Assessment
What is the first step of the nursing assessment
WHAT IS :
Gathering subjective and objective data
In the analysis phase, what do nurses focus on identifying?
WHAT IS:
The Problem/s. Priorities based on dataWhat is the main goal of the planning phase
WHAT IS:
to set measurable achievable goals for the client
(Remember your goal/plan has to be measurable, and timed)
What does implementation/intervention involve in the nursing process
WHAT IS:
To carry out the nursing task or interventions that is decided on in the planning phase of the nursing process.
What is the purpose of the evaluation step in the nursing process
WHAT IS:
To determine if the client’s goal/s been met
What is an example subjective data
WHAT IS : A client stating, “ I have pain in my chest.”
What is an example of a PRIORITY nursing problem
Pneumonia / infection
Obstruction
Bleeding
Heart attack
Stroke
Extreme of temperatures
Seizures/Neuro
Gunshot ……etc……
What is an example of a short-term goal for a client with acute pain
WHAT IS:
The client will report a pain scale level of 3/10 within 2 hours of receiving pain medication
What is one example of a nursing intervention for a client with a high risk for fall
You as the nurse have to implement(to do) the intervention (nurse will….)
WHAT IS:
Ensuring the bed is in the lowest position
Making sure the Call light is within reach
What should a nurse do if a client’s goals were not met
WHAT IS:
Go back to the plan and revise
Reassess the client & modify the care plan
What are the 5 main vital signs
you assess during the initial
client assessment
WHAT IS:
Blood pressure
pulse/O2 saturation
respirations
heart rate
pain level/scale
When analyzing client data, what framework can help determine priority issues
WHAT IS:
Maslow’s hierarchy of needs
What should be prioritized in a care plan for a post-operative client?
WHAT IS:
Pain management & prevention of complications such as infection
What is the purpose of documenting nursing interventions
WHAT IS:
To track the care provided by the team and ensure continuity of care
What is an example of a measurable outcome that can be evaluated
💡(REMEMBER:outcomes are what your interventions will or will not accomplish )
WHAT IS:
Ex: The client's blood pressure decreasing from 160/90 to 120/80 after taking medication
also any correct example 👍🏽
What is one of the best ways to assess a client's pain level
WHAT IS:
Ask the client to rate their pain on a scale of 0/10
What is the difference between a medical diagnosis and a nursing analysis
WHAT IS:
Medical diagnosis focus on disease
Nursing analysis focuses on the clients response to health conditions
When creating a care plan, what is a SMART goal
WHAT IS:
Specific - Measurable - Achievable- Relevant- Time bound-
What is a nursing intervention for a patient with impaired mobility
WHAT IS:
Nurse will assist the client with range-of-motion exercises twice a day
How often should you evaluate a client’s progress towards their goals
WHAT IS:
Regularly as specified in the care plan , or whenever there is a change in the client’s condition
What body systems are included in a head to toe assessment(medical terms only)
WHAT IS:
Dermis:Skin
Neurological
Cardiovascular /cardiac
Respiratory
Musculoskeletal
Gastrointestinal
Genitourinary
When should a nurse analyze data again after the initial analysis
WHAT IS:
Each time new data is collected
and
Each time a clients condition changes
What key factors should you consider when setting priorities for care
WHAT IS:
Client’s condition- safety- urgency of the problem
How do nurses prioritize which interventions to implement first
WHAT IS:
Emergent -Immediate threats to health
ABC
Urgency of the situation
Safety
What should be done if interventions were not effective
WHAT IS:
Modify the interventions
update the care plan
continue monitoring the client