LECTURE 10 NURSING PRACTICE AND THE UTILIZATION OF THE NURSING PROCESS [Autosaved].pdf

Valerie Suge - Michieka
NURS 213
FUNDAMENTALS OF NURSING PRACTICE III
LECTURE 11: NURSING PRACTICE AND
UTILIZATION OF THE NURSING PROCESS

NURSING PROCESS -
INTRODUCTION
• The term NURSING PROCESS originated in
1955 by Haul.
• Johnson (1959), Orlando (1961), and
Wiedenbach (1963) were the first users of the
term nursing process.
• The Nursing Process enables the nurse to
organize and deliver nursing care.

Introduction
4
• In 1960’s nursing was described as a distinct entity among healthcare
professional
• Nursing process lays out a plan of care which can guide the care provided and
gives accurate recording
• Nursing is an art and a science it is concerned with, physical, sociological,
psychological, cultural and spiritual concerns of the patient
• In the early development of nursing , there was no way to define its practice
and we did not control our practice.
• AMA developed the 1st policy in 1980, which defined nursing as the diagnosis
and treatment of human responses to actual or potential health problems

NURSING PROCESS - INTRODUCTION
• For the successful application of Nursing
Process,
• the nurse integrates elements of critical thinking to
make judgments
• and take actions based on reason.
• The nursing process is used to
• identify, diagnose and treat human responses to
health and illness.

Critical
thinking
ASSESSMENT
DIAGNOSING
PLANNING
IMPLEMENTING
EVALUATING

1. Definition
• It is a systematic, rational method of
planning and providing nursing care. Its
goal is to identify a client’s health care
status and actual or potential health
problems, to establish plans to meet the
identified needs, and to deliver specific
nursing interventions to address those
needs.

Definition conti…
• The nursing process is cyclical, that is, its
components follow a logical sequence, but
more than one component may be
involved at one time.
• At the end of the first cycle, care may be
terminated if goals are achieved, or cycle
may continue with reassessment or plan
of care may be modified.

• It is synonymous with the PROBLEM SOLVING
APPROACH that directs the nurse and the
client to determine the need for nursing care, to
plan and implement the care and evaluate the
result.
• It is a G O S H approach (goal-oriented,
organized, systematic and humanistic care) for
efficient and effective provision of nursing care.

• It is a dynamic continuous process as the
clients need change.
• The use of Nursing Process promotes
individualized nursing care
• And assists the nurse in responding to client
needs in a timely and reasonable manner to
improve or maintain the client’s level of health.
NURSING PROCESS - Summary

2. PURPOSE OF THE NURSING
PROCESS
1. Identify a client’s health status and actual or
Potential health problems or needs.
2. To establish plans to meet the identified
needs.
3. Deliver specific nursing interventions to meet
those needs.

PURPOSE OF THE NURSING PROCESS
4. To Achieve Scientifically- Based,
Holistic, Individualized Care For
The Client.
5. To Achieve The Opportunity To
Work Collaboratively With
Clients, Others.
6. To Achieve Continuity Of Care.
Collaboration

3. Benefits of Nursing
Process
1. Provides an orderly & systematic method for planning
& providing care
2. Enhances nursing efficiency by standardizing nursing
practice
3. Facilitates documentation of care
4. Provides a unity of language for the nursing profession
5. Is economical
6. Stresses the independent function of nurses
7. Increases care quality through the use of deliberate
actions

3. Benefits of Nursing Process-
summary
1. Continuity of care
2. Prevention of duplication
3. Individualized care
4. Standards of care
5. Increased client participation
6. Collaboration of care

Advantages of Nursing
Process
•Provides
individualized care
•Client is an active
participant
•Promotes continuity
of care
•Provides more
effective
communication
among nurses and
healthcare
professionals
•Develops a clear
and efficient plan of
care
•Provides personal
satisfaction as you
see client achieve
goals
•Professional growth
as you evaluate
effectiveness of
your interventions

4. Characteristics of the Nursing
Process
1] Cyclic & dynamic in nature
2] Client centered
3] Focus on problem solving & Decision making
4] Interpersonal & Collaborative style
5] Universal applicability
6] Use of critical thinking.
7] Data from each phase provide input into the next phase.
8]Decision making involved in every phase of nursing process.

