What is composed in the nursing process? Correct Answer-assessment,
diagnosis, planning, implementation, and evaluation
Assessment stage Correct Answer-Gathering Subjective and Objective
Data.
1. health history
2. physical assessment
3. relevant information from family, healthcare team, medical record
4. recording data in EHR
Diagnosis stage Correct Answer-Analysis, Prioritizing Problems
1. based on collection and analysis of assessment data
2. identify actual or potential health problems 3. NOT medical diagnosis
(some) are collaborative problems
Examples: impaired skin integrity, impaired physical mobility,
dehydration, anxiety, confusion, risk for falls, impaired elimination
Planning Correct Answer-Generate Solutions
1.Prioritization
a.) Maslow's Hierarchy is a basic method (bottom to top)
Physiologic needs
Safety and security
Belongingness and affection
, Esteem and self-respect
Self-actualization
2. ABC's (airway, breathing, circulation)
3. Determine nursing action: plan interventions to move the patient
toward the goals
4. Establish expected patient outcomes (SMART goals)
a.) Specific, measurable, attainable, relevant, timely
Implementation Correct Answer-Taking Action
1. Carry out the plan of care
2. Goals are focus
3. "ongoing assessment"
4. Make revisions when necessary
5. All interventions should be patient-focused
Evaluation Correct Answer-1. The step where the nurse evaluates
whether the goals have been met
2. Decide to continue with goal, close goal, or modify
Risk factors for Malnutrition or Impaired Nutrition Correct Answer--
Dental problems
-NPO
-Prolonged use of IVF
-N/V/ Diarrhea