chapters- 15-18
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What is the purpose of Quick Priority Assessments in nursing?

  • To gain the most important information needed first in a short, focused, and prioritized manner (correct)
  • To identify life-threatening problems in a crisis situation like the ER
  • To collect data on all aspects of a patient's health during initial admission
  • To gather data about a specific problem already identified, such as a child pulling on their ear

    • When is an Emergency Assessment typically performed in nursing?

  • During initial admission to collect data on all aspects of a patient's health
  • As part of a systematic and continuous collection, analysis, validation, and communication of patient data
  • In a crisis situation like the ER to identify life-threatening problems (correct)
  • In urgent care to gather data about a specific problem already identified

    • What is the main focus of Focused Assessments in nursing?

  • Collecting data on all aspects of a patient's health during initial admission
  • Gathering data about a specific problem already identified (correct)
  • Identifying life-threatening problems in a crisis situation like the ER
  • Completing short, focused, prioritized assessments to gain the most important information needed first

    • What is the characteristic of Nursing Assessments that involves short, focused, prioritized assessments completed to gain the most important information needed first?

    <p>Quick and Prioritized</p> Signup and view all the answers

    Which type of nursing diagnoses focuses on potential problems that may develop in a patient?

    <p>Risk</p> Signup and view all the answers

    What are the three steps of data interpretation and analysis mentioned in the text?

    <p>Recognizing significant data, recognizing patterns, identifying strengths and problems</p> Signup and view all the answers

    What is required to validate nursing diagnoses?

    <p>Sufficient, accurate data; demonstration of pattern; scientific evidence</p> Signup and view all the answers

    What is the goal of outcome identification and planning in nursing?

    <p>Establish priorities, identify expected patient outcomes, select evidence-based interventions, communicate plan</p> Signup and view all the answers

    What does initial planning in nursing involve?

    <p>Developed by assessing nurse; addresses problems; identifies goals and related nursing care</p> Signup and view all the answers

    Who carries out discharge planning for a patient?

    <p>Closest working nurse</p> Signup and view all the answers

    What are the components of measurable outcomes mentioned in the text?

    <p>Specific, measurable, attainable, realistic, time-bound</p> Signup and view all the answers

    Which step is involved in ongoing planning in nursing?

    <p>Updated by any interacting nurse</p> Signup and view all the answers

    What does a formal care plan in nursing aim to do?

    <p>Individualizes care,set priorities,promote communication</p> Signup and view all the answers

    What are common errors in writing nursing diagnoses mentioned in the text?

    <p>Premature diagnoses based on an incomplete database. Erroneous (incorrect) diagnoses resulting from an inaccurate database or a faulty data analysis. Routine diagnoses resulting from the nurse’s failure to tailor data collection and analysis to the unique needs of the patient. Errors of omission meaning leaving out something important that should not have been left out.</p> Signup and view all the answers

    What is the focus of Nursing Implementation?

    <p>Planned nursing actions carried out during the implementation step of nursing practice</p> Signup and view all the answers

    Which type of intervention involves actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders?

    <p>Physician-initiated</p> Signup and view all the answers

    What are examples of Nurse-Initiated Interventions?

    <p>Monitor health status, Resolve, prevent, or manage a problem</p> Signup and view all the answers

    What is the purpose of Implementations in nursing?

    <p>Help the patient achieve valued health outcomes</p> Signup and view all the answers

    What are the IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care?

    <p>-Safety: Avoid Injury -Effective: Avoiding overuse and underuse -Patient-Centered: Responding to patient preferences, needs and values (incorporate patients family and needs as well) -Timely: Reducing waits and delays -Efficient: Avoiding waste -Equitable: Providing care that does not vary in quality to all recipients</p> Signup and view all the answers

    What are the types of outcomes described in the text?

    <p>Cognitive, Psychomotor, Affective</p> Signup and view all the answers

    What are the characteristics of Collaborative interventions?

