Assessment/Recognize cues
What is the primary purpose of the assessment phase in the nursing process?
The primary purpose of the assessment phase is to collect, organize, and document patient data to establish a baseline for care.
What is the primary purpose of the diagnosis phase in the nursing process?
The diagnosis phase involves identifying the patient’s health problems or needs based on the data collected during the assessment. It leads to the formulation of nursing diagnoses, which guide patient care.
What is the primary goal of the planning phase in the nursing process?
The primary goal of the planning phase is to set patient-centered goals and determine appropriate nursing interventions to address the identified nursing diagnoses.
What is the primary purpose of the implementation phase in the nursing process?
The primary purpose of the implementation phase is to carry out the nursing interventions that were planned to help the patient achieve the set goals.
What is the main purpose of the evaluation phase in the nursing process?
The main purpose of the evaluation phase is to determine whether the patient’s goals have been met and if the nursing interventions were effective in addressing the nursing diagnoses.
Describe the difference between subjective and objective data in the nursing assessment.
Subjective data refers to information reported by the patient, such as pain or feelings of nausea.
Objective data includes measurable or observable signs, like vital signs or physical exam findings.
What is the difference between a medical diagnosis and a nursing diagnosis?
A medical diagnosis identifies a disease or condition (e.g., pneumonia)
A nursing diagnosis identifies a patient’s response to health issues or life processes (e.g., impaired gas exchange)
What are the characteristics of an effective patient-centered goal?
An effective patient-centered goal should be SMART: Specific, Measurable, Achievable, Relevant, and Time-bound.
Why is it important for nurses to use evidence-based interventions during the implementation phase?
Using evidence-based interventions ensures that the care provided is supported by current research and best practices, which leads to better patient outcomes and enhances the quality of care.
What should a nurse do if the patient’s goals have not been met during the evaluation phase?
If the patient’s goals have not been met, the nurse should reassess the patient, review the care plan, and modify the interventions or goals as needed.
Given the scenario: A patient reports shortness of breath and has a respiratory rate of 28 breaths per minute. What type of data is this, and how would you prioritize this in your assessment?
The patient’s report of shortness of breath is subjective data, while the respiratory rate is objective data. This situation should be prioritized as it could indicate respiratory distress, requiring immediate attention.
A patient is experiencing shortness of breath, wheezing, and has a history of asthma. Using the cues from your assessment, formulate an appropriate nursing diagnosis.
An appropriate nursing diagnosis could be: "Ineffective airway clearance related to bronchoconstriction and mucus production as evidenced by shortness of breath and wheezing."
A patient has a nursing diagnosis of "Impaired physical mobility related to postoperative pain." Create a SMART goal to address this diagnosis.
SMART Goal: "The patient will ambulate 50 feet with the assistance of a walker by the end of the third postoperative day."
A patient has a nursing diagnosis of "Risk for infection related to a surgical wound." What specific nursing interventions would you implement to prevent infection?
Intervention 1: Perform hand hygiene before and after wound care.
Intervention 2: Use a sterile technique when changing the wound dressing.
Intervention 3: Monitor the wound for signs of infection (e.g., redness, swelling, discharge).
Intervention 4: Educate the patient on proper wound care at home.
A patient with a nursing diagnosis of "Impaired gas exchange" has a goal of maintaining an oxygen saturation of 95% or higher within 48 hours. Upon evaluation, the patient’s oxygen saturation remains at 90%. What steps should you take next?
Reassess the patient’s respiratory status, including breath sounds, respiratory rate, and effort.
Determine if there are any contributing factors (e.g., pneumonia, improper oxygen therapy).
Review and possibly adjust the interventions (e.g., increasing oxygen flow rate, changing the position of the patient, or consulting the provider for further treatment).
Modify the goal or timeline if necessary, and continue to monitor the patient's progress.
How do you determine which data collected during the assessment are significant, and how do you use this information to identify the priority nursing diagnosis?
Significant data are those that deviate from the patient's baseline
Nurses analyze trends and patterns in data, comparing findings with normal values and the patient’s history to identify the priority nursing diagnosis
How do you differentiate between an actual nursing diagnosis and a risk nursing diagnosis?
