lecture 3 Flashcards
steps of nursing process
assessment
diagnose
plan
implement
evaluate
assessment
subjective data
objetive data
subjective data
info reported by patient and family and documented in patient’s own words
objective data
can be seen or measured
physical examination
inspection and observation
palpation to assess parts of body
percussion
tapping on the skin to assess underlying tissues
auscultation
listening to sounds produced by the body using a stethoscope
medical diagnosis
process of determining which disease or condition explains a person’s symptoms and signs
PES format
p = problem
e = etiology or cause of the problem
s = signs and symptoms of the problem
intervention
actual performance of the nursing interventions in the plan of care
includes : direct patient care, health teaching, carrying out ordered medical treatment
evaluation
change, modify, or discontinue
used to determine of nurses have carried out the nursing process as documented in patient records
concept map
visual plan of care that illustrates the relationships between pathophysiology, signs, and symptoms
what should nursing documentation include
-all treatments and care, including medications
-procedures performed at bedside
- reactions to procedures
observations
-subjective and objective
-evidence of changes
-any unusual incidents
nurse notes
pages of narrative recordings containing data carried out by the nurse
flow sheets
graphs of vital signs or tables which nurses may check or initial boxes indicating activities or care provided
what format is charting done in
SOAPIER
s- subjective
o- objective
a- assessment
p- plan
i- intervention
e- evaluation
r- revision
what is the first step in the nursing process
assessment
inference
drawing conclusions
nursing process is…
assess
diagnose
plan
implement
evaluate
the interview consists of 3 basic stages
- opening
- body
- closing
what should medical charts include
-face sheet
-nurse’s notes
-physicians progress notes and history
- medication administration record
-surgery operative report
-diagnosis test
-nursing care plan
head to toe assessment
initial observation
-breathing
-how the patient is feeling
-general appearance
-skin color
-affect
head
-level of consciousness
-ability to communicate
-appearance of eyes
vital signs
-temperature
-pulse rate
-respiration
-blood pressure
heart and lungs
abdomen
extremities
tubes and equipment
As part of an assessment, the nurse asks for
information from the patient. This information is
a subjective indication of illness perceived by
the patient and is called a/an:
1) assessment
2) symptom.
3) sign
4) observation
- symptom
All of the following components can be found on
the chart except the:
1) face sheet
2) physician’s order
3) patient’s history and physical
4) patient’s nurse assignment.
4) patient’s nurse assignment
Linda knows as part of her nursing assignment
that she is to review and update the nursing
care plan on her patients:
1) hourly
2) every shift
3) every 24 hours.
4) weekly
3) every 24 hours
defining characteristics
problem statements and nursing diagnoses differ from medical diagnoses whereas medical diagnosis labels the illness
long term care
long term care facility begins the care planning process when patient is admitted
home health care
problem statements must include problems identified in family’s ability to cope with illness or situation
Which one of the following sets of assessment data is most
likely to be present with the nursing diagnosis Risk for
infection?
1) Fever, dysuria, change in urine concentration, and
urinary urgency
2) Abdominal pain, sore mouth, hyperactive bowel sounds,
and leukopenia
3) Fatigue, electrocardiographic changes, dependent
edema, and activity intolerance
4) Abdominal incision, decreased hemoglobin, and
indwelling catheter present.
4) Abdominal incision, decreased hemoglobin, and
indwelling catheter present.
short term goals
achievable within 7-10 days
long term goals
may take many weeks or months to achieve
A nurse has established expected outcomes for an assigned patient. The nurse carries out this
important activity for the purpose of:
1) evaluating the occurrence of complications.
2) measuring quality of care.
3) measuring the effectiveness of nursing interventions..
4) stopping care when outcomes are met.
3) measuring the effectiveness of nursing interventions..
interventions in clinical setting
constantly being reprioritized based on patient’s fluctuating situation and unit environment
implementing care
-expected to perform at standard of care listed in the procedure manual
-consider which interventions for a patient can be combined
-range of motion exercises may also be incorporated into the bath routine
During the implementation of the nursing process:
1) The planned nursing interventions are carried
out.
2) Reassessment of data is used to determine
whether the expected outcomes have been
achieved
3) Revision of the nursing care plan is performed
4) Goals are established for the patient
1) The planned nursing interventions are carried
out.
Before Ms. Bricker, LPN, carries out any interventions such as the administration of a
medication, she must know:
1) the reason for the intervention
2) the usual standard of care
3) the expected outcome
4) any potential danger
5) All of the above.
5) All of the above.
After Ms. Bricker, LPN, has given her patient medication, she returns later to the patient’s room to evaluate the effectiveness of the medication. She knows that in the
evaluation phase of the nursing process:
1) the nursing process has been completed.
2) she doesn’t need to revise the care plan if needs aren’t
met.
3) if the expected outcomes are considered met, the nurse’s notes must contain data to support this
4) there will be no further need for reassessment.
3) if the expected outcomes are considered met, the nurse’s notes must contain data to support this
Debbie, a student nurse, is learning about care plans. She knows all of the following are true regarding care plans
except:
1) the family and patient are invited to the care planning
2) the care plan for the home health patient encompasses
the needs and concerns of the family as well as the patient
3) an LPN is responsible for constructing the care plan.
4) students are required by most instructors to come to the
clinical experience with a nursing care plan in hand for
assigned patients
3) an LPN is responsible for constructing the care plan
Flora, an LPN, is helping her patient understand the side effects of a medication. This is what
type of action?
1) Independent.
2) Dependent
3) Interdependent
4) Evaluation
1) Independent
