NURSING NUR1212 test 1 Fall 2023 with complete solution

NURSING NUR1212 test 1 Fall 2023 with complete solution Assessment - First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification. Yes, but it is the nurses responsibility to assign and validate data collected and complete physical assessment - Can I delegate an assessment? subjective data and objective data - Types of data subjective data - Info communicated by the nurse by pt. ( what the pt says ) objective data - what the health professional observes during physical exam or diagnostic tests Vital signs and urine output - Ex. Of obj data primary data - Subjective and Objective info obtained directly from the client in wha client says or what you observe. secondary data - Obtained secondhand ex from the medical record or from another caregiver Initial and ongoing assessments - When you gather as much information as possible Initial assessment is database Ongoing is patient progress comprehensive assessment - health history and complete physical examination, usually conducted when a patient first enters a health care setting; provides a baseline for comparing later assessment Example where do you live ,do you smoke ,religious views focused assessment - assessment conducted to assess a specific problem; focuses on pertinent history and body regions Special needs assessment - A type of focused assessment, provides in depth information about a particular area of client functioning and often involves using a specially designed form Nutritional assessment, pain assessment, cultural assessment, wellness assessment, family assessment - Types of special needs assessments Functional ability assessment - Health problems and normal aging changes often bring a decline in functional status. Functional ability is especially important in discharge planning and home care. Biographical data, chief complaint, history of present illness, clients perception of health status, past health history, social history, medication history - Health history should include Tool for recording assessment data - Graphic flowsheet, intake and output sheet, nursing Admission assessment, nursing discharge summary, special purpose forms, electronica documentation diagnosis - Analyze and interpret data, draw conclusions, verify conclusions, write diagnostic statement, prioritize problems Actual medical diagnosis - PROBLEM THAT IS PRESENT A problem that exists at the time of the assessment example constipation risk (potential) nursing diagnosis - PROBLEM MAY OCCUR A problem that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it there are no signs or symptoms of the problem, but the risk factors are present that increase the patient's vulnerability Possible nursing diagnosis - A PROBLEM MAY BE PRESENT When your intuition and experience direct you to suspect that a diagnosis is present but you do not have enough data to support the diagnosis. Example: maybe be constipated syndrome nursing diagnosis - SEVERAL RELATED PROBLEMS ARE PRESENT Represents a collection of nursing diagnosis that usually occur together wellness nursing diagnosis - NO PROBLEM IS PRESENT describes a health status but does not describe a problem can apply to an individual family group or community Steps to analyzing and interpreting data - Step one identify significant data step two cluster cues step three identify data gaps and inconsistencies Identify significant data - Influence your conclusions about the clients health status. Usually or unhealthy responses Cluster cues - A cluster is a group of cues that are related to each other in someway. The cluster may suggest a health problem to help ensure accuracy you should always drive a nursing diagnosis from data clusters rather than from one single Cue. Identify Gaps and Inconsistencies - As you cluster and think about relationships among the cues you were identify the need for data that were not previously apparent Inferences - Nursing diagnosis are inferences and are only your reasoned judgment about a patient's health status Draw conclusions about health status - Make inferences and identify a problem etiology Maslow's Hierarchy of Needs - (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization Syndrome diagnosis are usually written as - A label that represents a collection of several nursing diagnosis wellness diagnosis - As a rule this is a one part statement beginning with the phrase readiness for enhanced. A wellness label does not describe a problem so there is no etiology Actual diagnosis - The etiology consist of related factors risk diagnosis - The etiology consist of risk factors possible diagnosis - The etiology consist of the patients cues which are not complete enough to diagnose The etiology consist of the patients cues which are not complete enough to diagnose - Planning - A professional nurse is responsible for care planning and cannot delegate it. Planning can be formal or informal Formal Planning - conscious, deliberate activity involving decision-making, critical-thinking, and creativity Work with the patient and family to do Rob design outcomes from identify problems Identify nursing interventions to help achieve those outcomes informal planning - occurs while you are performing other nursing process steps Must have accurate complete assessment data Need correctly identified and prioritize nursing diagnosis - How is planning related to other steps of the nursing process initial planning - Begins with the first patient contact. It refers to the development of the initial comprehensive care plan which should be written as soon as possible after the initial assessment ongoing planning - Refers to changes made in the plan as you evaluate the patient's responses to care or as you obtain new data and make new nursing diagnosis discharge planning - The process of planning for self-care and continuity of care after pt leaves a healthcare setting The purpose of discharge planning is to promote the patient's progress toward health And to reduce readmissions to hospitals Initial Assessment - Discharge planning begins at Comprehensive care plans include directions for four different kinds of care and include both medical and nursing interventions Basic needs and activities of daily living ADL Medical treatment Nursing diagnosis and collaborative problems Special discharge needs or teaching needs - What information does a comprehensive nursing care plan contain Standardized nursing care plans - Detail nursing care for a particular nursing diagnosis; for all nursing diagnoses that commonly occur with a certain medical condition 1. Make a working problem list 2. Determine which problems can be managed with standardized care plans or critical pathways 3.Individualize the standardized plan is needed 4. Transcribe medical orders to appropriate documents 5. Right ADLs in basic care needs in the patient care summary 6. Develop individualized care plans for problems not addressed by standardized documents - What is the process for writing an individualized nursing care plan Subject. The subject is understood to be the client but it can also be a function or part of the client Action verb. Use an action verb to indicate what activity the Pt Will preform Performance criteria. These describe the extent to which you expect to see the action or behavior using concrete observable terms Target time. This is the realistic day or time by which the client should achieve the performance or behavior Special conditions. Special conditions describe the amount of assistance needed for the client - What are the components of a goal statement Nursing interventions are actions based on clinical judgment and nursing knowledge that nurses perform to achieve Client outcomes - What are nursing interventions Direct care interventions - treatments performed through interactions with patients Indirect care interventions - Treatments performed away from the patient but on behalf of the patient or group of patients Independent interventions - activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills dependent interventions - One that is prescribed by a physician or Advance practice nurse they carried out by the nurse Dependent interventions are usually prescriptions for diagnostic test, medications, treatments, diet and activity Independent collaborative interventions - One that is carried out in collaboration with other healthcare team members Review the nursing diagnosis Review the desired patient outcomes Identify several interventions or actions Choose the best intervention for the patient Individualize standardized interventions - What process can I use for generating and selecting interventions Review the nursing diagnosis - Choose strategies you expect overdose or remove the etiology factors that contribute to actual problems When is it not possible to change the etiology When you do not know the etiology of the problem Review the desired patient outcomes - Desired outcomes suggest nursing strategies that are specific to the individual patient Identify several interventions or actions - The next step is to think of several nursing activities that might achieve the desired outcomes Date, subject, action verb, times and limits, signature - Components of a nursing order implementation phase - Implementation involves action During implementation you perform or delegate plan interventions carry out the care plan Implementation Evolves into evaluation as you document the resulting client responses Clarify orders. As a nurse you are obligated ethically and legally to clarify or question orders that you believe to be incorrect Be sure you are qualified. Do you have the required knowledge? Can you except accountability for the outcomes of your action? Be sure the action is safe reasonable and prudent. - Check your knowledge and abilities You must work efficiently in order to control healthcare costs in to make the most of every patient contact - Organize your work Before performing a nurse activity identify and reassess the patient to make sure the activity is still necessary and the patient is physically and physiologically ready for the intervention Check your assumptions. Don't assume that an intervention is still needed simply because it is written on the car plan Assess the patient's readiness. To obtain the most benefit from an intervention a client must be physically and physiologically ready Explain what you will do in with the patient will feel Pr