CHARACTERISTICS:
a. Systematic:
• The nursing process has an ordered
sequence of activities and each activity
depends on the accuracy of the activity
that precedes it and influences the
activity following it.

b.Dynamic:
• The nursing process has great
interaction and overlapping among
the activities and each activity is fluid
and flows into the next activity

c. Interpersonal: The nursing process ensures that
nurses are client-centered rather than task-centered
and encourages them to work to enhance client’s
strengths and meet human needs.

• d. Goal-directed: The nursing process is
a means for nurses and clients to work
together to identify specific goals
(wellness promotion, disease and illness
prevention, health restoration, coping
and altered functioning) that are most
important to the client, and to match
them with the appropriate nursing actions

e. Universally applicable:
• The nursing process allows nurses to practice nursing
with well or ill people, young or old, in any type of
practice setting

Nursing Diagnosis
22
• A clinical judgment about individual, family, or
community responses to actual and potential health
problems or life processes
• The goal of a nursing diagnosis is to identify actual and
potential responses

Medical Diagnosis
23
• Identification of a disease condition based on a specific
evaluation of physical signs, symptoms, history,
diagnostic tests, and procedures
• The goals of a medical diagnosis is to identify the cause
of a illness or injury and design a treatment plan

Nursing Diagnosis
24
• Actual or potential health problems that can be
prevented or resolved by independent nursing
interventions

Nursing Diagnosis
25
• Nursing diagnoses provide the basis for selecting
nursing interventions that will achieve valued patient
outcomes for which the nurse is responsible

NANDA
26
• NANDA: North American Nursing Diagnosis Association
• Established in 1973 to identify standards and classify
health problems treated by nurses

NANDA
27
• NANDA conferences are held every two years to
continue progress in defining, classifying and describing
diagnoses

NANDAS’ Definition of Nursing Diagnosis
28
• Nursing diagnosis is a clinical judgment about
individual, family, or potential health problems/life
processes.
• Nursing diagnosis provides the basis for selection of
nursing interventions to achieve outcomes for which the
nurse is accountable

Nursing Diagnosis
29
• Clinical judgment about individual, family or community
• Response to actual or potential health or life process
• Provides basis for nursing interventions
• Label and action of describing functional problems
• Identify and synthesize information gathered during assessment

Nursing Diagnosis vs. Medical Diagnosis
30
• Medical diagnosis
• Identify disease
• Nursing diagnosis
• Focus on unhealthy response to health or illness
• Medical diagnosis
• Physician directs treatment
• Nursing diagnosis
• Nurse treats problem within scope of independent nursing practice

Nursing Diagnosis vs. Medical
Diagnosis
31
• Medical Diagnosis
• Remains the same as long as the disease is present
• Nursing Diagnosis
• May change from day to day as the patient’s responses
change

Nsg Dx vs MD Dx
• Within the scope of
nursing practice
• Identify responses
to health and illness
• Can change from
day to day
• Within the scope of
medical practice
• Focuses on curing
pathology
• Stays the same as
long as the disease
is present

Nursing Diagnosis
33
• Medical Diagnosis
• Myocardial infarction
• Nursing Diagnosis
• Fear
• Altered health maintenance
• Knowledge deficit
• Pain
• Altered tissue perfusion

Development of Nursing Diagnosis
34
• Assess the patient
• Review data and find actual and potential problems
• Use diagnostic reasoning to identify patient needs
• Arrange data in clusters or defining characteristics
• Use all data available
• Reach conclusions for patient needs
• Determine Nursing Diagnosis according to NANDA approved
diagnoses

Components of a Nursing Diagnosis
35
• Diagnostic label – name of the nursing diagnosis with
descriptors
• Related factors – includes factors which contribute to the
problem and are not the cause ,but are associated with it.
THESE ARE NOT MEDICAL DIAGNOSIS.
• Defining characteristics - Assessment data which supports
the nursing diagnosis
• Subjective data – what the patients tells you
• Objective data – what you observe or data obtained
• Risk factors – clues which point to potential problems
• Example: We will write the ND in 3 parts:
diagnosis
related to - etiology
• as evidenced by – data collected

Nursing Diagnosis
36
• Types of diagnoses
• Actual
• Risk
• Wellness
• Possible nursing diagnosis
• Syndrome diagnosis

Actual nursing diagnosis:
37
• It is a client problem that is present at the time of the nursing assessment.
• An actual nursing diagnosis is based on the presence of associated signs and
symptoms.
• May have 4 parts: label, definition, defining characteristics and related factors
• Represents a problem that has been validated by the presence of major
defining characteristics
• Examples are Ineffective Breathing Pattern and Anxiety.

