Nursing Process and Evaluation

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Questions and Answers

What is the primary purpose of evaluating in the nursing process?

To provide patient education

To document patient information

To measure patient achievement of expected outcomes (correct)

To implement new nursing practices

What should a nurse do if a patient is experiencing difficulties achieving expected outcomes?

Increase the frequency of assessment

Continue the plan without changes

Terminate the plan of care immediately

Modify the plan of care as necessary (correct)

How are cognitive outcomes assessed in patients?

By asking patients to repeat information (correct)

By evaluating their emotional responses

By conducting a skills demonstration

By observing their physical abilities

Which type of outcome involves the patient demonstrating new skills?

Psychomotor Outcomes (B) Signup and view all the answers

What method is used to evaluate physiologic outcomes?

Physical assessments and data comparison (C) Signup and view all the answers

What is the significance of time criteria in evaluating patient outcomes?

They specify when to collect evaluative data (C) Signup and view all the answers

What is the final step after collecting and interpreting data on patient outcomes?

Document the findings and make a judgment (B) Signup and view all the answers

Which of the following actions can lead to the termination of a nursing care plan?

If all expected outcomes are achieved (D) Signup and view all the answers

Which nurse variable is NOT mentioned as influencing the implementation of the plan of care?

Level of education (D) Signup and view all the answers

What is essential for the effectiveness of a well-designed plan of care?

Adequate staff, equipment, and supplies (A) Signup and view all the answers

Which of the following is a benefit of using research findings in nursing practice?

Enhancement of nursing practice (B) Signup and view all the answers

What is an important aspect of ethical nursing practice?

Becoming sensitive to ethical and legal dimensions (C) Signup and view all the answers

Why is ongoing data collection considered a vital nursing intervention?

To monitor patient responses and update the care plan (A) Signup and view all the answers

Which of the following is NOT a common reason for a patient’s noncompliance with the plan of care?

Strong personal motivation (C) Signup and view all the answers

What role does risk management play in the nursing process?

Identifies and addresses new problems during ongoing monitoring (A) Signup and view all the answers

Which method is most effective for improving nursing practice according to the content?

Reading professional journals and attending educational workshops (D) Signup and view all the answers

What is an example of an independent nursing intervention?

Educating a patient about their medication (A) Signup and view all the answers

What is the primary focus of ongoing planning in nursing care?

To keep the care plan up to date (A) Signup and view all the answers

Which of the following best describes a dependent nursing intervention?

Administering prescribed pain medication (D) Signup and view all the answers

Which nursing intervention type involves collaboration with multiple healthcare professionals?

Interdependent intervention (A) Signup and view all the answers

When should the outcomes of a nursing intervention be modified?

Based on the patient's response to planned interventions (B) Signup and view all the answers

During admission, a nurse lists fluid balance monitoring as part of the initial plan. What is the goal of this intervention?

To improve the patient's breathing and reduce swelling (A) Signup and view all the answers

What must a nurse do before implementing any intervention?

Assess the patient’s current condition (D) Signup and view all the answers

Which question is important for identifying patient outcomes?

What must I observe in the patient according to the nursing diagnoses? (A) Signup and view all the answers

What is a crucial factor for the successful implementation of a plan of care in a healthcare environment?

High organization and efficiency (C) Signup and view all the answers

What should a nurse consider when selecting evidence-based interventions?

The potential for patient benefit and harm (C) Signup and view all the answers

Which statement reflects a responsibility of nurses when implementing the plan of care?

Ask for help if unsure of competencies (A) Signup and view all the answers

Why is it important to reassess a patient before initiating nursing interventions?

Patient conditions can change rapidly (A) Signup and view all the answers

What is the main objective of comprehensive planning in acute care settings?

To develop an effective and efficient plan for patient care (C) Signup and view all the answers

What is an essential component to trust in clinical practice?

Ignoring personal biases while keeping an open mind (C) Signup and view all the answers

In the context of nursing interventions, what do self-care promotions focus on?

Teaching patients to understand their health needs (D) Signup and view all the answers

Which aspect of patient care should a nurse prioritize in planning?

Patient problems requiring immediate attention (C) Signup and view all the answers

What is the primary purpose of the nursing process?

To design a plan of care that results in better patient outcomes (A) Signup and view all the answers

Which characteristic is NOT identified for Patient B who had a modified radical mastectomy?

Ineffective Coping (B), Disturbed Body Image (C) Signup and view all the answers

What is a key component of the planning step in the nursing process?

Identifying patient-centered goals and expected outcomes (B) Signup and view all the answers

In nursing diagnosis, what is meant by 'powerlessness' in Patient C?

Feeling a lack of control over life circumstances (D) Signup and view all the answers

What does the term 'dynamic' imply regarding a nursing care plan?

It evolves as the patient's needs change (D) Signup and view all the answers

What is essential for successful implementation of the nursing process?

High-level critical thinking skills (D) Signup and view all the answers

Which statement accurately reflects the nurse's role in patient-centered care?

Nurses collaborate with patients and families to enhance care (C) Signup and view all the answers

What is the role of evidence-based interventions in the nursing process?

