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ULL Nursing 204 Exam
ANA Scope and Standards of Practice Standard 1. Assessment correct answersThe RN collects pertinent data and information relative to the healthcare consumer's health or the situation. ANA Scope and Standards of Practice Standard 2. Diagnosis correct answersThe RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues ANA Scope and Standards of Practice Standard 3. Outcome identification correct answersThe RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation ANA Scope and Standards of Practice Standard 4. Planning correct answersThe RN develops a plan that prescribes strategies to attain expected, measurable outcomes ANA Scope and Standards of Practice Standard 5. Implementation correct answersThe RN implements the identified plan. •5A Coordination of Care 5B Health Teaching and Health Promotion ANA Scope and Standards of Practice Standard 6. Evaluation correct answersThe RN evaluates progress toward attainment of goals and outcomes Nursing Process correct answersDynamic, systematic clinical management tool: The primary means of directing the sequence, planning, implementation, and evaluation of nursing care to achieve specific health goals. communication plays a major role in the Nursing Process correct answers•Establish & maintain a therapeutic relationship •Promote, maintain, or restore health, or facilitate a peaceful death •Manage difficult health care issues
•Provide quality nursing care that is safe and efficient ADPIE - Nursing Process correct answersThese phases/steps - flexible & overlapping •Because of this - can be modified at any phase •Starts with first encounter •Ends with Discharge or Referral/Transfer off unit/Death Communication is used for all phases/steps. Assessment correct answersCollection, Analysis & Verification of information (is ongoing) •Begins: first encounter between nurse & patient/family •Next step: obtain information about the patient's current and past problems. The entire experiences are questioned. ********If the current situation changes - DO ANOTHER ASSESSMENT! Find out what is going on! •Ends: with discharge or referral Assessment-collecting data correct answers•History/Interview Patient •Past records & tests •Other members of Health Care Team •Family •Nurse's own observations; Physical Exam •Current tests, measurements NOTE: strengths, limitations, resources available and changes in condition or status. Subjective (Stated) data correct answers•patient's perception of data & what patient or family says about the data Document: Patient states, "..."
•Describes the patient's human responses to health issues & medical diagnoses. NANDA nursing diagnosis defined correct answers*A clinical judgment about individual, family or community responses to actual or potential health problems/ life processes. *Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability How to Use the Carpenito Textbook to Develop a Nursing Diagnosis correct answers1. Nursing Assessment Tool (NAT). Example in Appendix B on pp. 1078-1081.
- Abnormalities are identified and highlighted.
- Note the Categories/Functional Health Patterns the abnormalities are located
- Appendix A - Health Patterns - on pp. 1076-1077 gives you ideas where to start to identify a Nursing Diagnosis
- Nursing Diagnosis Index - pages i and ii and in the Table of Contents on pp. xv - xix (in the very front of book)
- RESEARCH (each section must be examined): •Nursing Diagnosis Definition •Defining Characteristics of the Nursing Diagnosis •Related Factors - Causes or Etiology •Note from the Author and Errors in Diagnostic Statements •Key Concepts. Types of Nursing Diagnoses correct answers•Problem-Focused •Risk & High-Risk •Possible •Health-Promotion •Syndrome Collaborative Problem (CP) correct answers*Certain physiologic complications that nurses monitor to detect onset or changes in status.