Risk nursing diagnosis
38
• clinical judgments that an individual, family or community is more vulnerable to
develop the problem than others in the same or similar situations
• It is a clinical judgment that a problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop unless nurses intervene.
• For example, all people admitted to a hospital have some possibility of
acquiring an infection; however, a client with diabetes or a compromised
immune system is at higher risk than others. Therefore, the nurse would
appropriately use the label Risk for Infection to describe the client’s health
status.

Wellness nursing diagnosis
39
• clinical judgments about an individual, group or community in
transition from a specific level of wellness to a highest level of
wellness
• “Describes human responses to levels of wellness in an individual,
family or community that have a readiness for enhancement.”
Examples of wellness diagnosis would be Readiness for Enhanced
spiritual Well Being or Readiness for Enhanced Family Coping.

POSSIBLE NURSING DIAGNOSIS
40
• It is one in which evidence about a health problem is incomplete or unclear.
• A possible diagnosis requires more data either to support or to refute it. For
example, an elderly widow who lives alone is admitted to the hospital. The
nurse notices that she has no visitors and is pleased with attention and
conversation from the nursing staff.
• Until more data are collected, the nurse may write a nursing diagnosis of
Possible Social Isolation related to unknown etiology.

SYNDROME DIAGNOSIS
41
• It is a diagnosis that is associated with a cluster of other
diagnoses.

What is the “Nursing Process”?
42
• It is a systematic method that directs the nurse and patient in
planning patient care, and enables you to organize and deliver
nursing care
• It is patient centered and outcome oriented
• The steps are interrelated and dependent on the accuracy of each
of the preceding steps
• It is used to identify, diagnose, and treat human responses to health
and illness

Nursing Process cont…
43
• It is a dynamic continuos process
• Using the nursing process promoted individualized
nursing care
• It is and approach that allows nurses to differentiate
their practice from that of physicians and other health
professionals

Together the nurse and the patient
accomplish the following:
44
• Assess the patient to determine need for nursing care
• Determine nursing diagnoses for actual and potential
health problems
• Identify expected out comes and plan care
• Implement care
• Evaluate the results

Five Steps of the Nursing Process
45
• Assessment – collection of patient data
• Diagnosis – identifies patients strengths and potential problems
• Planning – develop the specific holistic desired goals and nursing
interventions to assist the patient
• Implementation – carry out the plan of care
• Evaluation – determine the effectiveness of the plan of care

The Nursing Process is a Systematic
Five Step Process
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

5 Steps in the Nursing Process
•Assessment
•Nursing Diagnosis
•Planning
•Implementing
•Evaluating
•Each step needs to be
completed before we can
progress further in the
process

Nursing Care Plans
• Written guidelines for client care
• Organized so nurse can quickly identify nursing actions
to be delivered
• Coordinates resources for care
• Enhances the continuity of care
• Organizes information for change of shift report

Assessment: Phase One of the Nursing
Process
50
• Purpose:
• Establish a baseline of information on the client and develop a
data base
• Determine client’s normal function
• Determine client’s risk for dysfunction
• Determine presence or absence of dysfunction
• Determine client’s strengths
• Provide data for diagnostic phase

Unique Focus of Nursing Assessment
51
• Nursing assessments do not duplicate medical
assessments
• Medical assessments target data pointing to pathologic
conditions
• Nursing assessments focus oh the patient’s responses
to health problems or potential health problems

Assessment
52
• The purpose is to establish a database by:
• Collecting data
• Subjective versus objective
• Interviewing and taking a health history
• Subjective and organized
• Performing a physical examination
• Vital signs, patient’s behavior, diagnostic and laboratory data, medical
records

Assessment
•First step of the Nursing Process
•Gather Information/Collect Data
•Primary Source - Client / Family
•Secondary Source - physical exam,
nursing history, team members, lab reports,
diagnostic tests…..
• Subjective -from the client (symptom)
• “I have a headache”
•Objective - observable data (sign)
• Blood Pressure 130/80
Form a data base on information collected about
the client

Assessment-collecting data
• Nursing Interview (history)
• Functional Heath Patterns
• Health Assessment -Review of Systems
• Physical Exam
• Inspection
• Palpation
• Percussion
• Auscultation

Assessment-collecting data
• Make sure information is complete & accurate
• Validate prn
• Interpret and analyze data
Compare to “standard norms”
• Organize and cluster data

Approaches for Data Collection
56
• Gordon’s 11 Functional Health Patterns
• Uses a series of questions which assist in formulating a
nursing diagnosis
• Problem focused assessment
• Focuses on the patient’s problem and develop you plan of
care around the problem

