NURS233 Exam 3 Nursing Process & Informatics
Chapter 15: Nursing Process - Assessment
Definition and Purpose of Nursing Assessment:
The systematic and continuous collection, analysis, validation, and communication of data.
It is the first step of the nursing process.
Data reflects the patient’s health status and responses to illness.
It creates a database used for care planning.
Characteristics of Nursing Assessments:
Purposeful: Focused on specific goals.
Prioritized: Addressing the most important problems first.
Complete: Ensuring all relevant data is collected.
Systematic: Following an organized approach.
Relevant: Applicable to the current situation.
Accurate and Factual: Based on objective and verifiable information.
Documented in a standard format.
Six Types of Nursing Assessments:
Comprehensive (Initial): Establishes a full database, performed upon admission.
Focused: Targets a specific problem (can be an ongoing or a new issue).
Emergency: Performed during life-threatening situations where priority is paramount.
Time-lapsed: Involves reassessment and comparison to baseline data.
Triage: Determines the urgency and severity of a condition (often done via phone or in Emergency Rooms).
Relationship Between Nursing Assessment and Medical Assessment:
Nursing Assessment Focus: Patient's responses to health problems.
Medical Assessment Focus: Identification of the disease or pathology.
Objective vs. Subjective Data:
Objective Data (Signs):
Observable and measurable.
Can be seen, heard, or felt by others.
Examples: Vital signs (, , etc.), temperature of , vomiting.
Subjective Data (Symptoms):
The patient’s personal experience.
Cannot be measured directly by another person.
Examples: Pain reported as , dizziness, nausea, feeling tired.
Sources of Patient Data:
Patient: The primary source.
Family/Significant others: Secondary sources.
Medical records and laboratory results.
Four Phases of a Nursing Interview:
Pre-introductory Phase: The nurse prepares by reviewing the chart and setting up a private environment.
Introductory Phase: The nurse introduces themselves, builds trust, and explains the purpose of the interview.
Working Phase: The nurse collects health information and patient history.
Termination: The nurse summarizes information, answers questions, and discusses the next steps.
Physical Assessment Methods:
Inspection: Deliberate, purposeful observation done in a systematic manner.
Palpation: Uses touch to assess temperature, texture, moisture, turgor, and vibrations.
Percussion: Tapping or striking to produce sound to assess underlying structures.
Auscultation: Listening with a stethoscope to internal body sounds (heart, lungs, bowel).
Data Validation and Privacy:
Data needs to be validated when subjective and objective data conflict (e.g., patient says "I'm fine" while grimacing).
Privacy, confidentiality, and professionalism are essential for data storage.
Nurses must know when to report significant data and ensure proper documentation.
Chapter 16: Nursing Process - Diagnosis
Overview and Purpose:
The second step of the nursing process.
Involves analyzing assessment data to identify problems.
Purposes: Identify patient responses to health conditions, determine etiologies (causes), and identify patient strengths/resources.
Steps of Data Interpretation and Analysis:
Recognize significant data by comparing it to normal values.
Identify patterns or clusters in the data.
Identify strengths and problems.
Identify potential complications.
Reach conclusions to determine the diagnosis.
Partner with the patient and family during this process.
Nursing vs. Medical Diagnoses:
Nursing Diagnosis:
Focus: Patient response to illness.
Can be treated independently by nurses.
Example: Activity intolerance related to decreased oxygen levels as evidenced by fatigue.
Medical Diagnosis:
Focus: Specific disease/pathology.
Managed primarily by a physician.
Example: Pneumonia.
Collaborative Problems: Situations requiring both nursing and medical interventions.
Writing Nursing Diagnoses (Three Components):
Problem: What is wrong.
Etiology: The cause, introduced by the phrase "related to."
Signs and Symptoms: Evidence, introduced by the phrase "as evidenced by."
Standard Formula: [Problem] related to [Cause] as evidenced by [Signs/Symptoms].
Example: Acute pain related to surgical incision as evidenced by patient reporting pain and guarding behavior.
Validation and Common Diagnostic Errors:
Validation: Ensure data is accurate, look for patterns, compare to normal research findings, and confirm the diagnosis can be treated by nursing interventions.
Common Errors: Diagnosing with incomplete data, misinterpreting data, using non-individualized (routine) diagnoses, and omitting important data.
