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CDI - LVN PROGRAM Terms in this set (93)What are the steps of developing a care plan? ADOPIE Nursing Process six-step systematic method for giving patient care; involves assessing, diagnosing, outcomes identification planning, implementing, and evaluating (Outcomes identification and planning often combined when creating a nursing care plan) Subjective Data things a person tells you about that you cannot observe through your senses; symptoms Objective Data information that is seen, heard, felt, or smelled by an observer; signs Primary vs. Secondary Source Primary: Patient and most accurate. Secondary: Family members, significant other, medical records, diagnostic procedures, and specialists. Nursing Diagnosis A nursing diagnosis revolves around the patients RESPONSE to what is happening. (ex. Medical Diagnosis the identification of a disease or condition by a doctor (Ex. Hypertension, Diabetes, Dementia, Obesity) How is data collected on assessment? Physical assessment with interview questions/assessment questions Maslows Hierarchy of Needs (level 1) Physiological Needs, Nursing the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations Outcomes Identification identifies expected outcomes for a plan individualized to the patient or situation ANA American Nurses Association Assessment Systematic, dynamic process by which the RN through interaction with patient, family, groups, communities, populations and health care providers, collects and analyzes data (ANA) Complete assessment Involves a review and physical examination of all body systems.
Focused assessment Review and examine a specific area of the body. What does a complete assessment entail? Cognitive, psychosocial, emotional, cultural, and spiritual components. Types of data? (3) Cue, Subjective, Objective Cue pieces of data, actual or potential problem. When is obtaining information from secondary sources When the patient is unable to supply information. What type of data is collected during interview process? - Biographic data What type of data is collected during the physical examination? - Head-to-toe format Diagnosis
Identify the type and cause of a health conditions "A clinical judgment about the patient's response to actual or potential health conditions or needs. Diagnoses provide the basis for determination of a plan of care to achieve expected outcomes" Etiology the study of the causes of diseases Nursing Diagnosis Examples -
Risk for self harm - Ineffective coping - Impaired nutrition - Impaired mobility - Chronic pain Medical Diagnosis examples - Depression Components of Nursing Diagnosis -Nursing diagnosis Acute vs. Chronic new onset vs. long standing Acute needs may pose more of a
threat Etiology and Risk Factors examples - Foley catheter Actual nursing diagnosis represents a condition that is currently present. -Problem Statement (r/t) Example of actual nursing diagnosis • Impaired skin integrity r/t immobility AEB 3 cm stage III pressure ulcer on sacrum - Fluid volume overload r/t congestive heart failure AEB +3 edema to b/l lower extremities, crackles in b/l lung bases, and blood pressure 168/98 What is ADOPIE? Nursing Process: Assessment What does r/t mean? related to What does AEB stand for? as evidenced by Example of risk diagnosis - Risk for falls r/t dementia and lower extremity weakness - Risk for impaired skin integrity r/t bowel incontinence T/F: A Medical diagnosis may change as care is provided or the condition changes. FALSE Nursing diagnosis may change or resolve as care is provided or the condition changes. Outcome Identification/Planning Outcomes statement indicates the degree of wellness desired, expected or possible for the patient to achieve Planning The nurse establishes priorities of care and nursing interventions are chosen that will best address the nursing diagnosis (patient-centered goals/desired patient outcomes) T/F : Physiologic needs come BEFORE safety and security TRUE T/F: Safety and security needs come BEFORE love and belonging needs TRUE Physician-prescribed interventions Actions ordered by a physician for a nurse or other health care provider to
perform Nurse-prescribed interventions Actions the nurse can legally order or begin independently What should nursing order include? • Date What is the product of the nursing process? Written nursing care plan Implementation The nurse and other members of the team put the established plan into action to promote outcome achievement
T/F: Documentation is a vital component of the implementation phase TRUE Make sure to reassess after carrying out an intervention! following pain medication, BP medication, antibiotic
Evaluation A determination is made about the extent to which the established outcomes have been achieved THREE (3) Evaluation judgments/decisions: - The outcome was achieved
Role of LVN (Nursing process) - Provide direct bedside nursing care ADOPIE What is the major advantage of using the nursing process to identify nursing diagnosis? 1. Helps nurses identify a disease or illness that creates problems for the
patient ANSWER: 2 The nurse must gather and analyze data to make clinical judgments and determine appropriate nursing diagnoses/patient problem statements. The nurse observes that the patient is pale; diaphoretic; slightly hunched over; and demonstrates deep rapid breathing. Based on the objective data, which question will the nurse use to elicit the most relevant subjective data? 1. "Do you feel chilled or feverish?" ANSWER: 3 Which intervention would be considered a prescribed nursing intervention? 1. Obtain and report peak and trough levels for vancomycin x3 days ANSWER 4 What would be an example of a collaborative problem? 1. Edema ANSWER 1 The post-surgical patient reports that he is having lower abdominal pain. What would the nurse include in the focused physical assessment? 1. Check peripheral
