Quiz 2 Flashcards
(22 cards)
Distinguishing relevant from irrelevant
Determining important information
Managing potential complications
Falls under Recognizing Cues
Interpreting (Tanners)
Gathering information through senses
Consider cues in context of client Hx & situation
Distinguishing relevant from irrelevant / expected vs not expected
Whats more concerning
Analyzing cues
What is the goal of interpreting data?
Analyzing & prioritizing data
Organizing data w/ common theme
* Theme is releated to situations; pick system related to systems/objective/subjective data
Based on what RN notices
Clustered infor needed for RN Dx
Ex of theme:
* Pain: Rating, PQRST, & pain meds
* FVO: Abnorm lung sounds, edema, weight gain, increased BP, SOB
* Infection: Increased temp, increased WBC, drainage, odor, swelling, cultures
Clustering Related Information
Determining that the data apperas to lead to opposing conclusions & more infor needed
What is unlike, dissimilar, & deveates from what is expected
Recognizing consistencies
Determining if & how data nees to be confirmed before being acted upon
Pt safety at risk when errors aren’t met
Recheck when questioning data
Look at vitals
Checking accuracy & reliability
S: Sleep problems
P: Problems eating
I: Incontinence
C: Confusion
E: Evidence of falls
S: Skin breakdown
SPICES tool
The identification of a disease condition based on a specific assessment of physical S/s, medical Hx, & test/lab results
Language of HCP
* physicians
* advanced practice nurses (midwife/NP)
Ex:
* DM
* pneumonia
Medical Dx
Clinical judgement made by RN to describe the pts response or vulnerability to health conditions or life events that the nurse is licensed & competent to treat
Diagnostic label that classifies an individuals/families/communities response to illness
Ex:
* impaired respiratory system - impaired gas exchange
* impaired tissue integrity
* impaired swallowing
Nursing Dx
Nurse educators recognized that assessment data need to be analyzed & clustered into patterns & interpreted before RNs could make accurate RN DXs
NANDA International (NANDA-I)
Which type of data helps a nuse to think less about individual data points & instead focus on pattern recognition?
A) Subjective data
B) Data Clusters
C) Objective data
B) Data Clusters
Involves placing lables on your data patterrn or cluster to clealy identify a pts response to a health problem
Data interpretation
Errors occur if you cluster data prematurely, incorrectly, or not at all
Occurs when you make a nursing Dx before grouping all patient data
Errors in Data Clustering
T/F: RNs can treat medical Dx
False - A RN cannot treat medical Dx; instead, they treat patients responses to the medical health condition
Involves analyzing data gathered about a patient for pattern recognition & validation of avalible cues
* Requires making clinical judgement decisions
Nursing Diagnostic Reasoning
What is the diference between a problem-focused nursing Dx (Negative Dx) & a risk nursing Dx?
Problem-focused (Negative Dx): Identifies actual undesirable human response to existing health problems
Risk nursing Dx: Identifies when there is an increasedpotential or volnerability for a patient to develope a problem or complication
What should a nursing Dx be gathered from?
A cluster of assessment findings
Problem-focused / negative Dx take priority over what other Dxs?
Wellness Dx
At-risk Dx
Health-promotion Dx
_ pts normally take priority over _ pts.
A) Short-term acute ; Long-term chronic
B) Long-term chronic ; Short-term acute
A) Short-term acute ; Long-term chronic
Measurable pt, family, or community behavior or perception that is measured in response to nursing interventions
Valid & reliable means to support nursing care quality & performance measurement in health care setting
Nurse-sensative patient outcome
What do the letters stand for in SMART?
S: Specific
* Outcomes reflect a specific patient behavior or response
* Ex: For pt w/ impaired mobility an outcome statement is “ Pt ambulates hall 3x/day by 4/22” ; Common error is to write “Pt ambulates hallway
M: Measurable
* Be able to measure or observe whether a change takes place in a pts status
* Ex: Body temp will remain below 37 degrees C (98.6F)” ;Don not use vage words (Normal, acceptable, stable)
A: Attainable
* Outcomes are more achievable when mutually set w/ pt
* always consider pts desire to recover & their physical / psychlogical condition
R: Realistic
* Set expected outcomes that are realistic & relavent for pts
* Ex: Are the pts cultural beliefs reflected in outcomes you set? ; “Pt will wash hands & face in 72hrs”
T: Timed
* Set time for each outcome to be met in order to help solve pt problems
* Help determine pt progress
Complex process involving 2 or more people from various professional fields to acheive common outcomes for a pt
Involves all health care providers working together
Interprofessional collaboration