An actual nursing diagnosis refers to an existing health problem, while a risk diagnosis identifies potential problems that the patient is vulnerable to developing. -
Example:
Actual: "Ineffective breathing pattern related to asthma exacerbation as evidenced by increased respiratory rate and use of accessory muscles."
Risk diagnosis: "Risk for aspiration related to decreased level of consciousness."
You have set a goal for a patient with a diagnosis of "Ineffective airway clearance related to mucus production." The patient is not meeting the goal of "improved airway clearance within 24 hours." What steps would you take to evaluate and adjust your care plan?
Reassess the patient’s condition to determine if any new factors (e.g., increased mucus, infection) are impacting the goal.
Evaluate the effectiveness of the interventions (e.g., deep breathing exercises, suctioning, hydration).
Modify the interventions or revise the goal to be more achievable (e.g., "improve airway clearance within 48 hours") or add new interventions (e.g., bronchodilators, chest physiotherapy
A patient with congestive heart failure has a goal to reduce fluid overload. During the implementation phase, you notice the patient is reluctant to follow a low-sodium diet. How would you address this barrier to the intervention?
First, assess the reason for the patient’s reluctance (e.g., lack of understanding, cultural preferences, or taste preferences).
Provide education on the importance of a low-sodium diet in managing heart failure and offer alternatives or modifications that align with the patient’s preferences.
Collaborate with a dietitian if needed to create a meal plan that the patient can follow
How can a nurse determine if an intervention needs to be continued, modified, or discontinued during the evaluation phase?
A nurse determines this by comparing the patient’s actual outcomes with the expected goals. If the goal is met, the intervention may be discontinued. If progress is made but the goal has not been fully achieved, the intervention may be continued or modified. If no progress has been made, the intervention may need to be re-evaluated or changed
A patient presents with generalized fatigue, elevated blood pressure, and a history of Type 2 diabetes. What cues would you analyze, and how would you prioritize nursing actions based on your assessment?
Cues: patient’s fatigue (subjective), elevated blood pressure (objective), and history of diabetes (patient history).
The priority may focus on managing hypertension and assessing for complications related to diabetes
A post-operative patient presents with pain (8/10), shallow breathing, and is hesitant to move. Using these cues, what nursing diagnoses could you formulate?
Possible nursing diagnoses: Acute pain related to surgical procedure as evidenced by patient-reported pain of 8/10. Impaired physical mobility related to pain as evidenced by patient reluctance to move. Ineffective breathing pattern related to shallow breathing due to pain.
A patient with chronic heart failure has the following nursing diagnosis: "Decreased cardiac output related to weakened heart muscle." Based on this diagnosis, generate a comprehensive care plan with at least one SMART goal and corresponding nursing interventions.
SMART goal: The patient will demonstrate improved activity tolerance, walking 100 feet without dyspnea within 5 days.
Intervention 1: Assist the patient with ambulation 3 times a day. Intervention 2: Teach the patient energy conservation techniques. Intervention 3: Monitor oxygen saturation levels during activity
During the implementation of a care plan for a patient with "Ineffective tissue perfusion related to peripheral vascular disease," the patient's condition worsens despite interventions such as leg elevation, medication administration, and skin care. What actions should you take?
First, reassess the patient’s condition to identify any new or worsening symptoms (e.g., increased pain, decreased pulse in extremities). Notify the healthcare provider about the patient's worsening condition. Based on new data, consider implementing more aggressive interventions such as modifying the medication regimen (e.g., adding anticoagulants or vasodilators), adjusting the position of the limbs, or consulting a vascular specialist
A patient with chronic kidney disease has a goal of maintaining stable electrolyte levels over two weeks. During evaluation, you notice that the patient's potassium levels are still elevated despite interventions such as dietary modifications and medication. What would your evaluation process look like, and how would you modify the care plan?
Evaluation process: Reassess the patient's recent lab results, diet, medication adherence, and any symptoms related to electrolyte imbalances. - Reviewing the effectiveness of the current interventions (e.g., whether the dietary modifications are appropriate or if the patient is taking medications like potassium binders as prescribed).
Consult with the healthcare provider to determine if medication adjustments (e.g., adding diuretics or increasing the dose of potassium binders) or more aggressive interventions are needed.
Modifying the care plan by setting a more achievable goal and adding or revising interventions to better address the patient's needs.