Nursing Process Overview

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Questions and Answers

What is the primary goal of the nursing process?

To establish a nurse's authority over a patient's care

To ensure that nursing interventions are implemented without reassessment

To identify clients' health care status and address health problems (correct)

To collect subjective data without any objective measures

Which step of the nursing process involves validating and documenting data?

Planning

Diagnosing

Evaluating

Assessment (correct)

In which step of the nursing process are goals and desired outcomes formulated?

Implementing

Assessment

Planning (correct)

Evaluating

What is included in the evaluation of nursing interventions?

Collecting data related to outcomes and comparing it with desired outcomes Signup and view all the answers

Which component of a nursing health history covers a patient's lifestyle habits?

Lifestyle Signup and view all the answers

What is analyzed during the diagnosing step of the nursing process?

Data to identify health problems, risks, and strengths Signup and view all the answers

What action is taken during the implementing step of the nursing process?

Determining the need for assistance Signup and view all the answers

Which option describes a common aspect of effective nursing documentation?

Thoroughly documenting all nursing activities and observations Signup and view all the answers

What occurs in an inevitable abortion?

Membranes rupture and bleeding occurs Signup and view all the answers

What is the management for incomplete abortion?

Hospitalization and D&C Signup and view all the answers

Which of the following is a sign of septic abortion?

Foul-smelling vaginal discharge Signup and view all the answers

What defines a complete abortion?

All products of conception are expelled Signup and view all the answers

What is the primary characteristic of a missed abortion?

Complete retention of pregnancy products after fetal death Signup and view all the answers

During a threatened abortion, which symptom is NOT typically present?

Severe uterine cramping Signup and view all the answers

What is the typical risk associated with habitual or recurrent pregnancy loss?

Often due to an incompetent cervix Signup and view all the answers

What symptom is a hallmark of an incomplete abortion?

Open cervix with passage of retained tissue Signup and view all the answers

What is the main goal of therapeutic abortion?

To preserve the life of the mother Signup and view all the answers

Which condition is a common predisposing cause of ectopic pregnancy?

Salpingitis Signup and view all the answers

What symptom is indicative of a possible tubal rupture during an ectopic pregnancy?

Severe sharp knife-like pain Signup and view all the answers

What is Cullen's sign and its significance?

Bluish discoloration of the umbilicus from blood in the peritoneal cavity Signup and view all the answers

Which diagnostic aid uses aspiration to detect bleeding in ectopic pregnancy?

Culdocentesis Signup and view all the answers

What is the primary purpose of salpingostomy in the context of ectopic pregnancy?

To remove a conceptus less than 2 cm from the fallopian tube Signup and view all the answers

Which of the following is NOT a suggested method to prevent abortion?

Increased physical exercise Signup and view all the answers

What is a common sign of hemorrhage in the context of ectopic pregnancy?

Cyanotic nail beds Signup and view all the answers

What is the primary symptom of pseudocyesis?

Experiencing all pregnancy symptoms without being pregnant Signup and view all the answers

Which of the following is an indication of hyperemesis gravidarum?

Dehydration and weight loss Signup and view all the answers

What defines gestational hypertension?

Hypertension that resolves without treatment after delivery Signup and view all the answers

Which risk factor is associated with developing pregnancy-induced hypertension?

Age below 17 years or above 35 years Signup and view all the answers

Which treatment is prioritized for managing hyperemesis gravidarum?

D10NSS 3000 ML in 24 hours Signup and view all the answers

What distinguishes chronic hypertension from gestational hypertension?

Chronic hypertension must exist before pregnancy Signup and view all the answers

How can one differentiate between pseudocyesis and actual pregnancy based on symptoms?

Subjective symptoms mimicking pregnancy without physical signs Signup and view all the answers

Which of the following is NOT associated with hyperemesis gravidarum?

Regular appetite Signup and view all the answers

Which of the following is NOT one of the components of HELLP syndrome?

Increased white blood cell count Signup and view all the answers

What criteria must be met for a patient to be managed at home for HELLP syndrome?

No fetal growth retardation Signup and view all the answers

During a convulsion, what is one of the main responsibilities of the nurse?

Maintaining a patent airway Signup and view all the answers

Which statement about bed rest in the management of HELLP syndrome is true?

Resting in the left lateral position promotes blood supply to the placenta Signup and view all the answers

Which of the following is a stage in the convulsion process?

Tonic phase Signup and view all the answers

What dietary considerations should be included in the management of HELLP syndrome?

High in protein and carbohydrates with moderate sodium restriction Signup and view all the answers

What may occur as a complication of HELLP syndrome?

Placenta abruptio Signup and view all the answers

What symptom is considered an impending sign of convulsion?

Epigastric pain Signup and view all the answers

Study Notes

Nursing Process

A systematic, rational method of planning and providing care.
Cyclical, with components following a logical sequence.
Terminated if the goal is achieved.
Cycle may continue with reassessment or modification of the plan of care.

