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A comprehensive overview of the nursing process, outlining its five key steps: assessment, nursing diagnosis, planning, implementation, and evaluation. It delves into the details of each step, including data collection, identifying patient problems, setting goals, implementing interventions, and evaluating outcomes. The document also explores the importance of smart goals and the use of the nanda international nursing diagnosis list.
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What are secondary sources nurses may us ---------CORRECT ANSWER--- --------------Database (nursing history, and assessment that is create upon admission) Lab and diagnostic results HX and updated notes from inter-professional healthcare team Medical records (old charts) What are tertiary sources? ---------CORRECT ANSWER-----------------nurses experience (intuition) Relevant literature What is used in collecting subjective data? ---------CORRECT ANSWER----- ------------Interview, and organize conversation Open ended questions Preparation Privacy What are the three phases in collecting subjective data? ---------CORRECT ANSWER-----------------Orientation Working Termination When are good interview skills when assessing a patient ---------CORRECT ANSWER-----------------Eye contact
Plain language Don't ask all questions Ask your own answers Accept answers Take notes Know the form How to organize subjective and objective data ---------CORRECT ANSWER-----------------Computer written form Can be modified according to patient status Prep and plan Gordon's functional health pattern framework What is a nursing diagnosis? ---------CORRECT ANSWER----------------- Identify the patient's problem What is plan of the nursing process? ---------CORRECT ANSWER------------- ----set goals of care and desired outcomes and identify appropriate nursing actions What is implement of the nursing process? ---------CORRECT ANSWER---- -------------perform the nursing actions identified in planning What is evaluate the nursing process? ---------CORRECT ANSWER---------- -------determine if goals and expected outcomes are achieved What should the nursing diagnosis include? ---------CORRECT ANSWER--- --------------Nanda international diagnosis list
What are the four types in the nursing diagnosis? ---------CORRECT ANSWER-----------------Actual Risk Wellness Health Promotion What does r/t mean ---------CORRECT ANSWER-----------------Nursing or medical problem what is contributing or causing the problem What does evidence by mean? ---------CORRECT ANSWER----------------- Signs or symptoms referred to objective and subjective data What are goals in the nursing process for nurses ---------CORRECT ANSWER-----------------Patient centre goals, good lines in expected outcomes and plan nursing interventions What is establishing priorities in goals ---------CORRECT ANSWER----------- ------Attention to the patient's most important needs first How should goals be written? ---------CORRECT ANSWER----------------- Smart How are goals established? ---------CORRECT ANSWER----------------- Highest priority, Intermediate priority Low priority, diagnosis
What is highest priority, in goals ---------CORRECT ANSWER----------------- Patient may be harmed, if not attended to What is intermediate priority in goals? ---------CORRECT ANSWER----------- ------Non-emergency What is low priority, diagnosis in goals ---------CORRECT ANSWER---------- -------Affect future well-being What is a short term goal? ---------CORRECT ANSWER----------------- Achieves in less than one week What is a long-term goal? ---------CORRECT ANSWER-----------------A goal that you plan on reaching over an extended period of time " patient will have full range of motion in three months" What are types of nursing interventions? ---------CORRECT ANSWER------- ----------nurse initiated physician initiated collaborative What are the steps in evaluation? ---------CORRECT ANSWER----------------- Identify criteria Collect data from patient Interpret and summarize your findings Options
What's R in smart goals ---------CORRECT ANSWER-----------------Relevant realistic What does relevant/realistic mean for smart goals ---------CORRECT ANSWER-----------------applies to your current role in his clearly linked to your key role responsibilities What is the T in SMART goals? ---------CORRECT ANSWER----------------- timely What does timely mean for your smart goals? ---------CORRECT ANSWER- ----------------Specific, timeless and a deadline. This will help motivate you to move toward your goal and evaluate your progress. What are the five steps of the nursing process ---------CORRECT ANSWER-----------------1. Assessment
What does the nursing process include? ---------CORRECT ANSWER-------- ---------Medical orders and independent care required by CNO standards What is the nursing process required by? ---------CORRECT ANSWER------- ----------Civil law. "If it is not charted, not done. " What are some characteristics of the nursing process? ---------CORRECT ANSWER-----------------Person focussed no task focus Goal oriented Individualize Applies to all ages, health problems, setting Where is the nursing process used? ---------CORRECT ANSWER------------- ----What is the universal nursing language that can include family in plan best for patient) How long has the nursing process been used for? ---------CORRECT ANSWER-----------------Over 50 years What is assessment in the nursing process? ---------CORRECT ANSWER-- ---------------the deliberate and systematic collection of data about a patient to determine the patient's current and past health and functional status To determine patient present and past coping patterns. What are the 2 stages of assessment ---------CORRECT ANSWER------------ -----1. Collection and verification of data
What are secondary sources? ---------CORRECT ANSWER----------------- Family and significant others When are secondary sources used? ---------CORRECT ANSWER------------- ----If patient is critically, ill, unconscious, disoriented