They are the foundation for selecting nursing interventions (A) Signup and view all the answers

What is an example of a nurse-initiated intervention?

Offering a patient 60 mL of juice every 2 hours. (D) Signup and view all the answers

What defines a physician-initiated intervention?

A nurse performing a task after receiving an order from a physician. (A) Signup and view all the answers

During implementation of the nursing process, what is the primary purpose?

To assist the patient in achieving health, preventing illness, and facilitating coping. (C) Signup and view all the answers

Which of the following is NOT a type of intervention carried out by nurses?

Patient-initiated interventions determined by the patient's preferences. (B) Signup and view all the answers

What aspect is crucial for nurses to consider while implementing a care plan?

Using critical thinking to reassess interventions based on patient conditions. (A) Signup and view all the answers

What is an important feature of student care plans compared to actual practice settings?

They are often more detailed to reflect the five steps of the nursing process. (B) Signup and view all the answers

Collaboration in nursing often includes interventions from which types of professionals?

Pharmacists, respiratory therapists, and occupational therapists. (A) Signup and view all the answers

Which intervention format is commonly used in nursing programs for student care plans?

A five-column format to incorporate multiple aspects of care. (A) Signup and view all the answers

Study Notes

Assessment - Nursing Diagnosis

Nurses perform ongoing assessments throughout the nursing process, establishing a database.
Nursing history gathers patient health status, strengths, problems, risks, and needs for care.
A physical examination is also used to collect relevant data.

Types of Nursing Assessments

First Assessment: Conducted after patient admission, creating a comprehensive database for care planning. Data collection includes patient's health, priorities for ongoing focus, and comparison to future assessments.
Focused Assessment: Data collection focuses on a specific, identified problem. Key questions include: symptoms, onset, factors that worsen or improve symptoms, and current treatment.
Emergency Assessment: Performed during a physiologic or psychological crisis (e.g., choking, bleeding, unresponsive). It aims to identify life threatening problems.

Data Collection

Data is structured systemically because many different types of data is collected about patients.
Nurses internalize assessment guidelines to effectively focus on the patient.
Gordon's framework identifies functional health patterns, organizing patient data.
Maslow's hierarchy of five human needs is also used as a guide.

Types of Data: Subjective and Objective

Subjective data: Information only perceived by the affected person, not verifiable by others (e.g., feelings, pain). Also called symptoms or covert data.
Objective data: Observable and measurable data, verifiable by others (e.g., temperature, skin condition, refusal of food). Also called signs or overt data.
Examples of subjective data include feeling nervous, nauseated, chilly and pain.
Examples of objective data include elevated temperature (39.2°C), moist skin, and refusal to eat.

Data Collection- Characteristics of Data

Purposeful: Nurses identify assessment purpose (comprehensive, focused, emergency, time-lapsed) before collecting data.
Complete: Collect all relevant data to understand patient health problems and create care plans.
Factual and Accurate: Describe observed behaviors, not just interpretations.
Example of factual data collection: Patient is observed lying with his face to the wall, refused lunch, and ate only soup.

Sources of Data

Patient: The primary source of information (unless unable to communicate).
Family and Significant Others: Are helpful when the patient has limited capacity.
Patient Record: Important for comprehensive care, containing medical history, physical examination, and progress notes.
Consultations: Specialists are consulted if needed, for diagnosis or treatment.
Reports of Laboratory and Other Diagnostic Studies: Includes lab results and imaging reports.
Reports of Therapies by Other Healthcare Professionals: Documentation from physical therapy, speech therapy, or nutritionists is included.
Nursing and Other Healthcare Literature: Consult literature to broaden understanding of specific health problems.

Methods of Data Collection

Nursing History: Obtained as soon as possible after patient presentation, including strengths, weaknesses, health risks, and existing problems.
Nursing Physical Assessment: This examination follows the nursing history and may verify or add to initial findings.

Data Collection- Methods of Data Collection- Nursing History

Patient Interview: A planned communication method, requiring strong interviewing skills to create a successful working partnership with the patient.

Data Collection- Methods of Data Collection- Nursing Physical Assessment

Physical assessment is the patient examination for objective data to better understand their condition and aid in care planning. This typically occurs after the nursing history.

Data Reporting and Recording

Patient data should be shared with other healthcare professionals promptly, especially any critical changes.
Initial data should be recorded the same day of admission.

Diagnosing

Assessment: Collecting data and making inferences.
Interpreting data: Analyzing and synthesizing collected data to create a list of potential problems/diagnoses.
Diagnosis: Completing the list of suspected problems/diagnoses, and naming those that are actual. Determining contributing factors and identifying risk factors.

History of Nursing Diagnoses

The term "nursing diagnosis" emerged around 1950.
The ANA (American Nurses Association) defined the first nursing diagnoses in 1973.
NANDA-I maintains a list and research continues to include new concepts as the need is recognized.

