Analysis
Subjective data- information perceived ONLY through the affected person. Examples: pain, dizziness, anxiety
Objective data- observable & measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples: temperature, skin moisture, vomiting
Define etiology.
Factors that contribute to, or cause, health problems
True or false: Planning should be in collaboration with the client, significant other(s), the RN, and other members of the interdisciplinary team.
True
Give 2 examples of tasks that can be delegated to a UAP?
Assisting with toileting (bedside commode), record client's intake & output, vitals
Peer review is done by who?
Peer review is the evaluation of one staff member by another staff member on the same level of the hierarchy of the organization.
What is the best way to get a baseline for a new patient?
Initial assessment
Which type of nursing diagnosis is this:
"Anxiety related to change in health status and situational crisis."
Actual Nursing Diagnosis
What are the 4 nursing care plans?
1. Informal
2. Formal
3. Standardized
4. Individualized
What's indirect patient care? Provide an example.
A treatment performed away from the patient, but on behalf of a patient or group of patient's
ex) Nurse meets with the collaborative care team to plan nursing measures for a patient.
Give an example of a nursing action reflecting evaluation.
Example- asking how the client feels 30 minutes after administering a medication
What are the 4 phases of a nursing interview?
1. Preparatory phase
2. Introduction phase
3. Working phase
4. Termination phase
What is the "formula" of a nursing diagnosis? (3 parts)
1. The problem
2. Etiology
3. Defining characteristics
What are the 3 elements of comprehensive planning and when do they begin?
1. Initial- should be initiated ASAP after the initial assessment
2. Ongoing- throughout the entire stay by all nurses
3. Discharge- begins at the moment the patient is admitted into a unit
What's direct patient care? Provide an example.
Hands-on, face-to-face contact with patients for the purpose of diagnosis, treatment, and monitoring
Ex) A nurse prays with patient before surgery; a nurse explains available birth control measures to a young couple
What exactly is being evaluated?
The client’s goal/outcome achievement
Which nursing skill is the conscious and deliberate use of all 5 senses?
Observation
1. Normal blood pressure values
2. A series of readings
What does ABC stand for?
Airway, Breathing, Cardiovascular status of the patient
What are the 5 rights of delegation?
Right task
Right circumstances
Right person
Right directions and communication
Right supervision and evaluation
What does it mean when we have to go back and reassess the care plan?
The goals were not reached or the problem was not resolved
Explain the difference between a medical assessment and a nursing assessment.
Medical assessment- target data pointing to pathological conditions
Nursing assessment- focus on patient's response to health problems
What are the 4 steps of data interpretation?
1. Recognizing significant data
2. Recognizing patterns or clusters
3. Identifying strengths & problems and potential health complications
4. Reaching conclusions
Describe patient outcomes (hint: SMART)
Specific
Measurable
Attainable
Realistic
Timely
What's the difference between dependent and independent nursing interventions? Provide 1 example for each
Dependent- needs a doctor's order
ex) administering medication
Independent- things nurses can do without a doctor's order
ex) positioning the patient, turning the patient, assisting with daily activities
What do we need to make sure of if the patient has met all the goals?
We need to make sure that they're comfortable and be aware that they may be anxious, scared, etc. that the helping relationship is coming to an end