    <p>Treatments initiated by other providers and carried out by a nurse</p> Signup and view all the answers

    What are protocols and standing orders in the context of nursing interventions?

    <p>Written plans that specify nursing actions for that skill.</p> Signup and view all the answers

    What is the Alfaro’s rule related to implementation?

    <p>Assess, Reassess, Revise, Record.</p> Signup and view all the answers

    What is the focus of Nursing Implementation?

    <p>All of the above</p> Signup and view all the answers

    Which assessment method focuses on assessing patient complexity using social determinants of health?

    <p>Patient-Centered Assessment Method</p> Signup and view all the answers

    What type of data includes observable and measurable information such as elevated temperature and skin moisture?

    <p>Objective Data</p> Signup and view all the answers

    Which is a step in the diagnosing process?

    <p>All of the above</p> Signup and view all the answers

    What is the approach to nursing diagnosis that involves predicting, preventing, managing, and promoting?

    <p>PPMP Approach</p> Signup and view all the answers

    Which method involves confirming inferences through physical examination, sharing with team members, and checking with research reports?

    <p>Validating Inferences</p> Signup and view all the answers

    Inspection, Palpation, Percussion, Auscultation are methods used for performing which type of assessment?

    <p>Comprehensive Assessment</p> Signup and view all the answers

    What does documentation of data involve according to the text?

    <p>Recording data immediately and accurately</p> Signup and view all the answers

    What is the purpose of establishing assessment priorities according to the text?

    <p>Focusing on health orientation, developmental stage, culture, and collecting objective vs. subjective data</p> Signup and view all the answers

    Look for evidence of risk factors regardless of the presence of problems' is associated with which nursing process according to the text?

    <p>Nursing Diagnosis</p> Signup and view all the answers

    What is the main focus of an Emergency Assessment in nursing?

    <p>Identifying life-threatening problems</p> Signup and view all the answers

    Which type of nursing assessment involves short, focused, prioritized assessments completed to gain the most important information needed first?

    <p>Quick Priority Assessment</p> Signup and view all the answers

    What is the characteristic of Nursing Assessments that involves systematic and continuous collection, analysis, validation, and communication of patient data?

    <p>All of the above</p> Signup and view all the answers

    Which assessment method involves comparison of a patient's current status to their previous data for reassessment and care plan adjustment?

    <p>Time-Lapsed Assessment</p> Signup and view all the answers

    What is the focus of Establishing Assessment Priorities in nursing?

    <p>Focusing on health orientation, developmental stage, culture, and collecting objective vs. subjective data</p> Signup and view all the answers

    What is the main purpose of Diagnosing Step in nursing?

    <p>Identifying the individual's response to health and life processes</p> Signup and view all the answers

    What does PPMP approach to nursing diagnosis involve?

    <p>'Predicting, Preventing, Managing, and Promoting health'</p> Signup and view all the answers

    'Look for evidence of risk factors regardless of the presence of problems' is associated with which nursing process according to the text?

    <p>'Diagnosing'</p> Signup and view all the answers

    What is the main focus of Triage Assessment in nursing?

    <p>Screening assessment for determining the extent and severity of a patient's problems</p> Signup and view all the answers

    What are examples of Subjective Data in nursing assessments?

    <p>Pain and feeling dizzy</p> Signup and view all the answers

    What are examples of sources of data in nursing assessments?

    <p>Patient, family, patient record, medical history, physical examination, consultations</p> Signup and view all the answers

    What does validating inferences involve in nursing assessments?

    <p>Confirming inferences through physical examination, sharing with team members, checking with research reports</p> Signup and view all the answers

    What are the methods used for performing physical assessments in nursing?

    <p>Observation, measurement, palpation, percussion, and auscultation</p> Signup and view all the answers

    Which of the following describes the Affective category of outcomes in nursing?

    <p>Changes in patient values, beliefs, and attitudes</p> Signup and view all the answers

    What is the main focus of Nurse-Initiated Interventions?