Goal of Nursing Process

Identify the client's healthcare status, actual or potential health problems.
Establish plans to meet identified needs.
Deliver specific nursing interventions to address these needs.

Steps of the Nursing Process

Assessment

Collect, organize, validate, and document data.
Includes subjective and objective data.

Diagnosing

Analyze data
Identify health problems, risks, and strengths.
Formulate diagnostic assessments. (Example: Ineffective airway clearance related to accumulated mucus obstructing airways)

Planning

Prioritize problems/diagnoses.
Formulate goals/desired outcomes.
Select nursing interventions.
Write nursing orders. (Example: restore effective breathing and lung ventilation, develop a care plan)

Implementing

Reassess the client.
Determine the nurse's need for assistance.
Implement the nursing interventions.
Supervise delegated care.
Document nursing activities.

Evaluating

Collect data related to planned outcomes.
Compare data with outcomes.
Relate nursing actions to client goals/outcomes.
Draw conclusions about problem status.
Continue, modify, or terminate the client's care plan.

Components of a Nursing Health History

Chief complaint/reason for visit.
History of present illness.
Biographic data. (Example: When did symptoms start? Was the onset sudden or gradual?)
Phenomena or symptoms associated with the chief complaint
Factors that aggravate or alleviate the problem.
Past History
Family History of Illness
Lifestyle

Severe Malnutrition

Happens before 16 weeks gestation.

Late Abortion

Happens between 16 - 20 weeks gestation.

Types of Abortion

Inevitable Vaginal bleeding or rupture of membranes before 20 weeks gestation, with advanced dilation of the cervix.
Incomplete Dilation of the cervix and expulsion of some products of conception.
Complete Closed cervix after expulsion of all products of conception.

Types of Abortion (Continued):

Spontaneous Unintended termination of pregnancy at any time before the fetus has attained viability.

Threatened Abortion

Possible loss of the products of conception.
Symptoms: Slight bleeding, mild uterine cramping, but no cervical dilation on vaginal examination, no passage of tissue.
Management: Bed rest, save all pads, no coitus up to 2 weeks after bleeding has stopped

Inevitable or Imminent Abortion

Loss of pregnancy that cannot be prevented.
Clinical Manifestations: Moderate to profuse bleeding, moderate to severe uterine cramping, dilated cervix, rupture of membranes.
Management: Hospitalization, D&C, Oxytocin after D & C, emotional support

Complete Abortion

All products of conception are expelled.
Symptoms: Moderate bleeding, mild uterine cramping, passage of tissue.
Management: Sympathetic understanding and emotional support

Incomplete Abortion

Not all products of conception are expelled from the uterus.
Symptoms: Profuse vaginal bleeding, severe uterine cramping, open cervix, passage of tissue, other products retained.
Treatment and Management: D & C, Oxytocin after D & C, emotional support.

Missed Abortion

Retention of all products of conception after the death of the fetus in the uterus.
Symptoms: No fetal heart tones, signs of pregnancy disappear.
Management: D&C.

Septic Abortion

Abortion complicated by infection.
Symptoms: Foul-smelling vaginal discharge, uterine cramping, fever.
Management: Treat abortion and administer antibiotics.

Habitual or Recurrent Pregnancy Loss

Spontaneous abortion in three or more successive pregnancies.
Usually due to incompetent cervix.

Induced Abortion

Intentional loss of pregnancy through direct chemical or mechanical stimulation.

Types of Induced Abortion

Therapeutic Abortion To preserve the life of the mother.
Elective Abortion

Reasons for Induced Abortion

Therapeutic To end a pregnancy that is life-threatening to the mother.
To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life.
To end an unwanted pregnancy that is a result of rape or incest.
To end a pregnancy because of a woman's choice not to have a child yet.

Prevention of Abortion

Pre-pregnancy correction of maternal disorders.
Immunization against infectious diseases.
Proper early antenatal care.
Treatment of pregnancy complications.
Correction of cervical incompetence.

Ectopic Pregnancy

Any pregnancy that occurs outside of the uterine cavity.
Second leading cause of bleeding in early pregnancy.
Types: Ampullar, Intestinal, Ovarian, Cervical, Abdominal

Predisposing Causes of Ectopic Pregnancy

Salpingitis
Peritubal adhesions
Previous Ectopic Pregnancy
Previous Tubal Surgery
Multiple previous abortions
Tumors that distort the tubes
External migration of the ovum
Intrauterine device (IUD)

Signs and Symptoms of Ectopic Pregnancy

Vaginal spotting or bleeding.
Cul de sac mass.
Absence of an amniotic sac.
Amenorrhea or abnormal menstruation followed by slight uterine bleeding.

Signs of Tubal Rupture

Severe sharp knife-like pain in the lower quadrant of the abdomen.
Abdominal rigidity.
Nausea and vomiting.
Low Hemoglobin and hematocrit.
Sharp localized pain in the cervix on internal examination (wiggling sign).

