.b. Signs/Symptoms]
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Examples for diagnoses are provided for clarity.
Nursing Interventions Classification (NIC)
- Classifies nursing interventions to guide interventions for each diagnosis.
Planning Interventions
- Adapting the care plan based on the client's condition is crucial and the plan to meet evolving needs is critical.
Writing Nursing Orders
- Subject, action verb, descriptive phase, time frame (e.g., q4h).
Ethical and Legal Considerations
- Nurses must abide by ethical and legal standards in their interventions, ensuring patient autonomy, their accountability, and balancing the cost and care implications.
Writing Outcome Statements
- Outcome statements should be Specific, Measurable, Achievable, Relevant, and Time-bound (SMART). They should be individualized, relevant to the client’s specific needs.
Evaluation
- Evaluating the client's health status according to the goals and the nursing care plan.
- Assessing the effectiveness of the nursing care plan.
- Methods of evaluation: Asking the client to verbalize their factors for wound healing, Asking the client to perform deep breathing techniques.
- Determine whether the outcome was achieved or not.
- Areas of assessment: Cognitive, psychomotor, affective, observing body functions and appearance; using the outcome statement.
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Description
Test your knowledge on the nursing process, including diagnosis, planning, and evaluation. This quiz covers key concepts like Maslow's Hierarchy, nursing diagnostic statements, and effective evaluation methods. Perfect for nursing students aiming to reinforce their understanding of the nursing care plan.