    <p>Resolve, prevent, or manage a problem</p> Signup and view all the answers

    What is the primary purpose of Implementation in nursing?

    <p>To help the patient achieve valued health outcomes</p> Signup and view all the answers

    What are the Five Rights of Delegation in nursing?

    <p>Right task, right circumstances, right person, right directions and communication</p> Signup and view all the answers

    What are common reasons for noncompliance for the plan of care according to the text?

    <p>All of the above</p> Signup and view all the answers

    What is required to validate nursing diagnoses?

    <p>Confirmation through physical examination and sharing with team members</p> Signup and view all the answers

    What is the main purpose of Diagnosing Step in nursing?

    <p>Identifying the individual's response to health and life processes</p> Signup and view all the answers

    Which type of nursing diagnosis focuses on potential problems that may develop in a patient?

    <p>Risk diagnosis</p> Signup and view all the answers

    What are the three main types of nursing diagnoses mentioned in the text?

    <p>Problem-focused, risk, and health promotion diagnoses</p> Signup and view all the answers

    What is the characteristic of Nursing Assessments that involves short, focused, prioritized assessments completed to gain the most important information needed first?

    <p>Quick priority assessment</p> Signup and view all the answers

    What is required to validate nursing diagnoses?

    <p>Sufficient and accurate data, demonstration of pattern, and scientific evidence</p> Signup and view all the answers

    What does a formal care plan in nursing aim to do?

    <p>Individualize care for each patient</p> Signup and view all the answers

    What is the purpose of establishing priorities according to the text?

    <p>To manage time efficiently and address the most critical issues first.</p> Signup and view all the answers

    What is the focus of Nursing Implementation?

    <p>Planned nursing actions are carried out during the implementation step of the nursing process. Focus on the scope of practice: who?, what?, when?, where?, why?. Care coordination and continuity of care. Alfaro's rule: Assess, Reassess, Revise &amp; Record.</p> Signup and view all the answers

    What is the characteristic of Nursing Assessments that involves systematic and continuous collection, analysis, validation,and communication of patient data?

    <p>Ongoing assessment.</p> Signup and view all the answers

    ____________ assessment is when a patient is initially admitted. (collect data on all aspects of pt’s health) focus on whole patient..

    Signup and view all the answers

    _____________assesment focused on a specific area: example: child comes in pulling on ear, check ear first (focused) gather data about a specific problem already identified. Performed at urgent care.

    Signup and view all the answers

    ________________assesment is short, focused, prioritized assessments completed to gain the most important information needed first. Can flag existing problems.

    Signup and view all the answers

    ____________ assesments, these assessments are performed when a crisis is present like the ER; to identify life threatening problems. Main thing to always keep in mind is ABC’s Airway, breathing, circulation.

    Signup and view all the answers

    _____________assements are performed to compare a patient’s current status to the baseline data obtained earlier. Performed to reassess health status and make any necessary revisions in care plan. Think of a timeline. Their baseline earlier was here and now it's here.

    Signup and view all the answers

    _____________assessments can be completed on the phone or in person. A screening assessment to determine the extent and severity of pt problems and recommend appropriate follow-up. Triage nurses need highly specialized nursing knowledge and clinical reasoning and judgement skills.

    Signup and view all the answers

    ________________ tool used by healthcare practitioners to assess patient complexity using social determinants of health. Helps ask questions to gain understanding about the pt’s health and wellbeing, social environment, health literacy, and communication skills. (patient safety and examining pt as a WHOLE) always ask how the patient is interpreting his/her health. Ask how they feel, how their symptoms make them feels and if they are taking anything to help with their current condition.

    Signup and view all the answers

    Assessing is preparing for data collection, collecting data, identifying cues and making inferences, validating data, clustering related data and identifying patterns, reporting and recording data.

    <p>True</p> Signup and view all the answers

    The database enables the nurse to partner with patients to develop a comprehensive and effective care plan.

