Nursing Process and Medical Surgical Nursing

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Questions and Answers

What is the primary purpose of the nursing process?

To identify a client's health care status and potential health problems (correct)

To develop a medical diagnosis for the client

To assess the client's ability to pay for healthcare services

To create a treatment plan for the client's diagnosed medical condition

What is the first phase of the nursing process?

Assessment (correct)

Diagnosis

Nursing Planning

Implementation

What characteristic of the nursing process involves working with others?

Client-centered

Problem-solving

Cyclic and dynamic

Interpersonal and collaborative (correct)

What is the result of the assessment phase of the nursing process?

Data is collected and organized Signup and view all the answers

What is the primary difference between a nursing diagnosis and a medical diagnosis?

A nursing diagnosis is focused on the client's response to a health problem Signup and view all the answers

Why is critical thinking important in the nursing process?

To make sound judgments in every phase of the nursing process Signup and view all the answers

What is the primary characteristic of an actual nursing diagnosis?

The presence of associated signs and symptoms Signup and view all the answers

What type of nursing diagnosis is concerned with a client's preparedness to implement healthy behaviors?

Health promotion diagnosis Signup and view all the answers

What is the purpose of the etiology component in a NANDA nursing diagnosis?

To provide direction for nursing therapy Signup and view all the answers

What is the defining characteristic of a risk nursing diagnosis?

The presence of risk factors that may lead to a problem Signup and view all the answers

What is the format of a NANDA nursing diagnosis?

PES format Signup and view all the answers

What is the purpose of the problem component in a NANDA nursing diagnosis?

To describe the client's health problem or response Signup and view all the answers

What does a complete physical examination include?

Patient's height, weight, vital signs, and head-to-toe examination of all body systems Signup and view all the answers

What is the purpose of palpation in physical examination?

To use the sense of touch to gather information Signup and view all the answers

What is auscultation?

Listening to sounds made by the body Signup and view all the answers

What is the purpose of validating data in the assessment phase?

To double-check or verify data to confirm that it is accurate and complete Signup and view all the answers

What is the definition of nursing diagnosis according to NANDA?

A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes Signup and view all the answers

What is the final step in the assessment phase?

Documenting data collected about the client's health status Signup and view all the answers

What is the primary difference between an actual nursing diagnosis and a risk nursing diagnosis?

The presence of signs and symptoms Signup and view all the answers

What are the three components of an actual nursing diagnosis?

Problem, related to, and as evidenced by Signup and view all the answers

What is the purpose of the 'related to' component in a nursing diagnosis?

To identify the factors contributing to the problem Signup and view all the answers

What is the correct format for a two-part nursing diagnosis statement?

Problem related to etiology Signup and view all the answers

What is the term for the signs and symptoms present in a client with an actual nursing diagnosis?

Defining characteristics Signup and view all the answers

What is included in a client's database?

All information about the client, including nursing health history and laboratory test results Signup and view all the answers

What type of data is described as sensations, feelings, values, beliefs, attitudes, and perception of personal health status?

Subjective data Signup and view all the answers

What type of data is detectable by an observer or can be measured or tested against an accepted standard?

Objective data Signup and view all the answers

Who is the primary source of data?

The client Signup and view all the answers

What is one method of data collection that uses the senses?

Observation Signup and view all the answers

What is a planned communication or conversation with a purpose?

Interview Signup and view all the answers

Study Notes

Types of Nursing Diagnosis

An actual diagnosis is a client problem that is present at the time of nursing assessment, based on associated signs and symptoms (e.g., ineffective breathing pattern and anxiety).
A risk nursing diagnosis is a clinical judgment that a problem doesn't exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene (e.g., all people admitted to a hospital have a higher risk for infection).
A health promotion diagnosis relates to clients' preparedness to implement behaviors to improve their health condition, with labels beginning with "Readiness for Enhanced" (e.g., Readiness for Enhanced Nutrition).

Components of a NANDA Nursing Diagnosis

Problem (diagnostic label) and definition: describes the client's health problem or response for which nursing therapy is given (e.g., Deficient Knowledge (Medications) or Deficient Knowledge (Diet)).
Etiology (related factors and risk factors): identifies one or more probable causes of the health problem, giving direction to required nursing therapy and enabling individualized care.
Defining characteristics (signs and symptoms): a cluster of signs and symptoms indicating the presence of a particular diagnostic label.

Nursing Process

Definition: a systematic, rational method of planning and providing nursing care to identify a client's health care status, actual or potential health problems, and establish plans to meet identified needs.
Phases: 5 phases of nursing process are assessment, diagnosis, nursing planning, implementation, and evaluation.
Characteristics: cyclic and dynamic, client-centered, adaptive, problem-solving, decision-making, interpersonal, and collaborative.

Assessment

Collection, systematic organization, and documentation of data.
Physical examination includes height, weight, vital signs, and a head-to-toe examination of all body systems.
Techniques of physical examination: inspection, palpation, percussion, and auscultation.
Diagnostic and laboratory data: organizing, validating, and documenting data.
Written or computerized format that organizes assessment systematically.

Nursing Diagnosis

Definition: a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.
Actual nursing diagnosis contains 3 parts: diagnostic label, related factors, and signs and symptoms (defining characteristics).
Example: Noncompliance related to knowledge deficit of the need for weekly blood pressure measurements, as evidenced by "I don't keep my BP appointments if I am busy."
Basic two-part statements: problem (P) and etiology (E).

Data

Database: all information about a client, including nursing health history, physical assessment, primary care provider's history, and laboratory and diagnostic tests.
Types of data: subjective (symptoms or covert data) and objective (signs or overt data).
Source of data: primary (client) and secondary (family members, other health professionals, records, and reports).
Methods of data collection: observation, interview, examination, diagnostic procedure, and lab investigation.

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Description

Test your understanding of the nursing process, its characteristics, steps, and components of a NANDA nursing diagnosis. Learn how to apply the nursing process in medical surgical nursing.