NRSG 2220 FINAL EXAM WITH ACCURATE
SOLUTIONS 100% VERIFIED
Nursing Process
Assessment, diagnosis, planning, implementation, evaluation
SBAR
Situation, background, assessment, recommendation
Situation (SBAR)
Identify self, unit, patient, and room number. Briefly state problem, when it happened,
and severity.
Background (SBAR)
Admitting dx, current meds/allergies, VS, labs, code status
Assessment (SBAR)
Nurses assessment of situation
Recommendation (SBAR)
Nurses recommendation (order change, see pt now, admittance notification)
Nursing diagnosis
A clinical judgment concerning a human response to health conditions/life processes, or
a judgment related to a human's vulnerability for that response. Nursing diagnosis
provides the foundation for selecting nursing interventions to attain outcomes for which
the nurse is accountable
,Medical diagnoses
describe problems for which the physician or advanced practice nurse directs the
primary treatment. A medical diagnosis remains the same for as long as the disease is
present, whereas patient problems may change daily as the patient's responses change
SMART goals
Specific, measurable, attainable, realistic, time bound
Cognitive Outcome
Describes an increase in patient's knowledge, intellectual behaviors
Psychomotor Outcome
describes the patient's achievement of a new skill
Affective Outcome
Describe the patient's changes in values, beliefs, and attitudes
Clinical Outcome
Describes the expected status of health issues at specific points in time after treatment
is complete; addresses whether or not problems have been resolved or to what degree
they have improved
Functional Outcome
Describes the person's ability to function with the desired usual activity
Quality-of-Life Outcome
Focus on critical factors that affect someone's ability to enjoy life and achieve personal
goals
, Initial Planning
Carried out by the nurse through the admission nursing history and physical
assessment
Identifies appropriate patient goals and the related nursing care
Standardized planning
Prepared care plans for specific nursing diagnoses, outcomes, and related nursing
interventions common to a particular problem or health problem provide a solid
foundation for the initial plan - allow the nurse to spend time individualizing the plan
Ongoing Planning
Carried out by any nurse who interacts with the patient
The purpose is to maintain the plan current to support the solution of health problems,
control of risk factors and promotion of functionality.
Standardized medical conditions or procedures may lead to new nursing
diagnoses/problems, individualization required to meet a unique patient's needs
Discharge Planning
Starts on admission!
Performed by the nurse who has spent most time with pt
"Ensures that the nurse uses teaching and counseling skills effectively to help the
patient and family develop sufficient knowledge of the health problem and the
therapeutic regimen to carry out necessary self-care behaviors at home competently
Short term goals/outcomes
Can be achieved in less than a week, temporary and specific
Long term goals/outcomes
>week, focus on comprehensive care, may be used as discharge goals
SOLUTIONS 100% VERIFIED
Nursing Process
Assessment, diagnosis, planning, implementation, evaluation
SBAR
Situation, background, assessment, recommendation
Situation (SBAR)
Identify self, unit, patient, and room number. Briefly state problem, when it happened,
and severity.
Background (SBAR)
Admitting dx, current meds/allergies, VS, labs, code status
Assessment (SBAR)
Nurses assessment of situation
Recommendation (SBAR)
Nurses recommendation (order change, see pt now, admittance notification)
Nursing diagnosis
A clinical judgment concerning a human response to health conditions/life processes, or
a judgment related to a human's vulnerability for that response. Nursing diagnosis
provides the foundation for selecting nursing interventions to attain outcomes for which
the nurse is accountable
,Medical diagnoses
describe problems for which the physician or advanced practice nurse directs the
primary treatment. A medical diagnosis remains the same for as long as the disease is
present, whereas patient problems may change daily as the patient's responses change
SMART goals
Specific, measurable, attainable, realistic, time bound
Cognitive Outcome
Describes an increase in patient's knowledge, intellectual behaviors
Psychomotor Outcome
describes the patient's achievement of a new skill
Affective Outcome
Describe the patient's changes in values, beliefs, and attitudes
Clinical Outcome
Describes the expected status of health issues at specific points in time after treatment
is complete; addresses whether or not problems have been resolved or to what degree
they have improved
Functional Outcome
Describes the person's ability to function with the desired usual activity
Quality-of-Life Outcome
Focus on critical factors that affect someone's ability to enjoy life and achieve personal
goals
, Initial Planning
Carried out by the nurse through the admission nursing history and physical
assessment
Identifies appropriate patient goals and the related nursing care
Standardized planning
Prepared care plans for specific nursing diagnoses, outcomes, and related nursing
interventions common to a particular problem or health problem provide a solid
foundation for the initial plan - allow the nurse to spend time individualizing the plan
Ongoing Planning
Carried out by any nurse who interacts with the patient
The purpose is to maintain the plan current to support the solution of health problems,
control of risk factors and promotion of functionality.
Standardized medical conditions or procedures may lead to new nursing
diagnoses/problems, individualization required to meet a unique patient's needs
Discharge Planning
Starts on admission!
Performed by the nurse who has spent most time with pt
"Ensures that the nurse uses teaching and counseling skills effectively to help the
patient and family develop sufficient knowledge of the health problem and the
therapeutic regimen to carry out necessary self-care behaviors at home competently
Short term goals/outcomes
Can be achieved in less than a week, temporary and specific
Long term goals/outcomes
>week, focus on comprehensive care, may be used as discharge goals