    <p>True</p> Signup and view all the answers

    the ____________ includes all the pertinent patient information collected by the nurse and other health care professionals.

    Signup and view all the answers

    What are the characteristics of nursing assessments?

    <p>Purposeful, prioritized, complete, systematic, factual and accurate, relevant and recorded in a standard manner.</p> Signup and view all the answers

    What are some priorities when assessing a patient? (in regard to establishing assessment priorities)

    <p>Health Orientation = How much the patient knows about their actual health. Do they know what's really going on right now? Developmental Stage = Is the patient a child that isnt going to udnertsand the questions we are asking? or is it an adult that can cooperate with us in the assessment? Culture = Are there any culture needs we should be aware of when we are assessing this patient? The need for nursing = The need for nursing</p> Signup and view all the answers

    We should always obtain data for health assessments from a medical history first.

    <p>False</p> Signup and view all the answers

    We should always seek data from the patient first.

    <p>True</p> Signup and view all the answers

    ___________ is the process of performing deliberate, purposeful observations in a systematic manner.

    Signup and view all the answers

    ______________is the use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body.

    Signup and view all the answers

    _____________ is the act of striking one object against another to produce sound.

    Signup and view all the answers

    ______________ is the act of listening with a stethoscope to sounds produced within the body.

    Signup and view all the answers

    Validating Inferences (conclusions) includes: performing a physical examination, using clarifying statements, sharing inferences with other team members, checking findings with research reports, comparing cure to the knowledge base of normal function, and checking consistency of cues.

    <p>True</p> Signup and view all the answers

    whenever possible you should use the patient's own words when documenting data.

    <p>True</p> Signup and view all the answers

    Clinical reasoning is analyzing, synthesizing, reflecting, and drawing conclusions..

    <p>True</p> Signup and view all the answers

    Diagnosis includes: creating a list of suspected problems/diagnosis, ruling out similar problems/diagnosis, naming actual and potential problems/diagnosis and clarifying what's causing or contributing to them, determining risk factors that must be managed, and identifying resources, strengths, and areas for health promotion.

    <p>True</p> Signup and view all the answers

    Match with the correct answer

    <p>Patient Problems = can change from day to day as the patients responses change. They focus on unhealthy responses to health and illness. Medical Diagnosis = identifies diseases and describe problems for which the physical or advanced practice nurses directs the primary treatment; Medical diagnosis remains the same as long as the disease is present. 0 = 0 N/A = N/A</p> Signup and view all the answers

    These are steps in what? -Recognizing significant data: comparing data to standards -Recognizing patterns or clusters -Identifying strengths and current or potential problems -Identifying potential complications -Reaching conclusions -Partnering with the patient and family members (to see the NANDA that you have created and see how your nursing interventions can help the patient)

    <p>Data Interpretation and analysis</p> Signup and view all the answers

    What are three components needed in order to formulate a nursing diagnosis?

    <p>Problem, Etiology, Signs and symptoms</p> Signup and view all the answers

    the following are common errors in writing nursing diagnoses:

    -premature diagnoses based on an incomplete database.

    -erroneous (incorrect) diagnoses resulting from an inaccurate database or a faulty data analysis.

    -routine diagnoses resulting from the nurse’s failure to tailor data collection and analysis to the unique needs of the patient.

    -errors of omission meaning leaving out something important that should not have been left out.

    <p>True</p> Signup and view all the answers

    The goals of outcome identification and the planning step are to: -Establish Priorities -Identify and write expected patient outcomes -Select evidence-based nursing interventions -Communicate the nursing plan of care

    <p>True</p> Signup and view all the answers

    Match the three elements of comprehensive planning.

