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Questions and Answers
What is the primary purpose of planning in nursing care?
What is the primary purpose of planning in nursing care?
Which type of planning occurs continuously throughout patient care?
Which type of planning occurs continuously throughout patient care?
What should be included in a nursing care plan to ensure its effectiveness?
What should be included in a nursing care plan to ensure its effectiveness?
What is the main focus of the evaluation phase in nursing care?
What is the main focus of the evaluation phase in nursing care?
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Which action can a nurse take after completing the evaluation process?
Which action can a nurse take after completing the evaluation process?
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What is the primary purpose of the nursing process?
What is the primary purpose of the nursing process?
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Which of the following is not a phase of the nursing process?
Which of the following is not a phase of the nursing process?
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Which characteristic of the nursing process emphasizes its adaptability?
Which characteristic of the nursing process emphasizes its adaptability?
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What type of assessment is conducted immediately after a client is admitted to a healthcare facility?
What type of assessment is conducted immediately after a client is admitted to a healthcare facility?
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What does a time-lapsed assessment compare?
What does a time-lapsed assessment compare?
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Which assessment is crucial during a physiologic crisis?
Which assessment is crucial during a physiologic crisis?
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In which phase of the nursing process is critical thinking predominantly applied?
In which phase of the nursing process is critical thinking predominantly applied?
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What type of assessment is an ongoing process focusing on a specific problem?
What type of assessment is an ongoing process focusing on a specific problem?
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Which of the following best describes subjective data?
Which of the following best describes subjective data?
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What is the primary source of data in health assessments?
What is the primary source of data in health assessments?
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Which method is NOT commonly used for data collection in health assessments?
Which method is NOT commonly used for data collection in health assessments?
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What does the technique of palpation involve?
What does the technique of palpation involve?
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Which of the following is considered a type of objective data?
Which of the following is considered a type of objective data?
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What is the purpose of conducting a physical examination?
What is the purpose of conducting a physical examination?
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Which technique of physical examination primarily uses visual observation?
Which technique of physical examination primarily uses visual observation?
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Which method uses sequential questioning to gather health information?
Which method uses sequential questioning to gather health information?
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What does percussion involve?
What does percussion involve?
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What is the primary purpose of auscultation?
What is the primary purpose of auscultation?
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What does the validation of data refer to in nursing assessment?
What does the validation of data refer to in nursing assessment?
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Which best describes an actual nursing diagnosis?
Which best describes an actual nursing diagnosis?
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What is a risk nursing diagnosis?
What is a risk nursing diagnosis?
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What is the initial phrase of a health promotion diagnosis?
What is the initial phrase of a health promotion diagnosis?
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What are the three components of a NANDA nursing diagnosis described in the PES format?
What are the three components of a NANDA nursing diagnosis described in the PES format?
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What do defining characteristics refer to in a nursing diagnosis?
What do defining characteristics refer to in a nursing diagnosis?
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What are the three parts of an actual nursing diagnosis?
What are the three parts of an actual nursing diagnosis?
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What is the primary difference between nursing diagnosis and medical diagnosis?
What is the primary difference between nursing diagnosis and medical diagnosis?
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Which of the following statements best exemplifies a risk nursing diagnosis?
Which of the following statements best exemplifies a risk nursing diagnosis?
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Which component would NOT be found in a basic two-part nursing diagnosis?
Which component would NOT be found in a basic two-part nursing diagnosis?
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In a three-part nursing diagnosis statement, which component represents the patient's response?
In a three-part nursing diagnosis statement, which component represents the patient's response?
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What is a common format for joining the problem and etiology in a nursing diagnosis?
What is a common format for joining the problem and etiology in a nursing diagnosis?
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Which of the following statements correctly represents signs and symptoms in a nursing diagnosis?
Which of the following statements correctly represents signs and symptoms in a nursing diagnosis?
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How do nursing diagnoses typically evolve over time?
How do nursing diagnoses typically evolve over time?
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Study Notes
Nursing Process Overview
- The nursing process is a systematic, rational method for planning and delivering nursing care.
- Its purpose is to identify a client's health status, actual or potential health problems, establish plans to meet these needs, and provide specific nursing interventions for those needs.
- The process involves five phases: assessment, diagnosis, planning, implementation, and evaluation.
- These phases are closely interrelated, with each phase affecting the others.
Characteristics of the Nursing Process
- Cyclic dynamic: The process is cyclical, with continuous assessment throughout.
- Client-centered: Focuses on the client's specific needs and health concerns.
- Problem-solving: Adaptable for a variety of problems and situations, allowing nurses to take a problem-solving approach.
- Decision-making: Decision-making is a key element at every step of the process.
- Interpersonal and Collaborative: The nature of nursing involves interpersonal interactions and teamwork.
- Critical Thinking Skills: Utilizing critical-thinking skills is essential for all aspects of the nursing process.
