question | answer |
Steps of Nursing Process | Assessment, diagnosis, planning, interventions, evaluating care provided |
What data is gathered during assessment | Baseline, subjective, and objective |
What are ways of planning | through forming goals and outlines |
Identify assessment data that is pertinent to medication administration | health history, physical assessment data, lab values (other measurable data), asseesion of medication effects (theraputic and Side effects) |
develop proper nursing diagnosis for clients receiving medication (when is it done, what does it do, must do) | after analysis of assessment data, focus on problem, verified with client or caregiver |
Why are diagnosis written | to address clients responses related to drug administration |
How do you set goals for a client receiving medication | from diagnosis |
What do goals focus onfor a client receiving medication | what the client should be able to achieve |
What do outcomes focus onfor a client receiving medication | measurable criteria that will be used to measure goal attainment |
Key interventions strategies to be implemented for clients receiving medication | Goal client to be optimal level doing it safetly and effectivelly |
Key intervention | monitoring drug effects, doc, medication, client teaching, |
Outcome of med. administration | begins new cycle of care, diagnosis reviewed, goals outcome refined, new interventions |
First step in the nursing process | Assessment, diagnosis, planning, interventions, evaluating care provided |
Begins with the nurse's initial contact with the client and continues with every interation therafter | assessment |
Used to compare to information obtained during later interations | baseline data |
what the clients say or pereives | subjective data |
gathered through physical assessment , | objective data |
lab test other diagnostic sources | objective data |
nursing judgments about the client and his or her reponses to health and illness ; second step in nursing process | nursing diagnoses |
provides basis for establishing goals and outcomes planning interventions and evaluating the effectiveness of the care given | Nursing diagnoses |
Diff b/t nursing diagnoses and medical diagnosis | Nursing diagnoses focus on a client's reponse to actual or potential health and life processes; med. focus on disease or conditon |
Per the N(north)A(american)N(nursing)D (diagnosis) A (association) nursing diagnoses provide the basis for | selection of nursing interventions to achieve outcomes for which the nurse is accountable |
Difficult part of the nursing process | Diagnosis |
KEY: pt. to remene about nursing diagnoses | it focuses on client's needs not the nurse's needs. |
Primary nursing role is to enable clients to ? | become active participants in their own care; encouraging the client to take a more active role in working toward meeting the identified goals |
Third step | planning ; ways to assitst the client to return to an optimun level of wellness. |
Goals are established to focus on >>> | what the client will be able to do or achieve not waht the nurse will do. |
objective measures of goals | Outomes |