    <p>Initial = -developed by the nurse who performs the nursing history and physical assessment. -addresses each problem listed in the prioritized problem list. -identifies appropriate patient goals and related nursing care. Ongoing = -carried out by any nurse who interacts with the patient -keeps the plan up to date, manages risk factors, and promotes function. -states problem statements more clearly -develops new problem statements -makes outcomes more realistic and develops new outcomes as needed -identifies nursing interventions Discharge = -Carried out by the nurse who worked most closely with the patient -Begins when the patient is admitted for treatment -Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently 0 = 0</p> Signup and view all the answers

    Match the three categories of outcomes

    <p>Cognitive = describes increases in patient knowledge or intellectual behaviors Psychomotor = describes patient’s achievement of new skills Affective = describes changes in patient values, beliefs, and attitudes 0 = 0</p> Signup and view all the answers

    All of these components are parts of a measurable outcome and need to be present in order to have a measurable outcome. for every single patient we take care of.

    • Subject • Verb • Conditions • Performance criteria • Target time

    <p>True</p> Signup and view all the answers

    Match the parts of a measurable outcome

    <p>Subject = Patient Verb = Action Target Time = E.g. “At the next visit, 12/23/20, the patient will correctly demonstrate relaxation exercises.&quot; Performance criteria = Expected behavior</p> Signup and view all the answers

    Match the types of interventions.

    <p>Nurse-initiated: = autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes Physician-initiated: = actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders Collaborative: = treatments initiated by other providers and carried out by a nurse 0 = 0</p> Signup and view all the answers

    The following are examples of nurse-initiated interventions:

     Monitor health status  Reduce risks  Resolve, prevent, or manage a problem  Promote independence with ADLs  Promote optimum sense of physical, psychological, and spiritual well-being  Give patients information needed to make informed decisions and be independent

    <p>True</p> Signup and view all the answers

    Implementation helps:

    -the patient achieve valued health outcomes -Promote health -Prevent disease and illness -Restore health -Facilitate coping with altered functioning -Educating the patient about the benefits of following a patient-centered care treatment

    <p>True</p> Signup and view all the answers

    the five rights of delegation are:

     Right task  Right circumstances  Right person  Right directions and communication  Right supervision and evaluation

    <p>True</p> Signup and view all the answers

    The following is a checklist for _________ ____________ responsibilities.

    -Patient profile and name by which patient is addressed -Patient’s chief complaint and reason for admission -Patient’s current health status -Routine assistance to meet basic human needs -Priorities for nursing care and special daily events -Special teaching, counseling, or advocacy needs -Special family needs -Plan for unexpected outcomes

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    The following are reasons for non-compliance for a plan of care:

     Lack of family support  Lack of understanding about the benefits  Low value attached to outcomes  Adverse physical or emotional effects of treatment  Inability to afford treatment  Limited access to treatment

    <p>True</p> Signup and view all the answers

    The following are examples of ? ___________ ___ ______

    -Immediately give verbal reporting of data whenever a critical change in the patient’s health status is assessed.

    -Enter initial database into computer or record ink on designated forms the same day patient is admitted. All information is entered into a computer unless computer system is down but other than that, always enter into a computer.

    -summarize objective and subjective data in concise, comprehensive, and easily retrievable manner

    -use good grammar and standard medical abbreviations

    -whenever possible, use patients own words

    -avoid nonspecific terms subject to individual interpretation or definition

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    Study Notes

    • Patient problems focus on unhealthy responses to health and illness, can change day to day

    • Medical diagnoses identify diseases and describe problems for treatment, remain constant with disease presence

    • Three steps of data interpretation and analysis: recognizing significant data, recognizing patterns, identifying strengths and problems

    • Three main types of nursing diagnoses: problem-focused, risk, and health promotion

    • To formulate a nursing diagnosis, identify problem, etiology, and signs/symptoms

    • Validating nursing diagnoses requires sufficient, accurate data, demonstration of pattern, and scientific evidence

    • Common errors in writing nursing diagnoses include incomplete or inaccurate data, faulty analysis, and omissions

    • Goal of outcome identification and planning: establish priorities, identify expected patient outcomes, select evidence-based interventions, communicate plan

    • A formal care plan individualizes care, sets priorities, promotes communication, coordinates care, and creates a record