Chapter 17: Nursing Process - Outcome Identification & Planning
Overview and Purpose:
The third step of the nursing process.
Involves planning what should happen and how to achieve it.
Goals: Establish priorities, identify expected patient outcomes, select evidence-based interventions, and communicate the care plan.
Establishing Priorities:
Based on Maslow’s Hierarchy of Needs:
Physiologic (Airway, Breathing, Circulation).
Safety.
Love/Belonging.
Self-esteem.
Self-actualization.
Priorities also consider patient preference, risk for complications, and clinical judgment.
Types of Planning:
Initial Planning: Done on admission by the nurse performing history and physical; develops the full care plan.
Ongoing Planning: Updates the plan as the patient changes; done by any nurse interacting with the patient.
Discharge Planning: Prepares the patient for home using teaching and counseling; starts at admission.
Patient Outcomes vs. Goals:
Goal: Broad, overall aim. Example: Improve patient understanding of medication regimen.
Outcome: Specific, measurable criteria. Example: Patient will correctly explain purpose, dosage, and timing of prescribed medication by the end of the teaching session.
Attributes of Good Outcomes:
Patient-centered.
Measurable and specific.
Based on nursing diagnoses.
Aligned with patient values (otherwise the plan is ineffective).
Writing Measurable Outcomes (Components):
Subject (the patient).
Verb (observable action).
Conditions.
Performance criteria.
Time frame.
Common Errors in Planning:
Writing outcomes as nursing actions instead of patient behaviors.
Using vague or non-measurable verbs.
Including multiple behaviors in one outcome.
Missing a time frame.
Chapter 18: Nursing Process - Implementation
Overview and Purpose:
The fourth step of the nursing process.
Involves carrying out the care plan to promote health, prevent disease, restore health, achieve outcomes, and support coping.
Clinical Reasoning and the Alfaro Rule:
The nurse must constantly check and adjust care for safety.
Assess before acting.
Reassess after intervention for changes in condition.
Alfaro Rule: Assess → Reassess → Revise → Record.
Types of Focus in Implementation:
Direct Care: Hands-on care (e.g., giving medication, checking vital signs).
Indirect Care: Care done away from the patient (e.g., updating the care plan).
Types of Nursing Interventions:
Nurse-initiated: Independent nursing actions (e.g., education, positioning, deep breathing exercises).
Physician-initiated: Provider orders carried out by the nurse (e.g., IV fluids, antibiotics, CT scans).
Collaborative: Actions shared with other healthcare professionals.
Protocols/Standing Orders: Standardized treatments.
Care Bundles: Grouped evidence-based interventions.
Five Rights of Delegation:
Right task.
Right circumstances.
Right person.
Right communication.
Right supervision/evaluation.
Delegation Guidelines:
Can Delegate: Routine tasks (e.g., stable patient vital signs, bathing) often assigned to Unlicensed Assistive Personnel (UAP).
Cannot Delegate: Assessments, nursing diagnoses, evaluations, or teaching; these require nursing judgment.
Barriers to Implementation:
Lack of understanding, low value placed on care, cost/access issues, side effects, or limited support systems.
Assessment vs. Therapeutic Intervention:
Assessment: Collecting info (e.g., listening to heart sounds, checking pulses).
Therapeutic Intervention: Treating/supporting the patient (e.g., giving oxygen, meds, rest).
Chapter 19: Nursing Process - Evaluation
Overview and Purpose:
The fifth step of the nursing process where the nurse and patient together measure goal achievement.
Purpose: Determine if outcomes were met, identify factors affecting progress, and modify the care plan.
Five Classic Elements of Evaluation:
1. Identify criteria and standards: Decide what the patient should achieve.
2. Collect evaluative data: Gather info on patient status.
3. Interpret and summarize findings: Compare results to expected outcomes.
4. Document judgments: Record if goals were "Met," "Partially Met," or "Not Met."
5. Terminate, continue, or modify care plan.
Types of Outcomes and Measurement:
Cognitive (Knowledge): Patient explains information (e.g., why they take BP medication).
Psychomotor (Skills): Patient demonstrates a skill (e.g., giving themselves insulin).
Affective (Attitudes): Patient expresses willingness or change in behavior (e.g., following a low-sodium diet).
Physiologic (Body changes): Physical data showing change (e.g., BP decreases to normal range).
