Assessment
An example of this type of assessment is when a nurse looks at a surgical incision for redness and asks about any pain (but does not complete a head-to-toe assessment)
What is a focused assessment
This type of problem statement describes a patient's response to a medical illness or disease process
What is a nursing diagnosis
The nurse should check with this person before activating a nursing diagnosis for a care plan
Who is the patient
An example of this is: the nurse administers medication ordered by a physician
What is a dependent intervention
This must be done anytime an ECO is not "met"
What is revise the plan of care
Type of data: A patient states, “My pain is a level 5. I would describe it as a sharp pain, and it is radiating down my arm.”
What is subjective data
This term describes ISCHEMIA in the following statement: "Impaired skin integrity related to ischemia as evidenced by redness and visible subcutaneous tissue."
What is etiology
Within the nursing diagnosis, this is where the nurse looks to plan interventions for a plan of care
What is the etiology
An example of this is: the nurse coordinates a nutrition consult with the dietitian
What is an interdependent (collaborative) intervention
Once it is determined that a care plan needs a revision, what can the nurse use to evaluate where to revise?
Revisit each step of the nursing process - dx still correct? interventions completed? eco not realistic?
Type & Source of data: Temperature 103.1 oral (obtained with thermometer)
What is objective data
What is secondary source
The term describes the BLADDER SCAN in the following statement: Urinary retention related to interruption in signal from urinary bladder to CNS as evidenced by bladder scan of 450mL.
What is symptom statement
An example of this type of ECO is "Patient will walk 25 feet by the end of the shift TODAY."
What is a short term goal
Which is the better ECO & explain why:
Patient will eat 50% of lunch today vs. Nurse will answer call lights in a timely manner within one hour
Patient will eat 50% lunch today - is measurable and time limited, may be realistic; is patient-centered. What is "timely manner;" is within one hour referring to timely manner or only being on time x1 hour? Should not focus on nurse action
ECO: Pt will perform incentive spirometry to 2500 ml Action: Pt performed incentive spirometry to 2000 ml How will the nurse document this outcome & what should be done about it?
Not met - revise the care plan
Type of knowledge used when a nurse gathers supplies and uses a Kangaroo pump to administer enteral tube feeding
What is practical knowledge
This type of nursing diagnosis only has a two-part statement, including ONLY the problem and etiology
What is a potential nursing diagnosis ("risk for")
This is where the nurse should start when planning the expected client outcome (ECO)
What is the patient problem (NANDA), or symptoms statement
Identify how assessment is related to implementation
What is evaluating the effectiveness of interventions; assessing the impact on the ECO; re-assessing for improvement in symptoms
An example of this type of assessment is when a nurse re-evaluates a patient's pain levels after providing pain medicine to the patient
What is intermittent assessment
The nurse uses this information process to select a nursing diagnosis (ex. fever, thick wound drainage, elevated white blood count)
What is clustered data cues
Identify the priority nursing problem & explain how you decided the priority: Impaired renal tissue perfusion vs. Risk for falls
What is impaired renal tissue perfusion. (ABC=circulation & Maslow physiologic vs. safety; actual vs. risk)
List the components of a S.M.A.R.T. expected client outcome
What is: Specific - Measurable - Attainable - Realistic - Time-limited
List the 5 rights of delegation
What is: Right person - right task - right circumstances - right supervision - right communication
This describes how assessment and evaluation are different
What is time - assessment is performed before interventions (planning), evaluation is performed after interventions are completed