    • Initial planning developed by assessing nurse, addresses problems, identifies goals and related nursing care

    • Ongoing planning updated by any interacting nurse, keeps plan current, manages risk, and develops new outcomes

    • Discharge planning carried out by closest working nurse, begins at admission, uses teaching and counseling skills, and ensures competent home care behaviors

    • Prioritizing care: Maslow's hierarchy of human needs, patient preference, anticipation of future problems, and clinical reasoning/judgement

    • Maslow's hierarchy includes physiologic, safety, love/belonging, self-esteem, and self-actualization needs

    • Measurable outcomes need specific, achievable, observable, relevant, and time-based components

    • ABC's Airway, Breathing, Circulation: main focus in patient assessment and care

    • Time-Lapsed Assessment: comparison of a patient's current status to their previous data for reassessment and care plan adjustment

    • Triage Assessment: a screening assessment for determining the extent and severity of a patient's problems, completed in person or on the phone

    • Patient-Centered Assessment Method: tool for assessing patient complexity using social determinants of health

    • Establishing Assessment Priorities: focusing on health orientation, developmental stage, culture, and collecting objective vs. subjective data

    • Objective Data: observable and measurable data, examples include elevated temperature and skin moisture

    • Subjective Data: information perceived only by the affected person, examples include pain and feeling dizzy

    • Sources of Data: patient, family, patient record, medical history, physical examination, consultations, laboratory reports, and nursing literature

    • Inspection, Palpation, Percussion, Auscultation: methods for performing physical assessments

    • Validating Inferences: confirming inferences through physical examination, sharing with team members, and checking with research reports

    • Documentation of Data: recording data immediately and accurately, using standard medical abbreviations, and summarizing in a concise and easily retrievable manner

    • Diagnosing Step Purposes: identifying the individual's response to health and life process, identifying contributing factors, and identifying resources for prevention and resolution.

    • Nursing Diagnosis: recognizing safety and infection transmission risks, anticipating complications, and taking immediate action.

    • PPMP: Predict, Prevent, Manage, and Promote approach to nursing diagnosis.

    • In the presence of known problems, predicting and preventing complications, and managing them if they cannot be prevented.

    • Look for evidence of risk factors regardless of the presence of problems.

    • Patient problems focus on unhealthy responses to health and illness, can change day to day

    • Medical diagnoses identify diseases and describe problems for treatment, remain constant with disease presence

    • Three steps of data interpretation and analysis: recognizing significant data, recognizing patterns, identifying strengths and problems

    • Three main types of nursing diagnoses: problem-focused, risk, and health promotion

    • To formulate a nursing diagnosis, identify problem, etiology, and signs/symptoms

    • Validating nursing diagnoses requires sufficient, accurate data, demonstration of pattern, and scientific evidence

    • Common errors in writing nursing diagnoses include incomplete or inaccurate data, faulty analysis, and omissions

    • Goal of outcome identification and planning: establish priorities, identify expected patient outcomes, select evidence-based interventions, communicate plan

    • A formal care plan individualizes care, sets priorities, promotes communication, coordinates care, and creates a record

    • Initial planning developed by assessing nurse, addresses problems, identifies goals and related nursing care

    • Ongoing planning updated by any interacting nurse, keeps plan current, manages risk, and develops new outcomes

    • Discharge planning carried out by closest working nurse, begins at admission, uses teaching and counseling skills, and ensures competent home care behaviors

    • Prioritizing care: Maslow's hierarchy of human needs, patient preference, anticipation of future problems, and clinical reasoning/judgement

    • Maslow's hierarchy includes physiologic, safety, love/belonging, self-esteem, and self-actualization needs

    • Measurable outcomes need specific, achievable, observable, relevant, and time-based components

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    Test your knowledge on the differences between patient problems and medical diagnoses. Learn how to identify and address risk factors to prevent health problems, ensure safety and learning needs are met, and promote independence and well-being.

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