Modifying the Care Plan:
If outcomes are not met, the nurse may modify the diagnosis, adjust outcome expectations, change interventions, or update time criteria.
Chapter 20: Nursing Process - Documentation & Reporting
Overview of Documentation and Reporting:
Documentation: Written or electronic record of care.
Reporting: Communication of patient information to others.
Rule: "If it’s not documented, it didn’t happen!!"
Purposes of Patient Records:
Communication, care planning, legal documentation, quality improvement, research, education, and reimbursement.
Characteristics of Effective Documentation:
Objective (no opinions), factual, concise, complete, accurate, timely, organized, and legally safe.
Confidentiality and HIPAA:
HIPAA protects patient privacy.
Confidential info: Diagnoses, treatments, history, personal identifiers (name, SSN, address).
Patient Rights: Access records, request updates, restrict disclosures.
Documentation Formats:
Source-oriented records: Organized by the source (labs, notes).
Problem-oriented medical records (POMR): Organized around patient problems.
PIE Charting: Problem, Intervention, Evaluation.
Focus Charting: Centers on patient concern, strength, or behavior.
Charting by Exception (CBE): Only abnormal/significant findings are documented; normal is assumed.
Electronic Health Records (EHRs): Digital records shared across providers.
Types of Reporting:
Shift handoff (SBAR).
Telephone/telemedicine reports.
Transfer/discharge reports.
Incident/variance reports.
Chapter 21: Informatics & Health Care Technology
Definition of Nursing Informatics:
Specialty combining nursing science, information science, and data technology.
ANA Definition: Uses data, information, knowledge, and wisdom to support nursing practice.
System Development Life Cycle (SDLC) Steps:
1. Analyze & plan.
2. Design & build.
3. Test.
4. Train users.
5. Implement.
6. Maintain.
7. Evaluate.
Important Concepts:
System Usability: Efficiency of the system.
Interoperability: Ability of different health systems to "talk to each other."
Standardized Terminology: Consistent language for data interpretation.
Telehealth vs. Telemedicine:
Telehealth: Long-distance healthcare (education, administration). Example: Virtual diabetes class.
Telemedicine: Remote clinical care, usually by physicians/NPs. Example: Video visit to prescribe antibiotics.
Patient Portals: Allow viewing records, labs, messaging providers, and scheduling.
Questions & Discussion
Group Presentations: Total of questions on the exam will come from group presentation topics.
Practice Questions:
Question 1: Which action represents subjective data collection?
Answer: Asking the patient to rate pain.
Rationale: Subjective data is what the patient reports; objective data (BP, lung sounds, skin color) is observable by the nurse.
Question 2: Which is an example of a nursing diagnosis?
Answer: Impaired gas exchange.
Rationale: Nursing diagnoses describe responses nurses treat independently; pneumonia and diabetes are medical diagnoses.
Question 3: Which patient should the nurse assess first?
Answer: Patient with oxygen saturation of .
Rationale: Physiological needs (ABC - Airway, Breathing, Circulation) are highest priority per Maslow.
Question 4: Which outcome is correctly written?
Answer: Patient will verbalize three foods allowed on a diabetic diet by discharge.
Rationale: Outcomes must be specific, measurable, behavior-based, and time-bound.
Question 5: Which task is appropriate to delegate to a UAP?
Answer: Taking vital signs on a stable patient.
Rationale: Assessment and evaluation must be done by the nurse.
Question 6: A patient goal was to ambulate , but they walked . How is this documented?
Answer: Partially met.
Question 7: Which action violates confidentiality?
Answer: Texting patient information to a coworker’s personal phone.
Question 8: Which example represents telehealth?
Answer: Provider assessing a patient via video call.
Question 9: What should the nurse do if a patient says "I'm fine" while grimacing?
Answer: Validate the data.
Rationale: Validation is needed when subjective and objective data conflict.
Question 10: Example of nurse-initiated intervention?
Answer: Teaching deep breathing exercises.
Rationale: This is an independent action within the nursing scope.
Question 11: Most appropriate documentation?
Answer: Patient states pain is and grimaces with movement.
Rationale: Documentation should be objective and factual.
Question 12: ER brief assessment to determine severity?
Answer: Emergency assessment (Triage).
Question 13: Which is objective data?
Answer: Temperature of .