Chapter 6 - Nursing Process and Clinical Thinking, Question and Answer Homework

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and population (page 121)

A complete assessment involves a review and physical examination of all body systems (musculo-skeletal, respiratory, gastrointestinal). This type of assessment also includes cognitive, psychosocial, emotional, cultural and spiritual components and is appropriate for a patient who is stable and not in acute distress. Information about functional abilities, lifestyle, and developmental concerns is also important (page 122)

SUBJECTIVE data are the verbal statements provided by the patient. Nausea, pain, fatigue, and anxiety are all exampes of subjective data. Other terms for subjective data are symptoms and subjective cues. Subjective data are hidden until shared by the subject, the patient.

OBJECTIVE data are observable and measurable signs. One is able to record objective data. A camera records a rash, a skin lesion, or puffy eyes. Other terms for objective data are signs and objective cues. (page 122)

Primary source of data is the patient. The patient is considered to be the most accurate reporter. The alert and oriented patient is able to provide information about past illnesses and surgeries and present signs, symptoms, and lifestyle.

Secondary sources include family members, significant others, medical records, diagnostic procedures, and nursing literature. Members of the patient's support system are also able to furnish information about patient's past health status, current illness, allergies and current medications (page 123)

1) IN the First method, you Conduct an interview, the nursing health history, to obtain information about the patient's health history. You will assess several components in the course of the interview. Ask about biographical data to provide information about the facts or events in a person's life. Also request information about the reason the patient is seeking health care, a history of present illness, health history and family history.

The SECOND METHOD of data collection is the performance of physical examination.
The physical examination is often guided by subjective data provided by the patient. Follow up on statements of pain by examining that part of the body. A head-to-toe format provides a systematic approach that helps avoid omitting important data. (pages 122-123)

1) Deviation from population norms
2) Changes in the patient's usual health status
3) Developmental delays
4) Dysfunctional behavior
5) Changes in usual behavior
(page 124)

1) Nursing Diagnosis title or label
The problem is identified after clustering and analysis is given a title or label. It is simply called a nursing diagnosis. Nursing diagnostic label is to describe the component. Constipation, fatigue, powerlessness, and pain are examples

2) Definition of the title or label
Presents a clear, precise description of the problem. Helps identify the differences between similar nursing diagnoses. To increase the accuracy of your diagnosis selection, carefully study the definitions for nursing diagnoses. Sample is Constipation against Perceived Constipation.

3) Contributing, etiologic or related factors
Conditions that are often involved in the development of a problem and are also found in nursing diagnosis handbook. These factors may become the focus for nursing interventions. These are referred to a "RELATED TO" factors.

Risk factors are circumstances that increase the susceptibility of a patient to problems. Risk factors are written as "related to". in risk nursing diagnosis statements.

4) Defining characteristics
Clinical cues, signs and symptoms that furnish evidence that the problem exists. They are written as "Manifested by" in the nursing diagnosis statement.

A syndrome diagnosis is used when a cluster of actual or risk nursing diagnosis are predicted to be present in certain circumstances. Post-trauma syndrome, risk for disease syndrome, impaired environmental interpretation syndrome, and relocation stress syndrome are the current syndrome diagnoses. Because these diagnoses are so specific, the syndrome diagnoses are written as one-part statements.
(page 126)

Physician prescribed intervention are those actions ordered by a physician for a nurse or other health care professional to perform. Physician orders are not orders for nurses but are prescriptive instructions for patients.

Nurse prescribed interventions are any actions that a nurse is legally able to order or begin independently. Nurses write interventions for themselves or for other nursing staff. Examples are turning a patient every 2 hours, provide back massage. When determining appropriate nursing interventions, the nurse should consider contributing, etiologic, and related factors; risk factors; patient-centered goals; or desired patient outcome; and the nursing diagnosis label itself. Nursing interventions are focused on any or all of these areas. (page 129)

1) Critical thinkers think with a purpose. They question information, conclusions and points of view.

2) Critical thinkers look beneath the surface. They are logical and fair in their thinking.

3) The skills related to critical thinking are applied to reading, listening, and writing and across all subjects.

4) Critical thinking is purposeful, informed, outcome-focused (results oriented) thinking that requires careful indentification of key problems, issues and risks. (page e134)