Approaches cont..
57
• Either of these methods allow for clustering of cues and inferences
which give rise to patterns or potential problems
• Cues – information obtained through the use of senses
• Inference – judgment or interpretation of cues

Gordon’s Health Patterns
58
• Health perception-
management
• Nutritional-metabolic
• Elimination
• Activity-exercise
• Sleep-rest
• Cognitive -perceptual
• Self-perception-self-
concept
• Role-relationship
• Sexuality-reproductive
• Coping-stress-tolerance
• Value-belief

Types of Nursing Assessments
59
• Initial assessment
• Focused assessment
• Emergency assessment
• Time-lapsed assessment

Types of Data
60
• Subjective Data
• Information perceived only the affected person
• Cannot be perceived or verified by another person
• Examples: feeling nervous, nauseated, chilly

Types of Data
61
• Objective Data
• Observable and measurable data
• Data that can be see, heard or felt by someone other than the
person experiencing it
• Examples: elevated temperature (>101 F), moist skin, refusal
to eat, vital signs

Characteristics of Data
62
• Complete
• Factual and accurate
• Relevant

Components of Data Collection
63
• Interview
• Orientation phase
• Working phase
• Termination

Sources of Data
64
• Primary
• patient
• Secondary
• Family members
• Significant other
• Other healthcare professionals
• Health records

Components of Data Collection
65
• Nursing History
• Biographical information
• Reasons for seeking healthcare
• History of Present illness or health concern
• Past Medical/surgical Health history
• Family social History to include:
• Environmental history
• Psychosocial and cultural history
(For female patients; include their gynae and
obstetric histories)
• Review of systems or functional health
patterns

Interpreting Assessment Data
66
• Data interpretation and validation
• Data clustering
• Data documentation

Example of Assessment
• Obtain info from nursing assessment,
history and physical (H&P) etc…...
• Client diagnosed with hypertension
• B/P 160/90
• 2 Gm Na diet and antihypertensive
medications were prescribed
• Client statement “ I really don’t watch my
salt” “ It’s hard to do and I just don’t get it
• Based on this assessment we can see
one factor effecting the client’s
uncontrolled hypertension is lack of
maintaining sodium intake restrictions

Diagnosis: Phase 2 of the Nursing Process
68
• Data is useless if not used
• An important part of nursing practice is determining what the client
needs
• Developing a nursing diagnosis is the next step in planning for the
care of the patient
• Looking at the data, we can see both problems treated by nursing
(nursing diagnosis) and treated by other disciplines (collaborative
problems).
• Nursing diagnosis are not medical diagnosis

Nursing Diagnosis
• Second step of the Nursing Process
• Interpret & analyze clustered data
• Identify client’s problems and strengths
• Formulate Nursing Diagnosis (NANDA :
North American Nursing Diagnosis
Association)-Statement of how the client is
RESPONDING to an actual or potential
problem that requires nursing intervention

Cont…
• Nursing Dx is a problem statement of how the client is
RESPONDING to a problem…it may be an actual or
potential problem
• Interpreted data is clustered inaccording to body
systems, risk factors, family factors,emotional factors
etc.

Formulating a Nursing
Diagnosis
• Composed of 3 parts:
• Problem statement- the client’s
response to a problem
• Etiology- what’s causing/contributing
to the client’s problem
• Defining Characteristics- what’s the
evidence of the problem

Nursing Diagnosis
• Problem( Diagnostic Label)-based on
your assessment of client…(gathered
information), pick a problem from the
NANDA list...
• Etiology- determine what the problem
is caused by or related to (R/T)...
• Defining characteristics- then state
as evidenced by (AEB) the specific
facts the problem is based on...

Example of Nursing Dx
• Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack of
knowledge
AEB B/P= 160/90, dietary sodium restrictions not being
observed, and client statements of “ I don’t watch my
salt” “It’s hard to do and I just don’t get it”.

• Based on our assessment of the client with hypertension
who wasn’t following the prescribed low salt diet this is an
example of a nsg dx.
• First part is the clients problem taken from the NANDA list
• Second part is a reason why the client has the problem
• Third part is the evidence of the problem

Types of Nursing Diagnoses
• Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea, and
pain AEB height 5’5” weight 55 kgs.
• Risk
Risk for falls RT altered gait and generalized
weakness
• Wellness
Family coping: potential for growth RT
unexpected birth of twins.

