NSG 122 Fundamentals Exam with correct response I Blueprint 2024

Standards of Nursing Practice 1. Standards allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where health care is provided. Each nurse is accountable for his or her own quality of practice and is responsible for the use of these standards to ensure knowledgeable, safe, and comprehensive nursing care. a. Standard 1. Assessment i. The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation. b. Standard 2. Diagnosis i. The registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues. c. Standard 3. Outcomes Identification i. The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation. d. Standard 4. Planning i. The registered nurse develops a plan that prescribes strategies and alternatives to attain expected, measurable outcomes. e. Standard 5. Implementation i. The registered nurse implements the identified plan. f. Standard 5a. Coordination of Care i. The registered nurse coordinates care delivery. g. Standard 5b. Health Teaching and Health Promotion i. The registered nurse employs strategies to promote health and a safe environment. h. Standard 6. Evaluation i. The registered nurse evaluates progress toward attainment of goals and outcomes. Nurse Practice Act: describes and defines legal boundaries of practice within each state 1. Licensed by state – compact states / apply and pay fee for other state license 2. License can be revoked for criminal, AODA Code of Ethics Five values that epitomize the caring, professional nurse: 1. altruism 2. autonomy 3. human dignity 4. integrity 5. social justice Nursing Process Steps 1. Systematically collect patient data (assessing) 2. Clearly identify patient strengths and actual and potential problems (diagnosing) 3. Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning) 4. Execute the care plan (implementing) 5. Evaluate the effectiveness of the care plan in terms of patient goal achievement (evaluating) Teaching A. make a judgment about a person's health status, ability to manage his or her own need for self-care, and the need for nursing care. B. plan and deliver thoughtful, person-centered nursing care that draws on the person's strengths and promotes optimum functioning, independence, and well-being. C. refer the patient to a provider or other health care professional, if indicated. Types of Assessments: Definitions and timing 1. Initial a. performed shortly after the patient is admitted to a health care facility or service. Purpose is to establish a complete database for problem identification and care planning. The nurse collects data concerning all aspects of the patient's health, establishing priorities for ongoing focused assessments, and creating a reference baseline for future comparison 2. Client Centered a. Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions 3. Focused a. the nurse gathers data about a specific problem that has already been identified. Helpful questions include: i. What are your signs and symptoms? ii. When did they start? iii. Were you doing anything different than usual when they started? iv. What makes your symptoms better? Worse? v. Are you taking any remedies (medical or natural) for your symptoms? 4. Time lapsed a. scheduled to compare a patient's current status to the baseline data obtained earlier. Periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the care plan. This assessment can be comprehensive or focused. 5. Emergency a. to identify life-threatening problems Subjective vs Objective data 1. Subjective: Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. “My leg hurts when I walk / I have a headache.” 2. Objective: Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), skin that is moist, and refusal to look at or eat food. Collecting and validating data Validation is the act of confirming or verifying. The purpose of validating is to keep data as free from error, bias, and misinterpretation as possible. Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Nursing Assessment: definitions and examples of each 1. Inspection: the process of performing deliberate, purposeful observations in a systematic manner 2. Palpation: use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body 3. Percussion: the act of striking one object against another to produce sound 4. Auscultation: the act of listening with a stethoscope to sounds produced within the body Planning Care: Analyzing and Interpreting Data: 1. Recognizing Significant data a. nurses must be familiar with comparative standards to be used in data interpretation and analysis / normative standards and patient-based b. Changes in a patient's usual health patterns that are unexplained by expected norms for growth and development c. Deviation from an appropriate population norm d. Behavior that is nonproductive in the whole-person context e. Behavior that indicates a developmental lag or evolving dysfunctional pattern 2. Recognizing patterns a. A data cluster is a grouping of patient data or cues that point to the existence of a health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. 3. Recognizing potential problems a. A person who does not meet a certain health standard probably has a limitation in that area and may benefit from professional care b. Recognize potential problems or complications that may arise for patient; managing ADLs, diet, medicines, therapies – what they can use help with 4. Identifying strengths patient motivation a. A person with a history of maintaining a well-balanced diet is usually better able to cope with illness than a person who has a history of eating poorly Discussing observed strengths with patients and counseling patients about ways to develop and use their strengths are important nursing measures. Nursing Diagnosis: Definition A. A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community. B. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. C. A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well- being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors and can be used in any health state. Nursing Diagnosis Statement 1. Problem statement: describes the health state or health problem of the patient as clearly and concisely as possible. Because this section of the nursing diagnosis identifies what is unhealthy about the patient and what the patient would like to change in his or her health status, it suggests patient outcomes. 2. Etiology: identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. Defining characteristics: subjective and objective data that signal the existence of the actual or possible health problem are the third component of the nursing diagnosis. Nursing Process/ Care Planning: Planning/Outcome identification 1. The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient's health expectations, as identified in the patient outcomes a. Establish priorities b. Identify and write expected patient outcomes c. Select evidence-based nursing interventions d. Communicate the nursing care plan 2. A goal is an aim or an end. A patient outcome is an expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation. The words goal, objective, and outcome are often used interchangeably. In some practice settings, the term goal or objective is used to describe what is wanted, and the term outcome is used to describe the results achieved. 3. Examples a. postoperative patient is complaining of incisional pain; she quickly reshuffles priorities to allow time to assess the course and qualities of the pain, and to determine nursing measures to reduce discomfort b. nurse has not seen a particular father hold his new daughter; he makes a mental note to observe the father–daughter interactions that evening and facilitate their bonding 4. Establishing priorities Nursing Process/ Care Planning: Definitions 1. Initial Planning: performed by the nurse with the admission nursing history and the physical assessment. This comprehensive plan addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care 2. Standardized Planning: prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. 3. Ongoing Planning: carried out by any nurse who interacts with the patient. Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the patient uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective Discharge Planning: carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources. Careful planning ensures that the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently. Maslow's hierarchy of human needs: related to Patient Care: Steps 1. Physiologic needs 2. Safety needs 3. Love and belonging needs 4. Self-esteem needs 5. Self-actualization needs ***Pain/discomfort / Patient preference Nursing Process/ Care Planning: Goals Whether short or long term, patient goals need to be patient centered and based on patient’s own baseline and current level of ADLs etc. 1. Short Term Goals a. Short period, end of shift b. Whenever observed, patient will report that comfort measures and medication are satisfactorily managing pain. 2. Long Term Goals a. Longer period, more than a week b. Patient returns to the long-term care facility pain free with her incision healed and her left leg in good alignment. Nursing Process/ Care Planning: Intervention --- cause of the problem (etiology) suggests the nursing interventions--- 1. Nurse Initiated Interventions: autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes a. Monitor patient health status and response to treatment b. Reduce risks