Signs of Hemorrhage

Cullen’s Sign Bluish discoloration of the umbilicus due to the presence of blood in the peritoneal cavity.
Hard or rigid boardlike abdomen.

Signs of Shock

Falling BP, rapid pulse.
Lightheadedness.
Pallor
Cyanotic Nailbeds
Cold clammy skin.

Diagnostic Aids for Ectopic Pregnancy

Culdocentesis
Ultrasound

Treatment and Management of Ectopic Pregnancy

If not yet ruptured:
- Salpingostomy

Cord Compression

Fetal hypoxia as a result of cord compression.
Prolonged labor

Pseudocyesis

Spurious pregnancy, occurs in women nearing menopause or women with an intense desire to become pregnant
Women develop the belief they are pregnant when they are not.
These women experience subjective symptoms of pregnancy (fatigue, amenorrhea, tingling sensations, fullness of the breast, nausea, and vomiting). Some women report feeling fetal movements, which are actually movement of air in the intestines or muscular contractions of the abdominal wall.
Management: Explain pregnancy test results, clarify misconceptions and false beliefs, provide referrals when necessary, psychological counseling, provide emotional support and understanding.

Hyperemesis Gravidarum

Excessive nausea and vomiting that persists beyond 12 weeks gestation.
Leading to complications like dehydration, weight loss, starvation, and fluid and electrolyte imbalance.
Etiology unknown.

Symptoms of Hyperemesis Gravidarum:

Excessive nausea and vomiting not relieved by ordinary remedies persisting beyond 12 weeks
Signs of dehydration: thirst, dry skin, increased pulse rate, weight loss, concentrated, and scanty urine.

Management of Hyperemesis Gravidarum

D10NSS 3000 ML in 24 hours is the priority of treatment.
Rest.
Antiemetics (Ex. Plasil).

Hypertensive Disorders in Pregnancy

Gestational Hypertension: Hypertension that develops during pregnancy or during the first 24 hours after delivery, not accompanied by edema, proteinuria, or convulsions, and disappears within 10 days after delivery.
Chronic Hypertension: The presence of hypertension before pregnancy or hypertension that develops before 20 weeks gestation in the absence of H-mole and persists beyond the postpartum period.
Pregnancy-Induced Hypertension (Toxemia): Hypertension that develops after the 20th week of gestation in a previously normotensive woman.

Risk Factors for Pregnancy-Induced Hypertension

Primiparas Higher incidence in primiparas below 17 and above 35 years old.
Low socioeconomic status Low protein intake.
History of chronic hypertension on the mother, H-mole, diabetes mellitus, multiple pregnancy, polyhydramnios, renal disease, heart disease.
Hereditary History of preeclampsia in mothers or sisters.

HELLP Syndrome

Hemolysis - Red blood cells break down.
Elevated liver enzymes - Damage to liver cells cause changes in liver function lab tests.
Low platelets - Cells found in the blood that are needed to help clot the blood to control bleeding.

Complications of HELLP Syndrome

Anemia - Breakdown of RBC’s may cause anemia
DIC - May lead to severe bleeding
Placenta abruptio - May also occur.

Management of Hypertensive Disorders in Pregnancy

Ambulatory Management
- Home management is allowed if:
  - BP is 140/90 or below.
  - There is no proteinuria.
  - There is no fetal growth retardation.
  - The patient is not a young primipara.
- Bed rest
- Consult the clinic as often as necessary.
- Diet should be high in protein, and carbohydrates with moderate sodium restriction.
- Hospitalization is necessary if the condition worsens.
- Provide detailed instructions about warning signs:
  - Epigastric pain - Aura to convulsion.
  - Visual disturbances
  - Severe continuous headache.
  - Nausea and vomiting.
Hospital Management
- BP goes above 140/90 mm Hg
- Bed rest is one of the most important principles of care:
  - Rest in the left lateral position to promote blood supply to the placenta and the fetus.

Stages of a Convulsion

Stage of Invasion Facial twitching, rolling of the eyes to one side, staring fixedly in space
Tonic Phase Body becomes rigid, as all muscles go into violent spasms or contractions, eyes protrude, hands are clenched, woman stops breathing for 15-20 seconds.
Clonic Phase Jaws, and eyelids close, and open violently, foaming of the mouth, face becomes congested and purple, muscles of the body contract and relax alternately. The contractions are so violent that the woman may throw herself out of bed. Lasts for about a few minutes.
Post Ictal Phase Woman is semicomatose, no more violent muscular contractions. The patient will not remember the convulsion, and the events immediately before and after.

Responsibilities During a Convulsion

Always monitor the patient for impending signs of convulsion:
- Epigastric pain.
- Severe headache.
- Nausea and vomiting.
Maintenance of a patent airway and protection of the patient from injury.
Turn patient to her side to allow drainage of saliva and prevent aspiration.

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Description

Explore the systematic method of planning and delivering nursing care through the nursing process. This quiz covers the critical steps including assessment, diagnosis, planning, and implementation of interventions, helping you understand how to identify and meet client healthcare needs effectively.