What a Nursing Diagnosis is Not
76
• A nursing diagnosis is NOT a medical diagnosis
• A nursing diagnosis is NOT a statement of patient need

77
• EXAMPLE: needs assistance with bathing
• INSTEAD: self care deficit: bathing and hygiene related
to immobility

Legal Ramifications of Nursing Diagnosis
78
• A nurse
• Can only identify problems within the scope of practice
• Cannot diagnose or treat medical disease
• Must identify problems within his/her scope o practice,
abilities and education

Collaborative Problems
• Require both nursing interventions and
medical interventions
EXAMPLE: Client admitted with medical dx of
pneumonia
Collaborative problem = respiratory
insufficiency
Nsg interventions: Raise HOB, Encourage
C&DB
MD interventions: Antibiotics IV, O2 therapy

Guidelines in formulating a
Nursing Diagnosis
80
• 1. Identify how and individual, group or community
responds to an actual or potential health and life
processes
• 2. Identify factors that contribute to or cause health
problems (etiology).
• 3. Identify resources or strengths the individual, group
or community can utilize to prevent or resolve problems

Health Problem
81
• A condition that necessitates intervention to prevent or
resolve the disease or illness or to promote coping and
wellness
• After the data is collected and recorded, the nurse
interprets an analyzes the data to identify strengths and
health problems

Health Problems for Nursing Focus
82
• Monitoring for changes in health status
• Promoting safety and preventing harm
• Identifying and meeting learning needs
• Tailoring treatment and medication
regimens for each individual
• Nurses should focus on certain types
of health problems to better
understand their responsibilities in
diagnosis and management of health
problems

Health Problems for Nursing Focus cont..
83
• Promoting comfort and managing pain
• Promoting health and a sense of well being
• Recognizing and addressing barriers to an
independent, healthy lifestyles
• Determining human responses

NANDA NURSING DIAGNOSIS
LABELS

LECTURE 10 NURSING PRACTICE AND THE UTILIZATION OF THE NURSING PROCESS [Autosaved].pdf

Planning
Third step of the Nursing Process
• This is when the nurse organizes a
nursing care plan based on the nursing
diagnoses.
• Nurse and client formulate goals to help
the client with their problems
• Expected outcomes are identified
• Interventions (nursing orders) are selected
to aid the client reach these goals.

Planning cont…
• Now that we have a nsg dx we need a plan to help this client
• Goals allow us to determine the specific outcome desired by the client
• Short term- goal in which a specific time frame with date ie Able to identify 20 foods which are low in sodium within 2 days
• Long term goal in which desired outcome is expected in a broader time frame ie Client be able to develop a daily meal
plan based on 2 Gm Na restrictions by the end of the month
• Cognitive goal - goal in which client gains new knowledge ie able to correctly identify foods high and low in sodium
• Psychomotor goal- goal in which client’s acquire a new skill ie client able to correctly monitor B/P using stethoscope and
sphygmomanometer
• Affective goal - goal in which the client’s values or attitudes change ie client able to accept the need for maintaining life
time dietary changes to control B/P
• Interventions are nursing orders that you are empowered to select based on your judgement of the client’s needs
• Prioritize most important goals first

Planning – Begin by prioritizing client
problems
• Prioritize list of client’s
nursing diagnoses
using Maslow
• Rank as high,
intermediate or low
• Client specific
• Priorities can change

Classification of
NURSING DIAGNOSIS:
• High – priority
- life threatening and requires
immediate attention.
• Medium – priority
- resulting to unhealthy consequences.
• Low – priority
- can be resolved with minimal
interventions.

Planning
Developing a goal and outcome
statement
• Goal and outcome
statements are client
focused.
• Worded positively
• Measurable, specific
observable, time-limited,
and realistic
• Goal = broad statement
• Expected outcome =
objective criterion for
measurement of goal
• Utilize NOC as
standardNOC = nursing
outcome classification
EXAMPLE
• Goal:
Client will achieve
therapeutic management
of disease process….
• Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of
understanding importance
of dietary sodium
restrictions by day of
discharge.