Assessment
- Systematic and continuous collection, organization, validation, and documentation of data.
- Types of assessment: initial, problem-focused, emergency, and time-lapsed.
- Initial assessment is performed after admission, establishing a complete data base.
- Problem-focused assessment is ongoing, monitoring a specific identified problem.
- Emergency assessment is applied during crises (physical or mental health).
- Time-lapsed assessment is conducted months after the initial assessment for comparison and possible changes.
Components of Assessment
- Collecting data: Gathering information about client health status to prevent the omission of significant data.
- Data base: All information about the client. This includes nursing health history, physical assessment, primary care provider's history and physical examination, and results of laboratory and diagnostic tests.
Types of Data
- Subjective data (symptoms): Perceived sensations, feelings, values, beliefs, and perceptions of health status. Examples include itching, pain, or feeling worried.
- Objective data (signs): Observed data that can be measured or tested against a standard. Examples include blood pressure readings or skin discoloration.
Source of Data
- Primary source: The client.
- Secondary sources: Family members, support persons, other health professionals, medical records, reports, laboratory, and diagnostic analyses.
Methods of Data Collection
- Observation: Using senses (sight, smell, hearing) to gather data.
- Interview: A planned communication or conversation with a purpose.
- Examination: Applying various techniques to collect data.
- Diagnostic procedures: Specific tests or procedures to obtain information.
- Lab investigations: Laboratory tests for data.
Physical Examination Techniques
- Inspection: Carefully looking, listening, and smelling.
- Palpation: Using the sense of touch to gather information.
- Percussion: Tapping the skin to vibrate underlying tissues and organs.
- Auscultation: Listening to sounds made by the body.
Organizing and Validating Data
- Organizing data: Using a written or computerized format to systematically organize the assessment.
- Validating data: Double-checking or verifying data to ensure accuracy and completeness.
- Documenting data: Recording all collected data about the client's health status.
Nursing Diagnosis
- North American Nursing Diagnosis Association (NANDA): An official working definition of nursing diagnosis.
- A clinical judgment about individual, family, and community responses to actual or potential health problems/life processes.
- Types of Nursing Diagnosis: actual, risk (potential). - Actual diagnosis: identifies a problem present during assessment. Example: ineffective breathing pattern, anxiety. - Risk diagnosis: Identifies factors that increase the chance for a problem to develop. Example: risk of infection. - Health Promotion Diagnosis: focuses on client's readiness to improve health. Ex: Readiness for Enhanced Nutrition.
Components of a NANDA Nursing Diagnosis (PES)
- Problem (diagnostic label and definition): Describes a client's health problem or response. Examples: Deficient Knowledge, or Impaired Skin Integrity.
- Etiology (related factors): Identify possible causes of a health problem.
- Defining characteristics (signs and symptoms): Physical and subjective manifestations of a problem.
Basic Two-Part Statements
- Used for potential (risk) problems.
- Problem statement (P) and etiology statement (E). E.g., Risk for Impaired Skin Integrity related to immobility.
Medical Diagnosis
- Made by a physician.
- Refers to disease processes.
- Remains the same as long as the disease is present.
Formulating Diagnostic Statements
- Basic three-part statements (problem, etiology, and defining characteristics).
Planning
- Involves decision-making and problem-solving.
- Formulating client goals.
- Designing nursing interventions.
- Prevent, reduce, or eliminate client's health problems.
Types of Planning
- Initial Planning: Planning done after initial assessment.
- Ongoing Planning: Continuous, ongoing planning.
- Discharge Planning: Planning for needs after discharge.
Maslow's Hierarchy of Needs
(Basic to complex):
- Physiological needs
- Safety needs
- Love and belonging needs
- Esteem needs
- Self-actualization needs
Guidelines for Writing Nursing Care Plans
- Date and sign the plan.
- Use standardized medical symbols and keywords.
- Be specific about the expected timing of intervention.
- Refer to procedure books or other references.
- Include interventions for ongoing assessment.
- Include collaborative and coordination activities in the plan.
- Include plans for client discharge and home care needs.
Implementation
- Consists of doing and documenting nursing activities.
- Implementing nursing interventions.
- Documenting nursing activities.
Evaluation
- A planned, ongoing, purposeful activity.
- Nurse determines client's progress towards achieving goals and outcomes.
- Assesses the effectiveness of the nursing care plan.
- Includes identifying criteria and standards, collecting evaluation data, interpreting and summarizing findings, and documenting findings.
- Care plan revision options: terminate, modify, or continue.
Example of a Nursing Care Plan
Provided at the end of the notes.
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Description
This quiz covers the systematic approach of the nursing process, which is essential for effective nursing care. Dive into the five phases: assessment, diagnosis, planning, implementation, and evaluation, and understand their interconnections. Explore the characteristics that make the nursing process client-centered and adaptable.
