Nursing 251 Final – NDSU Questions and Correct Answers
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Course
Nurs 251
Institution
Nurs 251
Nursing Process Assessment Diagnosis Planning Implementation Evaluation
Assessment Gathers information about the patient's condition
The systematic collection and verification of data Purpose is to establish baseline data about the client Seeing If there are changes from first assessment Gives th...
Nursing 251 Final – NDSU Questions
and Correct Answers
Nursing Process ✅Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment ✅Gathers information about the patient's condition
The systematic collection and verification of data
Purpose is to establish baseline data about the client
Seeing If there are changes from first assessment
Gives the nurse the necessary information about risk factors so care can be
individualized
The data is analyzed to develop nursing diagnosis
Important for nurse to know disease conditions and the client's responses to illness and
treatment
Diagnosis ✅Identify the patient's problems
Planning ✅Set goals of care and desired outcomes and identify appropriate nursing
actions
Implementation ✅Perform the nursing actions identified in planning
Evaluation ✅Determine if goals and expected outcomes are achieved
ANA Standard 1: Assessment ✅Nurses are responsible for collecting comprehensive
data that is pertinent to the patient's health and the situation
Getting all the information
Data needs to be documented or it didn't happen
First step in determining priorities to individualize care
The data must also be documented in a retrievable format
Assessment Components ✅§ Data collection methods (fist part in assessment)
Observation
ex. Is the patient engaged, facial reactions, 5 senses
Interview:
1. Pre-interaction phase
2. Orientation phase
,3. Working phase
4. Termination phase
Examination
Medical record review
Pre-interaction phase ✅· Before meeting the client
o Review data
o Talk to other caregivers
o Anticipate concerns or issues that may arise
o Plan for adequate time
o Identify locations that foster comfort & privacy
Orientation phase ✅· The nurse and the client meet
· Get to know one another
· Set the tone
o Warmth
o Empathetic
o Caring manner
· Clarifies the role of nurse/client
Working phase ✅· Nurse & client work together to:
o Solve problems
o Accomplish goals
· Therapeutic communication to facilitate interactions
· Uses appropriate self-disclosure & confrontation
Termination phase ✅· During the ending of the nurse/client relationship
o Reminds that termination is near
o Evaluates goal achievement with the client
o Separates from the client
o Transition from nurse to caregiver
Assessment Frameworks ✅Maslow's basic needs: nursing stay within the first two
needs most often
Physiological needs (base)
Ex: food, water, shelter, bp, pulse, O2 (ABC's = airway, breathing, circulation)
Safety/security needs
Love and belonging
Self-esteem
Self-actualization
Gordon's functional heath status
Nursing Diagnosis: used for care planning
Type of data ✅subjective: what they report and feel
objective: what you observe
,Sources of data ✅Client
Family and significant others
Health care team members
Medical records/other records
Literature review
Nurse's experience
Other Records
Data collection is based on ✅Assessment
Client review
Chart review
Health History ✅Biological
Expectations
Family history
Past medical history
Present medical history
Environmental
Spiritual
Review of systems (ROS)
Psychological
Reasons for seeking healthcare
ANA Standard 2: Diagnosis ✅The registered nurse analyzes the assessment data to
determine the diagnoses or issues.
ADVANTAGES OF NURSING DIAGNOSIS
Defines nursing domain: how we practice as a nurse
Facilitates communication: between shifts and other healthcare facilities
Helps prioritize the needs of the client: ABC's
Useful in documentation
Provides coordination & continuity of nursing care: between shifts and other healthcare
facilities
Helpful in quality improvement of nursing care: reflecting to make adjustments
Improve patient care in terms of meeting clients' needs or preventing potential
problems
Provides an individualization of care for each client: pain levels are different for
everyone
Nursing Diagnosis ✅The client's actual or potential response to a health problem used
as a basis for nursing intervention to achieve outcomes
Medical Diagnosis ✅identified illness and design treatment plan to cure patient
Analysis and Interpretation of Data ✅Validation of information
Clustering data: data that is similarly related to each other
, Defining characteristics: clinical criterial objective and subjective data that supports
findings that patient states is the problem (prove)
Identification of the Patient's Problem ✅§ Is an actual problem?
The nursing diagnosis must be supported by assessment data (clinical signs and
symptoms)
Is a potential problem that you wish to avoid (at risk for/risk factors)?
No defining characteristics are identified but the patient has risk factors that could lead
to a problem
Has not actual signs or symptoms YET
Is it a wellness issue (readiness for enhanced)?
It could get better. Ex: working on quitting smoking
Labeling the Data Clusters: Categories ✅Activity/Rest
Circulation
Ego Integrity
Elimination
Food/Fluid
Hygiene
Neurosensory
Pain/Discomfort
Respiration
Safety
Sexuality
Social Interaction
Teaching/Learning
Rules of Labeling Data Clusters ✅Only one diagnosis per category (typically)
Only use the nursing diagnosis as listed
Ex: acute/chronic pain not intense
CANNOT write verbatim from the guide
Sources of errors in nursing diagnosis ✅Data collection
If it's hard to put it together, it's probably not right
Interpretation and analysis of data
Use your pocket guide to move things in the right spots
Data clustering
Use the nursing diagnosis formulation
Errors in the diagnostic statements
ANA Standard 3: Outcomes Identification ✅The registered nurse identifies expected
outcomes for a plan individualized to the patient or situation
ANA Standard 4: Planning ✅The registered nurse develops a plan that prescribes
strategies and alternatives to attain expected outcomes.
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