Assessment
Completed shorty after admission to facility to establish database for problem identification and care planning.
What is initial assessment?
Hypertension, osteoarthritis and diabetes
What are medical diagnoses?
Takes into consideration patient and nurse capabilities, time and resources.
What is planning?
Repositioning and assistance with ADLs.
What is a nurse initiated intervention?
Last step of the nursing process.
What is evaluation?
Reassessment of a pressure ulcer over a period of time.
What is a time lapsed assessment?
Identification of how an individual, group or community responds to actual or potential health problems.
What is purpose of diagnosing analyzing?
Initiated when the patient is first admitted.
What is initial planning?
Administration of antihypertensive medication.
What is a physician initiated intervention?
Cognitive, psychomotor, affective and physiologic.
What are ways to evaluate outcomes?
Preparing for data collection, collecting data, identifying cues and making inferences, validating data, clustering data/identifying patterns, recording/reporting data.
What is assessing?
Identifies the factors that are maintaining the unhealthy state or response (causative or contributing factors).
Why is etiology?
Addresses each problem identified and prioritized (data obtained during assessment)
What is comprehensive assessment?
Act in partnership with the patient/family, approach patient caringly and competently, reassess to determine if action still needed and modify nursing interventions.
What are implementation guidelines?
Patient, nurse and healthcare system.
What are variables affecting outcome achievement?
Purposeful, prioritized, complete, systematic, factual/accurate relevant and recorded.
What are characteristics of a nursing assessment?
Identifies the subjective and objective data that signal existence of the problem (cues that reflect the existence of a problem).
What are defining characteristics?
This begins when the patient is admitted.
What is discharge planning?
Lack of family support, lack of understanding benefits, low value attached to outcomes, adverse physical/emotional effects of treatment, cost and limited access to treatment.
What are common reasons for nonadherence?
Decide if outcome was met, partially met or not met, list patient data or behaviors that support this decision.
What are evaluative statements?
"I feel like I can't catch my breath!"
What is subjective data?
This diagnoses has no related factors (etiology).
What is risk diagnosis?
Patient will walk up and down a flight of stairs, maintaining SPO2 of 93% or greater, without oxygen by discharge.
What is a SMART goal?
Level of expertise, creativity, willingness to provide care and available time.
What are nurse variables influencing outcome achievement?
Identifying evaluative criteria and standards, collecting data to determine if criteria and standards are met, interpreting and summarizing findings, documenting judgment and terminating, continuing, or modifying the plan
What are five classic elements of evaluation?