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Flashcards in Identifying Clinical Problems in Nursing Practice 2 Deck (24):

What is the nursing process?

involves a series of interrelated steps the nurse takes to identify clinical issues and make decisions about nursing care.


What are the 4 categories in the nursing process?

1. assessment and diagnoses
2. planing
3. implementation
4. evaluation


action demand consist of what 2 pieces of data?

1. synthesis statement
2. actions to take


create action demand statement for university student who gained weight from increase intake of food due to stress

synthesis statement:
improve nutrition in a 20 year old university student who gained weight, overeats and is stressed.

actions to take:
limiting fast food intake
develop meal plan using food guide
cooking own meals
keeping a diary of consumed foods
developing daily routine exercise
doing relaxation exercises daily


What is self care?

actions one does to ensure their well being


what are self care practices?

specific activities we perform for self care


what is self care ability?

capabilities of an individual that enables them to engage in self care


why assess one's ability?

unless ability is assessed, nurses have no rational basis for:

1. Making judgments about existing or potential self-care deficits and the reason for their existence.

2. Selecting valid and reliable ways of intervening to address the deficits.


What is required in order to engage in self care?

1. Sufficient energy to give proper attention to self-care
2. A knowledge base about self-care; (talk to them about it)
3. A repertoire of self-care skills;
4. The ability to reason, solve problems and make decisions in the course of self-care;
5. Motivation to engage in self-care;
6. A strongly held value for health.


What are the 10 power components?

#1 Knowledge
#2 Motivation
#3 Attention span
#4 Physical energy
#5 Control of body position
#6 Ability to reason
#7 Ability to make decisions
#8 Cognitive, perceptual, communication and interpersonal skills
#9 Ability to prioritize self care actions
#10 Ability to follow regimen on regular basis


what is the power component knowledge?

helping person achieve goal by teaching them the knowledge

Can your patient recount, explain and demonstrate self-care practices/information the health care team has given him/her
Can your patient answer questions about his/her health state?
Can your patient explain to you what he/she must do to meet a particular self-care requisite


What is the power component motivation?

Does your patient value health and being able to do self-care?
Perseverance toward health goals
Does your patient begin and follow through with actions aimed at health goals?


What is the power component attention span?

hat is the level of consciousness? (alert to person and place and time)
What is the length of his/her attention span?
Are answers to questions sensible?
Can he/she remember recent events/occurrences?
Can he/she recognize problems without someone else pointing it out?


What is the power component physical energy?

Does the patient appear tired and/or lethargic?
Does he/she state that fatigue exists?
Is the patient slow-moving or hyperactive?
Does the patient manage their use of energy in order to prioritize self-care?


What is the power component control of body position?

What are gross(walking,running) and fine motor skills(putting on makeup, shaving)?

Does the patient have full range of motion of joints?

Does he/she say that he/she is able to initiate and complete the task?


What is the power component ability to reason within a self care framework?

Is the patient able to make a decision by looking at all of the facts?
Can he/she use general principles to arrive at a decision?
Is he/she able to associate his/her needs with related actions?


What is the power component ability to make decisions about self care?

Does your patient use all available information to make decisions regarding their self-care practices?
Is your patient able to tell you when he/she will perform certain actions?
Does your patient make decisions to engage in therapeutic self-care practices even when it is complicated?


What is the power component Repertoire of cognitive, perceptual, manipulative, communication and interpersonal skills?

Logic, connectedness of ideas
Intactness of senses (smell, hearing, vision, taste, touch)
Fine motor coordination
Is your patient able to communicate in a clear, correct manner?


What is the power component ability to prioritize self care actions?

Time sequencing
Distance sequencing
Common sense


What is the power component ability to follow regimen on regular basis

Is your patient able to follow a regimen on a regular basis, while at the same time maintaining other responsibilities and relationships?


When do patients require nursing care?

1. When there is a self care deficit:

2. Limitations in any of the power components

3. Self-care ability is less than Action Demand


How to formulate self care deficit statement (action demand)

Inability to Synthesis Statement (Verb + USCR + in a + Age + Sex of the patient + story that makes it particular) related to the following limitations:

List all of the limitations of power


NANDA international nursing diagnosis limitations in the following?

Risk for aspiration (food goes down trachea and into lungs), action to take is change pt position to upright (45-90), have suction ready, avoid liquids. would affect knowledge, control of body position, power component, motivation

Risk for constipation, action to take is exercise, change of diet, drink a lot of liquid, increase fibre. would affect, lack of energy, motivation, inability to preform self-care
Ineffective breathing pattern, action to take is semi fowler position, supply oxygen. would affect knowledge, control of body, energy

Ineffective coping, action to take is spiritual retreat, relaxation yoga. would affect lack of motivation, knowledge,

Caregiver role strain, action to take is search out resources for support provide physical/emotional support, find respite group. would affect knowledge, motivation, decrease in energy,

Risk for falls , action to take is use aid for mobility. would affect knowledge, motivation, control of body positioning, energy level

Risk for Contamination , action to take is isolate, use personal protective equipment. would affect knowledge, motivation


remember to assess the patients story and go through all of the power components and see if they are capable of each component, then formulate your action demand statement based on their ability or inability and state reasons why