*Nurses manage CPs using physician-prescribed AND nursing-prescribed interventions to minimize the complications of the events. •Not medical diagnosis, although sometimes use the same terminology. Key is, "Can the nurse monitor the condition?" •Example: Risk for Complications of Pneumonia (RC of: Pneumonia) Risk for Complications correct answersnurses monitor the patient's condition and responses to help prevent or reduce complications related to the Medical Diagnosis (MD) problem focused ND correct answers-Human response to health conditions/life processes that can exist in an individual, family, or community. -Supported by defining characteristics that cluster in patterns of related cues or inferences. major defining characteristics correct answers(80% to 100% frequency to occur): at least one must be present from each individual section Minor defining characteristics correct answers(50% to 79% frequency to occur): provide support, but may or may not be present Risk and High Risk Nursing Diagnosis correct answersHuman response to health conditions/life processes that may develop in a vulnerable individual, family, or community. -Supported by risk factors that contribute to increased vulnerability. •Risk: expected or predictive diagnoses for all individuals who are undergoing some situation •High-risk: for people with additional risk factors that may be more vulnerable for the problem to occur. possible nursing diagnoses correct answersDescribe a suspected problem requiring additional data to confirm or rule out (r/o). Once additional data is collected the nurse can: •Confirm presence of major s/s and label as Problem-Focused ND. •Confirm presence of potential risk factors and label as Risk ND. •R/O presence of diagnosis at this time.
component of Syndrome correct answers1. Problem + the word "syndrome" component of Risk Complication correct answers1. the abbreviation " RC of" + physiologic condition Maslow's Hierarchy of Needs correct answers1. self-actualization
- self-esteem
- love and belonging
- safety and security
- physiological
- what requires immediate attention? *verify with patient and health team *consider culture, age, gender avoiding errors in diagnostic statements correct answersto increase the accuracy and usefulness of diagnostic statement. nurses should avoid several common areas:
- cues (e.g. crying, hemoglobin levels)
- Goals (e.g. should perform own colostomy care)
- individual needs (e.g. needs to walk every shift, needs to express fears)
- medical diagnoses (e.g. risk for infection related to diabetes melitus)
- treatment or equipment (e.g. imbalanced nutrition related to feeding tube)
- medication side effects (e.g. risk for infection related to chemotherapy)
- diagnostic studies (e.g. cardiac catheterization)
- situations (e.g. dying)
- avoid legally inadvisable or judgmental statements (fear related to frequent beatings by husband. risk for impaired parenting related to low IQ of mother) Planning (nursing process) correct answers-Identify & develop expected patient outcomes (several) -Nurse & patient mutually decide on a plan of care (POC) and anticipated outcomes.
•Based on assessment data (Patient needs, strengths, and resources) •Specifies short-term goals (outcome criteria) •Includes actions to support achievement of expected outcomes. identifying expected outcomes correct answers*Patient - Centered OR Client - Centered *Described in specific measurable terms *Based on nursing diagnoses *Developed collaboratively with patient and other healthcare (HC) providers *Realistic and achievable (attainable) *Specify the action (behavior) patient will demonstrate once HC problem is resolved. Outcome statement components - BMCT correct answers1. subject/who?
- verb/behavior
- performance criteria/measurable
- condition/circumstances
- target time/time frame implementation of nursing process correct answersTaking agreed-on action to alter patient's status/ symptoms. •Consists of: Encouraging, supporting, and validating the patient to achieve goals through integrated therapeutic nursing interventions and communication strategies. nurse-prescribed interventions correct answersNurse formulates for self or other nursing staff to implement physician-prescribed (delegated) interventions correct answersPhysician formulates for nursing staff to implement problem-focused ND focus of nursing interventions correct answers•Reduce or eliminate contributing factors of the diagnosis
- Care plan's status and currency how to do evaluation correct answers1. Develop response statements that evaluate the patient's progress toward meeting his outcome criteria. •Look at outcome criteria and see if the patient met them. •A MEASUREABLE statement
- Develop a statement regarding the care plan's status. •Was the diagnosis correct? •Client participating? •More time needed? •Outcomes need revision? •Plan needs revision? Patient-Centered (PC) Pre-interaction phase correct answersNo Patient Contact - Nurse performs self- reflection (goals, biases, actions to perform) Patient-Centered (PC) Orientation phase correct answersBegin relationship (trust and rapport) NP: Assessment - gather data NP: Diagnosis - define the problem Patient-Centered (PC) Working phase correct answersNP: Planning - identify NOCs NP: Implementation - perform NICs Patient-Centered (PC) Termination phase correct answersNP: Evaluation - were problems corrected, were NOCs achieved? standardized language correct answers-Use of standardized terminologies & taxonomies (coding systems) help: •Classify nursing care & outcomes. •Clearly communicate a common message.
