Clinical Assessment Preparation

CPNE Study Guide

5. Nursing interventions. CAUTION!! These are also listed globally: • Can be assessment or corrective interventions • Use the patient’s Kardex to help determine the appropriate nursing interventions, such as instructing the patient to cough and breathe deeply every hour while awake • Gathering Assessment Data:  Use the patient record (e.g., flow sheets, MAR, narrative notes) • Use report information • Focus on the assigned areas of care from PCS Kardex • The Nursing Diagnosis:  3 parts: • NANDA diagnostic label • Contributing factors (related to) • Signs and symptoms (defining characteristics)  Ineffective peripheral tissue perfusion r/t sedentary lifestyle AEB decreased bilateral pedal pulses Nursing Care Plan Components:  Collect assessment data to validate nursing diagnosis  One nursing diagnosis (may not use acute pain, chronic pain, or a readiness nursing diagnosis)  Rationale for the selected nursing diagnosis, which explains why you chose this nursing diagnosis  Related factor explains what is causing or contributing to the nursing diagnosis  1 outcome statement per ND  2 interventions per outcome statement  Rationale for each nursing intervention explaining how each moves patient toward achievement of expected patient outcome • Nursing Diagnostic Labels:  One actual nursing diagnostic (ND) label • From the NANDA list of ND • Pertinent to the patient’s selected areas of competencies on the PCS Kardex • Use Maslow’s hierarchy of needs to help you prioritize your nursing diagnosis • Do not choose: Collaborative problem, medical diagnosis, risk for ND, readiness, or health-seeking behaviors (e.g., Decreased cardiac output, ineffective airway clearance, impaired skin integrity, etc.) •

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