Assessment
What is an assessment?
The gathering of information related to the mental, physical, spiritual, socioeconomic, and cultural status of an individual, group or community.
What is diagnosing?
Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status.
How often should restraints be checked?
Every 2 hours
Your patient at clinical reports that they work nights. They state, "I can never sleep for a full 6-8 hours so I just take naps when I can." The pt also reports feeling more confused than normal in the evenings. What is a good diagnosis for this pt?
Sleep deprivation
Order: 20mg of vancomycin EX.
The lab has 40mg tablets available. How much do you give?
0.5 tablet
What is an assessment used to determine?
Diagnosis, planning outcomes and interventions, implementation and evaluation
What is an etiology?
Factors contributing to the problem
How often should you allow a patient in restraints toilet, eat and drink?
Every 2 hours
Your patient at clinical has been receiving medication for an injury she acquired. She reports pain in her back as a 7 on a scale of 0-10. She also reports that she enjoys exercise and is supposed to compete in a power lifting competition in 2 weeks. What is a good nursing diagnosis for this patient?
Order: 100mg metoprolol.
The pharmacy has 50mg/mL available. How many mL's do you give?
2mLs
What are proper guidelines for gathering assessment data?
Only RN and LPN can assess, document as soon as possible, don't use acronyms if possible, record pt quotes, use proper spelling and grammar, don't document for other people.
What makes up a nursing diagnosis?
A diagnostic label and etiology
How long can you keep restraints on a patient?
Orders are only good for 24 hours. If over 24 hours then the Physician will need to re-write the order
Your patient at clinical has been receiving medication for an injury she acquired. She reports pain in her back as a 7 on a scale of 0-10. She also reports that she enjoys exercise and is supposed to compete in a power lifting competition in 2 weeks. What are 2 nursing interventions you can do for this patient?
Assess alleviating/aggravating factors
Provide/teach the patient with non-pharmacologic pain relieving methods
Administer the pts meds in a timely manner
Assess whether the pt needs a different pain med or increase in dose
Order: 75mg of guaifenesin orally.
The pharmacy has 25mg tablets of guaifenesin available. How many tablets do you give?
3 tablets
When do you complete an assessment?
Admission, surgery, medications, shift assessment and any change in pt status.
How many defining characteristics should a diagnosis have according to the NANDA definition?
2-3 defining characteristics
When taking a blood glucose test what should you remember to do before testing the blood?
Wipe away the first drop of blood
You walk into your patient's room at clinical and note that there has been no visitors. While assessing the patient's psychosocial they state, "My parents have both passed away and I do not have any siblings. I haven't seen my friends in years and my cousins all live on the other side of the country. I usually stay at home and keep to myself." What is a good nursing diagnosis for this patient?
Risk for loneliness
Order: 1,000mg of clindamycin orally.
The pharmacy has 2g tablets of clindamycin available. How many tablets do you give?
0.5 tablet
What is the difference between Subjective and Objective data?
Subjective- Something the patient tells you.
Objective- What you observe.
What is the difference between a nursing diagnosis and a medical diagnosis
Medical diagnosis can't change and a nursing diagnosis can
The nurse notes what value as normal for a pulse oximetry?
92-100%
You have a patient at clinical that is recovering from a foot amputation 2 weeks ago due to necrosis of the tissue. What should be your main priority with this patient?
Falls risk
Infection
Order: Lisinopril 35mg with systolic >150.
Your patient's BP is 145/90. The pharmacy has 35mg tablets available. How many tablets do you give?
0