Assessment
The patient states they are feeling dizzy.
What is subjective data (cues)?
Which statement describes a nursing problem: Pneumonia or Airway Clearance?
What is Airway Clearance? (page 131)
Etiology: pneumonia, excessive mucus...
Signs/Symptoms: Absent/diminished cough, adventitious breath sounds, altered RR and rhythm...
The patient will be able to walk without assistance prior to discharge home. This is an example of a Nursing Outcome or an Expected Outcome?
What is a Nursing Outcome? (Broad, NOC)
Alternatively, an Expected Outcome for this NOC might be: Patient will safely demonstrate ability to ambulate 30 feet independently prior to discharge.
Repositioning a patient and teaching coughing exercises are examples of this type of nursing action that does not require an order.
What are independent nursing interventions?
After giving pain medication, the nurse asks for a new pain rating. This action is called:
What is reassessment?
The patient has a temp of 38.2, has visible shaking chills, and an elevated white blood count.
What is objective data (cues)?
The patient has dry oral mucosa, poor intake, and dark urine. Which nursing problem does this cluster suggest?
What is Fluid Volume Deficit (pg. 430)?
Etiology: dehydration, malnutrition, inadequate access to fluids...
S/S: decreased urine output, dry mouth or mucus membranes, increased urine concentration, thirst...
A patient feels dizzy upon standing and needs assistance with walking. Name two fall prevention interventions to include in the plan.
What is assisted mobility and call light within reach?
Administering a prescribed medication is this type of intervention?
What is a dependent nursing intervention?
The expected outcome states "Patient's oxygen saturation will remain at or above 94% during ambulation.". During the afternoon ambulation with the patient the nurse notes the patients oxygen saturation fell to 89%. How does the nurse evaluate the outcome?
What is "not met"?
The patient's BP monitor displays a BP reading of 90/60. The patient is alert and oriented. What is the next best assessment step?
What is validate the data? (retake the BP, look at BP trends and verify if this is normal for this patient, HR, etc)
A post operative patient states, "I am dizzy when I stand" and needs assistance with walking. Name the nursing problem
Problem label... related to... as evidenced by..
What is Risk for Falls related to ? post op surgery as evidenced by reports of dizziness and need for assistance.
The patient will take inhaler medications correctly (NOC). Name one expected outcome.
What is The patient will take inhaler medication correctly after nursing education as observed during the next inhaler medication scheduled administration?
The nurse places a nursing referral to the dietitian for counseling on a low sodium diet. This is an example of which type of intervention.
What is an interdependent/collaborative intervention?
Patient's expected outcome is to walk 50 feet by noon. At noon, the patient walks 20 feet and stops due to fatigue. Is the outcome met, partially met, not met and what are the nurse's next steps?
What is: the goal is partially met, and the nurse will reassess and revise the plan?
The patient reports new onset shortness of breath. What focused action should occur before the nurse develops a problem statement.
What is a respiratory assessment? (noting RR, effort of breathing, oxygen saturation, lung sounds, etc.)
Write a nursing focused problem statement based on the following cues, 80 yo patient admitted with pneumonia, patient has thick secretions, weak cough, lung sounds - coarse crackles and difficulty clearing secretions.
What is Ineffective Airway Clearance related to thick secretions and weak cough as evidenced by coarse crackles and difficulty clearing secretions.
A patient has ineffective airway clearance. Name one appropriate expected outcome and one matching nursing intervention.
What are:
Outcome: The patient will be able to effectively clear secretions without assistance following education session.
Intervention: Nurse will teach cough and deep breathing techniques, ensure hydration, administers prescribed medications.
A nurse is implementing the care plan for the following nursing intervention: Mobilize patient from bed to chair 3 times daily for meals. What should be done to anticipate and prevent complications?
What is identify risks and mitigate for risks.
Example: Nurse should assess for need for mobility assistive devices and should assess patient's health and safety status during mobility (strength, skills, dizziness, etc.).
Put these phases in order: Evaluation, Planning, Assessment, Implementation, Analysis
What is the Nursing Process: Assessment, Analysis, Planning, Implementation, and Evaluation?