Planning- Types of goals
• Short term goals
• Long term goals
• Cognitive goals
• Psychomotor goals
• Affective goals

Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)

Planning-select interventions
• Interventions are selected and written.
• The nurse uses clinical judgment and
professional knowledge to select appropriate
interventions that will aid the client in
reaching their goal.
• Interventions should be examined for
feasibility and acceptability to the client
• Interventions should be written clearly and
specifically. Be specific clearly state what
teaching is needed, materials to be used etc
• Utilize research and evidence based practice
protocols

Interventions – 3 types
• Independent ( Nurse initiated )- any
action the nurse can initiate without
direct supervision
• Dependent ( Physician initiated )-
nursing actions requiring MD orders
• Collaborative- nursing actions
performed jointly with other health care
team members

Implemention
• The fourth step in the Nursing Process
• This is the “Doing” step
• Carrying out nursing interventions (orders)
selected during the planning step
• This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
• Utilize NIC as standard (NIC = nursing
intervention classification)

Implementation
• Putting your plan into action
• Set priorities after report
• Assess and reassess
• Perform interventions
• Chart client responses
• Give report to next shift

Implementation of Nursing
Interventions
• Describes a category of nursing behaviors in which the
actions necessary for achieving the goals and
outcomes are initiated and completed
• Action taken by nurse

Types of Nursing Interventions
• Protocols: Written plan specifying the procedures to be
followed during care of a client with a select clinical
condition or situation
• Standing Orders: Document containing orders for the
conduct of routine therapies, monitoring guidelines,
and/or diagnostic procedure for specific condition

Implementation Process involves:
• Reassessing the client
• Reviewing and revising the existing care plan
• Organizing resources and care delivery (equipment,
personnel, environment)

Implementing- “Doing”
• Monitor VS q4h
• Maintain prescribed diet (2
Gm Na)
• Teaching may be given to
client as well as family
members…state this in the
nursing interventions:
• Teach client amount of
sodium restriction, foods high
in sodium, use of nutrition
labels, food preparation and
sodium substitutes
• Teach potential
complications of
hypertension to instill
importance of maintaining
Na restrictions
• Specific handouts, dietary
consults etc all would be
included/given to the
patient
• Assess for cultural factors
affecting dietary regime

Implementing – “Doing”
• Teach the client-
hypertension can’t
be cured but it can
be controlled.
• Remind the client to
continue medication
even though no S/S
are present.
• Teach client
importance of life
style changes:
(weight reduction,
smoking cessation,
increasing activity)
• Stress the
importance of
ongoing follow-up
care even though
the patient feels well.

Evaluation- To determine
effectiveness of NCP
• Final step of the Nursing Process but
also done concurrently throughout client care
• A comparison of client behavior and/or
response to the established outcome criteria
• Continuous review of the nursing care plan
• Examines if nursing interventions are working
• Determines changes needed to help client
reach stated goals.

Evaluation
• Outcome criteria met? Problem resolved!
• Outcome criteria not fully met? Continue plan of care-
ongoing.
• Outcome criteria unobtainable- review each previous
step of NCP and determine if modification of the NCP is
needed.
• Were the nsg interventions appropriate/effective?

Evaluation
Factors that impede goal attainment:
• Incomplete database
• Unrealistic client outcomes
• Nonspecific nsg interventions
• Inadequate time for clients to achieve outcomes.

Checkpoint
Identify which stage of the nursing process
is being described below:
• The nurse writes nursing interventions
• A goal is agreed upon
• The nurse performs a physical assessment
• A revision is made to the NCP
• The nurse administers antibiotic medication
• A statement is written that outlines the clients
response to a potential health problem

Qs. 6 S and O Data Quiz Indicate
a. RR 22/min, even unlabored
b. “I can only walk 3 blocks before my legs start to hurt”
c. Pain rated 3 on a scale of 0-10
d. Skin pink, warm and dry
e. Urine output 300mL/8 hr
f. “My wife doesn’t come to visit very often”
g. Dressing clean, dry and intact.

questions
• The nurse records the following subjective data in the
client’s medical record:
• A.Breath sounds clear to auscultation
• B.Amber urine in sufficient quantities
• C.Pain intensity 8 out of 10
• D.Skin warm and dry

Questions
• When interviewing a client, the nurse uses the following open-
ended style sentence:
• A.Do you have any concerns right now?
• B.Is your family worried about you being in the hospital?
• C.How many times do you get up to go to the bathroom at night?
• D.What do you mean when you say, “I don’t feel quite right?”

Questions
In order for an actual nursing diagnosis to be valid it must
have one or more supporting:
• A.Laboratory results
• B.Diagnostic data
• C.Defining characteristics
• D.Medical diagnoses

Questions
Nursing diagnoses are aimed at identifying client
problems that are treatable by _______.
• A.The physician
• B.The nurse
• C.Invasive techniques
• D.Complementary strategies

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