PNR 104 Exam 2 (Answered) Verified Solution

PNR 104 Exam 2 (Answered) Verified Solution Steps of the nursing process in order Assessment, nursing dx, planning, implementation, and evaluation Assessment and nursing DX RN's are responsible for this part of the nursing process Data Collection LPN's main role in nursing process Documentation of the plan Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs.) Problem solving process steps define the problem clearly, consider all possible alternatives as solutions to the problem, consider the possible outcomes for each alternative, predict the likelihood of each outcome occurring, choose the best alternative with the fewest undesirable outcomes. A medical diagnosis is never included in a nursing diagnosis True (example: stroke, MI) Nursing diagnosis = problem + etiology +signs and symptoms Etiology causes of the problem Defining characteristics characteristics that must be present for a nursing DX Constructing a nursing care plan assess the pt, analyze the data, identify nursing problems, prioritize, make goals, write expected outcomes, and choose interventions. purposes of charting written record of history, treatment, care, claims for reimbursement, and evidence in court 6 main methods of documentation source-oriented (narrative) charing, problem oriented medical record charting (POMR) focus charting, charting by exception, computer assisted charting, and case management system charting. source oriented charting (narrative) narrative notes are phrases and sentences written without any standardized structure. benefits of this method are that it gives info on pt condition in chronological order, indicates pt baseline for each shift, and includes aspects of all steps in the nursing process POMR focuses of patient status, emphasizing a problem solving approach. contains 5 steps - the data base, problem list, plan, progress note, and the discharge summary. This format is known as a SOAP(IE) note. s- subjective o - objective a- assessment p- plan i- implementation e- eval focus charting