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A comprehensive overview of the nursing process, a systematic problem-solving approach used in nursing practice. It covers key concepts such as assessment, diagnosis, planning, implementation, and evaluation, with examples and explanations. The document also explores different types of nursing diagnoses, including actual, risk, and wellness diagnoses, and discusses the importance of validating data and interpreting cues. It further delves into the concept of goals, both short-term and long-term, and the different types of nursing interventions, including independent, dependent, and interdependent interventions. The document concludes with a discussion on documentation, delegation, and handoffs, highlighting the importance of accurate and timely communication in nursing practice.
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Nursing process - answer - a systematic problem-solvingprocess that guides all nursing actions Assessment - answer- the systematic gathering of information related to the physiological, psychiological, sociocultural, devlopmental, and spiritual status of anindividual, group, or community. What is the purpose of an assessment? - answer - obtaindata to allow you to help the patient Where do we get Primary sources from? - answer- Subjective and Objective Where do we get secondary sources from? - answer- Family/friends, health record, healthcare team Subjective Data (Client States) Objective Data (Nurse observes) - answer-" My throathurts when i swallow" Parenteral - answer - any route other than through thealimentary canal (passage from mouth to anus) IV therapy - answer- the administration of fluids, electrolytes,
medications, or nutrients by the venousroute What type of technique is used every time you start (initiate) or work with (maintain) an IV site or infusion?
What happens to the $$ your facility receives if a clientin your care gets a CRBSI (catheter releated bloodstream infection)? - answer- The hospital must pay Lab value for serum osmolality - answer - 275 - 295 Primary source ( Client states or Nurse Observes) Secondarysource (everything else) - answer-" My heartfeels like it's beating fast" "I am feeling short of breath at night"
norms (oral temp of 103)
stays up late partying and sleeps most of teh day. Despite a previous close relationship with her parents,she barley talks to them when they contact her.
Suppose that Todd tells you that he prays, participates in religious actvities, and trusts in God, but he would liek to feeel eve closer to God. He asks to meet with the minster from his church. You might make diagnosis of Readiness for Enchanched Spiritual Well-Being is what type of diagnosis?
Medical diagnosis - answer-describes a disease, illness,or injury Todd (Meet Your Patient) has two medical diagnosis :chronic renal failure and type 2 DM
Nursing Diagnosis - answer-Identifies client response tohealth problem Collaborative Problems - answer-Working on problemas a team (Nurse, PT, Doctor, NP)
Suppose that on Todd's transfer from the ED (Meet Your Patient), you made the follwoing nurisng diagnosisfor him. Using problem urgency as your criterion, assign each of these diagnosis a low medium, or high priority.
goals- Long term goals- - answer-those you expect the patientto achieve within a few hours or days are changes in health status that you wish to achieveover a longer period of time What type of goal is this - describe pain as <3 on a 1 - 10 scale within 30 min after recieving analesic
What type of goal is this- Limits food intake to 1,500calories per day
every 6 hours for 24 hours. " She prepares and administers themedication
Interdependent - answer-one that is carried out incollaboration with other health team members (physcial therapists, physicians) Nurse C notes that a client newly diagnosed with diabetes has been seen by a dietitian, who taught andpro vided materials about a diabetic diet. The nurse observes the clients's menu chocies. She notes that theclient is eating candy brought by visitors. She explains to the client how concentrated sugar affects his diabetes; she also communicates her assessments and teaching to the dieitian.
Documentation - answer-the act of recording patientstatus and care Delegation - answer-transfer of responsibility NOTaccountability for outcome Occurrence report - answer-incident report, is a formalrecord of an unusual occurrence or accident.
Standard techniques for documentation
For TO order what must you do
F. Order co-signed - answer-all the above What are the steps in a nursing process? - answer-Assess, Diagnose, Plan, Implement, Evaluate Once a nurse accesses a client's condition andidentifies appropriate nursing diagnosis, a A. Plan is developed for nursing care B. Physical assessment begins C. List of priorities is determined D. Review of assessment is conducted with other team members - answer- A. Plan is developed for nursing care Planning is a category of nursing behaviors in which:
goals and expected outcomes are established Priorities are establish to help the nurse anticipate andsequence nursing interventions when a client has multiple problesm or alterations. Priorities are determined by the clinet's:
A client centered goal is a specific and measurablebehavior or resposne that reflects a client's:
answer-B. Highest possible level of wellness and independence in function Collaborative interventions are therapies that require:
about. - answer-4. Ask the client if thereis anything in particular he or she is anxious about. Which describes the correct way to state a nursingdiagnosis?
phrase
phrase - answer-3. A problem and an etiology linked by a connecting phrase Which are examples of a direct-care nursingintervention? Select all that apply.
According to Maslow's Hierarchy of Needs, what is theappropriate order of priority of the client needs?
When creating a care plan, which describes outcomesthat can be influenced by nursing interventions?
Which nursing interventions are considered direct-careinterventions? Select All That Apply.
The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursingplan?
During an assessment, the nurse notes that the clienthas an elevated temperature. Which type of data is this?
Which describes benefits of the comprehensive writtennursing care plan?
Select all that apply.
Why is the diagnosis step critical to the nursingprocess?
and follow-up evaluation.
the hospital.
diagnosis.