Nursing Diagnosis
2 types of nursing diagnoses
What is problem focused, risk, and health promotion
Noncompliance due to hostility toward nursing staff
Bad: due to implies a direct cause-and-effect relationship
Use: Noncompliance related to hostility toward nursing staff (denotes a relation between the problem and etiology but not necessarily a causal relation)
What does ADPIE stand for?
Assessment
Diagnosis
Plan
Implement
Evaluate
1 cup= oz
What is 8 oz
This method of temperature is taken in the ear
What is Tympanic temperature
This term identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient's health problem)
What is Problem
Complicated grieving related to inability to accept death of spouse.
Good
An outcome must always be _____
1 kg= lbs
2.2 lbs
The normal range for a healthy adult's pulse
What is 60-100 bpm
This term identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors)
What is etiology
Impaired home maintenance related to mobility, endurance and comfort alterations.
Good
During this type of nursing assessment, the nurse gathers data about a condition that has already been diagnosed
What is a focused assessment
1 Tsp= mL
5 mL
Name 3 things that can make a patient tachycardic
What is hypovolemia, elevated temperature, exercise, emotional response to anxiety/fear/excitement, heart disease, age (infant), medications, orthostatic response, pain, hyperthyroidism, anemia, hypoxemia, shock, hemorrhage
This term identifies the subjective and objective data that signal the existence of the problem.
What is defining characteristics, cues, or evidence.
Deficient knowledge related to alteration in parenting
Bad: avoid reversing the problem statement and etiologic statement.
Use- Impaired parenting related to knowledge deficit: child growth and development, discipline.
Three actions nurses can take during the evaluation phase based on patient response
What is terminate, modify, or continue
1000 mcg= mg
1 mg
Pulse amplitude grade (documentation) when the nurse feels a diminished, weaker than expected bilateral radial pulse
What is 1+ radial pulse bil
Name two things a nursing diagnosis is not
What is medical diagnosis, medical pathology, diagnostic tests, treatments, equipment, therapeutic patient needs, therapeutic nursing goals, a single sign or symptom, an invalidated nursing inference.
Impaired skin integrity related to patient's lying on back all night
Bad: this statement may be interpreted as libel or imply nursing negligence
Use- Impaired skin integrity related to mobility deficit
When prioritizing a nursing diagnosis, a nurse should always consider this.
What is Maslow's Hierarchy of Human Needs
1 Tbsp= mL
15 mL
BP classification for adult with 134/82 RUE cuff pressure
What is Stage 1 HTN