•Compare & evaluate effectiveness of care. •Describe care given, its effects, or to establish cost for nursing's contributions. -Goals: improve communication, make nursing practice visible within the health information systems, and to assist in establishing evidence-based nursing practice. (Nursing Care is part of the room charge! Place value in what you do!) taxonomy correct answersHierarchical method of classifying a vocabulary of terms according to certain rules. (EX: Biology, Mathematics, Geology) Bloom's Taxonomy correct answersUsed in nursing to communicate & compare across health care settings & providers, insurers, and payers, and policy makers who set priorities and allocate resources. NIC - Nursing Interventions Classification (standardized language using nursing taxonomies) correct answers•Focus on Nursing Interventions
- Actions nurses perform - What nurses do. NANDA - North American Nursing Diagnosis Association (standardized language using nursing taxonomies) correct answers*Focus on Nursing Diagnoses *Health problems that nurses can treat. NOC - Nursing Outcomes Classification (standardized language using nursing taxonomies) correct answers•Focus on Patient Outcomes •Patient outcomes attained through nursing actions - What patient is expected to do after the nurse's intervention is done. critical thinking correct answersthinking that does not blindly accept arguments and conclusions. Rather, it examines assumptions, discerns hidden values, evaluates evidence, and assesses conclusions. Uses Complex, Analytical Thinking Processes: •Clinical Reasoning Tool •Tool of Inquiry •Identify & Analyze the Problem Leads to: Clear, Objective Decision Making
attitude (affective component) correct answerscontains the feelings or emotions one has about a given object or situation. -Be inquisitive -Desire to seek the truth -Seek to develop analytical and systematic thinking -Maintain open-mindedness and flexibility in thinking and learning -Engage in self-reflective inquiry -Be willing to apply the CT process ANA Standard 14. Quality of Practice correct answers"The RN contributes to quality nursing practice." •Some competencies include: •Recommends strategies to improve nursing quality. •Uses creativity and innovation to enhance nursing care. •Identifies barriers and opportunities to improve healthcare. Patient-Centered Care (PCC) correct answers•Empowering the patient/family to be a full partner in providing compassionate, coordinated care. -Knowledge: integrate multiple dimensions of care, inc. communication to involve the patient & family. -Skills: elicit patient values & preferences during your initial interview & care plan development to communicate patient preferences to other HC members. -Attitudes: value expressions of patient values, as well as their expertise regarding their own health status. ANA Standard 13. Evidence-based Practice and Research correct answers"The RN integrates evidence and research findings into practice." Some of these competencies include: •Articulates the values of research and its application •Identifies question that can be answered by nursing research •Incorporates evidence when initiating changes in nursing practice
evidence-based practice (EBP) correct answersnursing care provided that is supported by sound scientific rationale •Extensive clinical experience + sound clinical research + professional judgment + pt. values When? in real-time patient situations = EBP •Incorporating the best practices base on the newest evidence with our clinical expertise to deliver optimal care -K: Identify sources -S: Use EBPs -A: Value research & appreciate need to seek EBP information four elements of EBP correct answers1. Best practices
- Evidence from scientific findings
- Clinical nursing expertise of professional nurses
- Preferences and values of clients and family members (patients are also part of the collaborative health care team) AHRQ correct answersAgency for Healthcare Research and Quality USPSTF correct answersU.S Preventative Services Task Force CINAHL correct answersCumulative Index to Nursing and Allied Health Literature UpToDate correct answersEvidence-based physician authored resource Provides disease state information including Etiology/Epidemiology Risk factors Diagnosis Treatment Practice changing updates Referenced
