A systematic, rational method of planning and providing individualized nursing care.
What is the nursing process
100
This phase involves organizing & validating data.
What is Assessment
100
Validating data of abdominal pain the nurse palpates the left abdominal quadrant & observes the client grimace and guard his left side.
What is Assessment
100
Standards for documentation are set by this organization
What is The Joint Commission (TJC)
100
The following is an example of this source of data:
A client's spouse says that his "wife is unable to go one day without taking anti-inflammatories".
What is secondary data
200
Priority setting framework that is critical to survival, dictates care in unstable clients and recognizes early signs of complications
What is CAB-Compressions, Airway, Breathing
200
The following action is part of this nursing process phase:
The nurse returns within 30 minutes of initiating 2L oxygen via nasal cannula and checks the client's oxygen saturation and listens to breath sounds.
What is evaluation
200
The nurse assist the client in repositioning, dims the lights, and administers ordered pain medication.
What is Intervention
200
These 3 thing must be included when documenting client response to intervention & outcomes.
What is treatments, teaching and preventative care
200
The following is an example of this type of data:
"My head hurts".
What is subjective data
300
A clinical judgment about the patient in response to an actual or potential health problem.
What is nursing diagnosis/problem
300
The purpose of this phase is to eliminate or reduce the etiology of the nursing diagnosis.
What is Intervention/Implementation
300
The nurse determines that the medication is not adequate to relieve the client's pain and requests the PCP increase the dosage or order a different classification of pain med.
What is Evaluation
300
A better way to chart the following: "Small ulcer right heel".
What is chart specific data. Measure the size & include unit of measurement (mm, cm, inch etc). Avoid imprecise descriptions such as large, small, good, normal.
300
4 types of nursing assessments used to collect data.
What is initial, problem-focused, emergency and time-lapsed
400
Involves setting priorities of client problems, selecting strategies and interventions
What is Planning
400
3 things that are involved in the diagnoses phase that allow the nurse to identify specific nursing diagnoses.
What is interpreting & analyzing data, determining client strengths, risks, and problems
400
Acute pain r/t tissue distention
What is Diagnosis
400
Three things not to include when a written documentation error is made.
What is erasure, blot out (dark ink markings) or correction fluid. The original entry must remain visible.
400
The 3 part structure of the nursing diagnosis.
What is the problem (Nanda diagnostic label), etiology (causal & risk factors), and signs/symptoms (defining characteristics)
500
A type of intervention that is nurse initiated and does not require supervision or direction by others.
What is independent nursing intervention
500
4 general categories used to cluster data in the assessment phase.
What is physiological, sociocultural, psychological and spiritual
500
The client will have management of pain as evidenced by pain no greater than 4 out of 10.
What is Planning
500
Three items included on the Official "Do Not Use" List
What is:
U, u
IU
QD, QOD (lower or upper case)
Trailing zero (X.0), lack of leading zero (.X mg)
MS, MSO, MGSO4
500
Guidelines for writing goals & interventions
What is SMART: specific, measurable, realistic, time oriented