Nursing Diagnosis vs Medical Diagnosis

Nursing diagnoses focus on unhealthy responses to health/illness, while medical diagnoses identify diseases.
Nursing diagnoses are written to describe patient problems that nurses can treat independently.
Medical diagnoses remain relatively constant, whereas nursing diagnoses might change as the patient's responses change.

Data Interpretation and Analysis

Experienced nurses begin interpreting data while collecting data.
"Cues" are significant pieces of data.
Important data should trigger attention.
Nurses must discern normal from abnormal responses based on patient’s specifics.

Data Interpretation and Analysis- Recognizing Significant Data

Differentiating normal patient responses from abnormal ones.
Heart rate, oxygen saturation, and other factors provide context when interpreting patient data.
A heart rate of 60-100 beats per minute is usually considered normal but athletic patients may have lower resting rates.
Normal oxygen saturation is 95-100%, though 88-92% may be normal for COPD patients.

Data Interpretation and Analysis- Recognizing Patterns

Data clusters form the basis for nursing diagnoses, rather than single data points.
Clinical examples may help determine if a pattern is actually significant or could be a normal response (e.g. patient crying may be a healthy response, not a sign of a diagnosed illness).

Data Interpretation and Analysis - Identifying Strengths and Problems

Assessing patient strengths related to coping and problem management.
Identifying limitations and problems from the patient's data interpretation.
Examples of using patient history to assess strengths related to coping and problem management, or identifying limitations related to eating poorly as a contributing factor to illness.

Data Interpretation and Analysis- Identifying Potential Complications

Patient are susceptible to many complications arising from their diagnoses, medication, or treatments.
Examples include slurred speech, changes in skin color/texture, or changes in levels of consciousness.

Data Interpretation and Analysis - Reaching Conclusions

Nurses gather conclusions after interpreting and analyzing data (e.g., no problem, possible problem, actual or potential nursing diagnosis, other clinical diagnosis).

Formulating and Validating Nursing Diagnoses

NANDA describes different types of nursing diagnoses (actual, risk, possible, wellness and syndrome).
Actual: The problem is already noted based on validated defining characteristics; components include label, definition, defining characteristics and related factors.
Risk: Identifies patient vulnerability to a problem greater than other patients in a similar situation.
Possible: A statement of suspected problem that needs more information to validate.
Syndrome: A cluster of actual or risk diagnoses that typically result from one event or condition (e.g., self-care deficiency or post-trauma syndromes).

Parts of Nursing Diagnosis Statements

Problem: Describes the patient's health state or health problem clearly.
Etiology: The contributing factors believed to be related to the problem (cause or trigger).
Defining Characteristics: Objective and subjective data that signal the existence of an actual or potential health problem.

Planning Nursing Care

Outcome Identification and Planning: Identifying patient-centered goals, along with associated expected outcomes, and creating individualized interventions.
Planning involves setting priorities and working with patients, families, and the care team for ongoing consultation. This plan should be dynamic, adapting to patient needs.
Unique focus—nursing plans are designed for prevention, reduction, or resolution of identified patient health problems.

Identifying and Writing Outcomes

Outcomes might be either short-term or long-term
Outcome timelines should be established in conjunction with the patient.

Identifying Nursing Interventions

Nurse-initiated interventions: Actions performed independently by the nurse, including monitoring health status, reducing risks, resolving problems, facilitating self-care, and promoting well-being.
Physician-initiated interventions: Actions provided in response to a physician's orders, based on medical diagnoses.
Collaborative interventions: Actions undertaken by nurses working with other healthcare professionals (e.g., pharmacists, physical therapists, respiratory therapists).

Implementing the Plan of Care

Executing the planned interventions based on patient needs, resources, and other influencing factors.
Reassessing patient status and altering as needed to ensure effective care.
Importance of organizing resources in terms of equipment, personnel, and environment.
Teaching, counseling, and advocating for patient self-care.

Establishing Priorities

High priority diagnoses pose the greatest threat to patient well-being.
Medium priority diagnoses are related to the patient's current health problems.
Low priority diagnoses are typically not currently affecting the patient.

Continuing Data Collection and Risk Management

Skilled nurses monitor patient responses to interventions and update the plan of care accordingly.
Ongoing risk management involves being alert to new or worsening problems requiring new diagnoses or collaborative interventions.

When a Patient Does Not Cooperate with the Plan of Care

Reasons for non-compliance include lack of family support, lack of understanding, negative effects of treatment, inability to afford treatment, or limited access to treatment.

Evaluating

Nurses and patients work together to evaluate how well the outcomes have been achieved.
This may necessitate terminating the plan of care, modifying it, or continuing it.
Different types of outcomes are used for assessment, including cognitive, psychomotor, affective, and physiologic outcomes.
Time criteria are used to determine when evaluations should occur.

Modifying the Plan of Care

The evaluation process may reveal that the plan of care must be altered.
Deletion, modification, or adjustment may be necessary.

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Description

This quiz focuses on the critical evaluation phase of the nursing process. It covers key concepts such as the purpose of evaluation, assessment of cognitive outcomes, and the significance of time criteria. Test your knowledge on effective nursing practices and patient care plan management.