Dyad Family correct answershusband and wife or other couple living alone without children single-parent family correct answersdivorced, never married, separated or widowed man or woman and at least one child step family correct answersfamily in which one or both spouses are divorced or widowed with one or more children from previous relationships who may or may not live with newly reconstituted family blended or reconstituted family correct answerscombination of two families with children from one or both families and sometimes children of the newly married couple Common-law family correct answersan unmarried couple living together with or without children no kin family correct answersa group of at least two people sharing a nonsexual relationship and exchange support who have no legal, blood, or strong emotional tie to each other polygamous family correct answersone man (or woman) with several spouses Same sex family correct answersa homosexual or lesbian couple living together with or without children commune family correct answersgroups of individuals (may or may not be related) living together and sharing resources group marriage correct answersall individuals are "married" to one another and are considered parents of all the children comparing differences between biological and blended families correct answersBiological Families Family is created without loss Shared family traditions One set of family rules
Children arrive one at a time Biological parents live together Blended Families Family is born of loss Two sets of family traditions Family rules varied & complicated Instant parenthood of children at different ages occurs Biological parents live apart Ludwig von Bertalanffy (1968): General Systems Theory correct answers-Examines interdependence among all parts of the system & how the parts support the system as a functional whole. -Systems thinking maintains that: •The whole is > the sum of its parts, with each part reciprocally influencing its function. •If one part fails, the whole fails (like a clock. it displays time correctly but only if all parts work together. if any part of the clock breaks, the time will not be accurate) Murray Bowen's Family Systems Theory correct answersConceptualizes the family as an interactive emotional unit. Family members: •Assume reciprocal family roles •Develop automatic communication patterns •React to each other in predictable, connected ways, particularly when family anxiety is high (for example, if one person is overly responsible, another may be less likely to assume normal responsibility) Differentiation of self correct answersRefers to a person's capacity to define himself within the family system as an individual having legitimate needs and wants. requires "I" statements Multigenerational Transmission Process correct answersrefers to the emotional transmission of behavioral patterns, roles and communication response styles for generation to generation
1.The married couple 2.Childbearing 3.Preschool-aged children 4.School-aged children 5.Teenage children 6.Launching the children 7.Middle-age parents 8.Aging family members Family Stress Theory correct answers-Explores family response to and coping with stressful events. -Factors associated with positive resolution: •Family system resources •Flexibility (resilient) •Problem-solving skills family centered care (FCC) correct answers-Gives the health care providers a uniform understanding of patient & family's knowledge, preferences, & values as the basis for shared decision making. -Health events of 1 family member can affect the whole family. nurse's role in family centered care correct answers1. Understand the impact of a medical crisis on the family
- Appreciate & respond empathetically
- Determine appropriate level of family involvement genogram correct answers1. Explores the basic dynamics of a multigenerational family.
- Can be used to identify patterns of inheritable medical conditions & family relationships
- Three parts to genogram construction: ◦Mapping the family structure ◦Recording family information
◦Describing the nature of family relationships
- Male family members denoted by a square 5 Female family members denoted by a circle ecomap correct answers1. Visually illustrates relationships between family members and the external environment
- Includes significant social and community-based systems that are pertinent to patient
- Can point out resource deficiencies and conflicts in support services that can be corrected family time line correct answers- offer a visual diagram that captures significant family stressors, life events, health, and developmental patterns through the life cycle
- are useful in looking at how the family history, developmental stage, and concurrent life events might interact with the current health concern ANA Standard 9. Communication correct answersThe RN communicates effectively in all areas of practice.
- Uses communication styles and methods that demonstrate:caringrespectdeep listeningauthenticity *trust
- Conveys accurate information applying the nursing process to family communication
- orienting the family correct answers•Begins with reciprocal relationship between nurses and family •Orientation to facility •Initial encounter sets tone for relationship -Ensure the patient's right to privacy. applying the nursing process to family communication
- gathering assessment data correct answers1. Determine the association/relationship of the family member to the patient
- Inquire about family's cultural identity, rituals, values, level of family involvement, decision making, spiritual beliefs& traditional behaviors
