foundations ch 5 part 2

What is an acute problem?

A health problem with rapid onset and limited duration that may become chronic if unresolved.

What is a chronic problem?

A health problem that is always present or recurs and usually lasts 3 months or longer.

Give an example of an acute problem.

Recent onset of pain.

Give an example of a chronic problem.

Prolonged pain.

What are contributing (related) factors?

Conditions involved in the development of a patient problem.

How are contributing factors written in a nursing diagnosis?

Using "related to" (r/t).

What is an example of a nursing diagnosis using "related to"?

Potential for Pressure Injury r/t lack of mobility and refusal to get out of bed.

What are defining characteristics?

Clinical cues, signs, and symptoms that support a nursing diagnosis.

How are defining characteristics written in a nursing diagnosis?

Using "as evidenced by" (AEB).

What is an example of a nursing diagnosis using AEB?

Infrequent or Difficult Bowel Elimination r/t insufficient fluid intake AEB no bowel movement for 5 days and straining.

What is data clustering?

Grouping related assessment findings to identify patterns and patient problems.

What assessment findings suggest inability to control urination due to physical stress?

Urine loss with exertion.

What assessment findings suggest inability to tolerate activity?

Abnormal blood pressure, increased heart rate, and fatigue.

What is an actual patient problem?

An existing health problem written as a three-part statement: problem, related factors, and defining characteristics.

What is an example of an actual patient problem?

Infrequent or Difficult Bowel Elimination r/t insufficient fluid intake AEB straining with defecation.

What is a potential patient problem?

A health problem that has not occurred but is likely to develop; written as a two-part statement.

What is an example of a potential patient problem?

Potential for Compromised Skin Integrity r/t physical immobilization.

What is outcome identification?

The phase of the nursing process where patient-centered goals are developed.

Who develops patient goal statements?

The nurse collaborates with the patient.

What should patient goals describe?

Specific, measurable behaviors the patient will achieve within a set time.

Why are patient goals important?

They guide nursing interventions and evaluate the effectiveness of care.

What should be the subject of every patient goal?

The patient or a part of the patient.

What type of verbs should patient goals use?

Measurable action verbs such as define, describe, walk, demonstrate, or verbalize.

How should patient goals relate to the patient's condition?

They should be specific, realistic, patient-centered, and not conflict with the medical plan of care.

What must every patient goal include?

A time frame for evaluation.

How do patient goal statements usually begin?

"The patient will…" or "The patient's… will…"

What should a patient goal accomplish?

It should show reversal or improvement of the nursing problem.

Give an example of a patient goal.

Patient will have intact skin within 3 weeks.

What is a long-term goal?

A broad desired outcome achieved over weeks or months.

Give an example of a long-term goal.

Patient will use a walker instead of a wheelchair within 2 months.

What is a short-term goal?

A specific measurable step toward achieving the long-term goal.

Give an example of a short-term goal.

Participate in lower extremity range-of-motion exercises twice daily.

Give another example of a short-term goal.

Ambulate 20 feet daily, increasing 5 feet each day with walker assistance.

What is the purpose of the planning phase?

To establish priorities, select nursing interventions, ensure continuity of care, and use evidence-based practice.

Why should patients and families be involved in planning?

Their participation increases motivation and helps prioritize care according to their needs and preferences.