Assessment
The "best" source to obtain assessment data:
What is the patient?
In the following dx, what is the etiology? Disturbed sleep pattern R/T excessive intake of coffee AEB c/o tired all day, irritability
What is "excessive intake of coffee"?
The two types of goals...
What are short term and long term goals?
Treatment that the nurse implements based off of assessment findings...
What is a nursing intervention?
A statement indicating whether a goal was met, partially met, or not met is within the _____ phase.
What is the evaluation phase?
Data that is gathered directly from the patient and data that is measurable and observable
What is subjective and objective assessment data?
The step in the nursing process that involves analyzing the collected data to identify actual, risk/potential, or health promotion problems
What is Diagnosing?
Actual Diagnosis
Risk Diagnosis
Health Promotion Diagnosis
This phase focuses on establishing goals and selecting appropriate nursing interventions for implementation
What is planning?
This step involves carrying out the planned nursing interventions and documenting them
What is implementation?
The acronym ADPIE represents the five core steps of the nursing process, which are Assessment, Diagnosis, Planning, Implementation, and ...
What is evaluation?
Look, listen, and feel
What is physical assessment?
After assessing the patient and finding out that they have a weakened range of motion and fatigue easily. An example of an appropriate diagnosis is...
What is limited mobility?
Written expected outcomes should start with:
The patient will...
Documentation is important in the nursing implementation phase, because if you did not document you did ____ do it.
What is "NOT"?
Not documented, not done
Reassessment, redefining diagnoses, goals and expected outcomes, and interventions
What is evaluating the effectiveness of a care plan?
The stage in Tanner's critical thinking process that aligns with assessment...
What is analyzing cues?
Nursing diagnosis, etiology (related factors), and symptoms (defining characteristics)...
What are the components of a nursing diagnosis statement?
(Problem, etiology, signs/symptoms)
Specific, Measurable,Achievable,Realistic and Time Frame- make up what acronym
What are SMART "goals"?
Thoughtful integration of the best available evidence coupled with clinical expertise
What is evidenced based practice?
What do you do if expected outcomes do not meet actual outcomes?
What is revise the plan of care
The cognitive process used to develop and implement the nursing process...
What is critical thinking?
Types of nursing diagnoses
What are actual, risk, and health promotion
When developing the plan of care, the _____ should be involved in the process
What is the patient?
All nursing interventions need to have
SMART goal w/time frame?
The nurse will turn and reposition the patient Q2hr
Lopressor 50mg po BID for HTN
The nurse is "re-evaluating" a patient's response to pain medication. An example of an outcome that would indicate that the medication is effective...
What is the patients pain decreased from a 8/10 to 3/10 within one hour of pain medication administration.
What is evaluating effectiveness of pain medication?