NursingProcess Word Scramble
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Question | Answer |
what are the 5 components of the nursing process? | assessment, diagnosis, planning, implementation, assessment. |
what is the definition of the nursing process? | An organized sequence of problem solving steps used to ID and manage the health problems of clients. |
Who accepts the nursing process for clinical practices? | American Nurses Association |
Goals of hte nursing process? | ID actual and potential health care problems. determine desired outcomes deliver specific nursing interventions to solve the problems. evaluate the care given. |
Characgteristics of the NP | Goal-directed ... prioritized ... dynamic |
Assessment? | Carefull observation and eval of clients health status at first sight. Collects data Organize data |
Types of data? | Measureable Observable |
Quick head-to-toe assessment? | Initial observation: breathing, how is patient feeling, appearance, affect skin color. Head: LOC, able to communicate, mental status, eyes. Vital signs: temp., pulse, respirations, blood pressure. |
Auscultation of lungs. | right lung: 3 lobes Left lung: 2 lobes listen to front and back. |
auscultation of heart | lub-dub sound |
Abdomen | shape, soft or hard, appetite, last BM, voiding status |
auscletataion of bowel sounds | ALWAYS look first for bag. do all 4 quadrants then feel for soft or hard, descended, or bag. |
Extremeties Pain Tubes and equipment | normal movement, skin tugor, and temp., peripheral pulses, edema, cap refill Oxygen, NG tube, catheter, dressings |
2nd step DIAGNOSIS | analyze data to ID actual or pot health probs. IDs nursing diagnosing Must use NANDA approved diagnosis |
What are the 3 parts of nursing diagnosis? | Name of problem Cause of problem Sign and symptoms |
What are etiological factors? | Characgteristcs that must be present for a nursing diagnosis to be appropriate for patient |
What are the types of nursing diagnosis? | actual, risk, possible, syndrome, wellness |
What are the Prioritization of Problems? | High priority: life threatening Medium priority: threaten health or coping ability Low priority: No major effect on person on the spot. |
What are the problems ranked in order of import? | Survival: airway and circulation After that, safety needs |
How frequently must work plan be evaluated and reprioritized? | Every 2 hours |
What is planning? | The process of prioritizing nursing diagnosis and collaborative problems, IDing measurable goals and outcomes, selecting interventions, documenting care of plan. Entails consultation with client. |
What are 2 types of goals? | short term (7-10 days) long term (weeks or months) |
What are expected outcomes? | A specific statement of the goal the patient is expected to achieve as a result of interventions. Should contain measurable criteria to be evaluated to see if outcomes have been achieved. |
SMART | Specific, Measurable, Attainable, Realistic, Timed |
How does a nurse select strategies? | Based on the knowledge that certain nursing actions produce desired effects. |
What 3 things should interventions be? | Safe, within legal scope of nursing practice, and compatible with nursing orders. |
What is a rationale? | A concept of reason |
What do nursing interventions require? | A scientific rationale |
What must interventions include? | A page number |
How can plans of care be documented? | Handwritten, computer generated, or standardized or based on agencies clinical pathways |
What is the evaluation? | Final step. Involves the analysis of the clients response to determin the effectiveness of the interventions. |
What is critical thinking? | Purposeful outcome directed thinking. Clinsiders client, family and community needs based on principles of nursing process and scientific method, makes judgements based on evidence not conjecture. |
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