pulses ans sensation ANSWER 2 Palpating the abdomen to locate any rigidity or rebound tenderness would be part of the focused physical assessment related to the patient's report of abdominal pain. An older adult patient is wetting the bed because he is unable to independently get up and go to the bathroom. For this particular patient, which phase of the nursing process is most critical to address the patients needs? 1. Assessment ANSWER 3 All phases of the nursing process are linked together. However, for this patient the problem is straightforward, and the solution seems simple, but careful planning is essential, because assisting this patient to the bathroom will be very time-consuming The caregiver of a patient with Alzheimers disease reports that the patient is unsteady and easily loses his balance, leaves the house, and needs coaching to accomplish tasks. Which nursing diagnosis will apply to this patient? (Select all that apply) 1. Acute confusion Answer 2, 3, 4, 5 Patients with Alzheimer's disease will have many problems. Acute confusion should not apply, unless the patient has delirium or a new injury/insult to the neurologic system. Chronic confusion would more accurately describe the patient's baseline behavior. The nurse is performing the assessment phase of the nursing process. Which nursing action would be done during this phase? 1. Observe a
patients ability to independently perform AM hygienic care Answer 1 The nurse is caring for a patient who is 1 day postoperative for abdominal surgery. The patient reports that the abdominal pain is unrelieved by medication. he also reports feeling dizzy, lightheaded, and slightly nauseated. What objective data should the nurse collect first? 1. Assess the dressing and observe for blood or drainage. Answer 1 According to Maslows Hierarchy of needs; what category is Acute pain? 1. Esteem ANSWER: 2 According to Maslows Hierarchy of needs; what category is rRisk for injury? 1. Love and belongingness ANWSER: 4 According to Maslows Hierarchy of needs; what category is Hopelessness? 1. Esteem ANSWER: 3 According to Maslows Hierarchy of needs; what category is Decreased cardiac output? 1. Love and belongingness ANSWER: 2 What are the sources of evidence that re used to support evidence based practice? (Select all that apply) 1. Research ANSWER: ALL APPLY (1,2,3,4) The nurse has identified 6 relevant nursing diagnosis's that would apply to the patients care. Which nursing action is the most important? 1. Determine how the nursing diagnoses relate to the medical diagnosis's Answer 3 Cluster cues a group of cues that are related to each other that may suggest a health problem ex. patient can only make sounds but no speech, bed bound, and incontinent. you see that theres a pattern of her incontinence and making sounds. you make the connection that she tries to communicate toileting needs but cannot express it, so you give her a call light, and she isn't incontinent anymore The emergency department nurse is gathering initial data on a child suspected of epiglottitis. Which is the nurse's highest priority 1.
Check for a patent airway. ANSWER: 1 The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? 1. Limiting cigarettes to 3 per day ANSWER: 4 The nurse is caring for a hospitalized child with a history of seizures who is receiving oral phenytoin sodium. Which should be included in the plan of care for this child? 1.Monitoring intake and output 2.Providing oral hygiene, especially care of the gums 3.Administering medications 1 hour before food intake 4.Checking the heart rate before administering the phenytoin ANSWER: 2 During which of the five steps in the nursing process does the nurse determine whether outcomes of care are achieved? 1. Implementation ANSWER: 2 Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. If the goal is achieved, the patient's needs are met. When considering the nursing process, the word "observe" is to "assess" as the word "explore" is to which of the following words? 1. Plan ANSWER: 2 The definitions of the words "observe" and "assess" are similar. Observe means to view something scientifically, and assess means to collect information. The word "analyze" fits the analogy. Explore means to examine. Analysis means to investigate. Which word best describes the role of the nurse when using the nursing process to meet the needs of the patient holistically? 1. Teacher ANSWER: 2 When the nurse supports, protects, and defends a patient from a holistic perspective, the nurse functions as an advocate. Advocacy includes exploring, informing, mediating, and affirming in all areas to help a patient navigate the health-care system, maintain autonomy, and achieve the best possible health outcomes. Which word is most closely associated with scientific principles? 1. Data ANSWER: 3 The word "rationale" (justification based on reasoning) is closely associated with the term "scientific principles" (established rules of action). Scientific principles are based on rationales. A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention? 1. Planning ANSWER: 4
Which action reflects the assessment step of the nursing process? 1. Taking a patient's apical pulse rate every 2 hours after being admitted for an ANSWER: 3 This action reflects the assessment step of the nursing process. Assessment involves collecting data via observation, physical examination, and interviewing. Which should the nurse do during the evaluation step of the nursing process? 1. Set the time frames for
goals. ANSWER: 2 During which step of the nursing process does determining which actions will be employed to meet the needs of a patient occur? 1. Implementation ANSWER: 3 The identification of nursing actions designed to help a patient achieve a goal occurs during the planning step of the nursing process. Which information supports the appropriateness of a nursing diagnosis? 1. Defining characteristics ANSWER: 1 Which is the primary goal of the assessment phase of the nursing process? 1. Build
trust ANSWER: 2 Which most directly influences the planning step of the nursing process? 1. Related factors ANSWER: 1 Related factors (i.e., "contributing to" factors, etiology) contribute to the problem statement of the nursing diagnosis and directly impact on the planning step of the nursing process. Nursing interventions are selected to minimize or relieve the effects of the related factors. If nursing interventions are appropriate and effective, the human response identified in the problem statement part of the nursing diagnosis will resolve. When two nursing diagnoses appear closely related, which should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient? 1. Reassess the patient. ANSWER: 4 Which is the primary reason why a nurse performs a physical assessment of a newly admitted patient? 1. Identify if the patient is at risk for falls. ANSWER: 3 A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing process is this evaluation most directly related?
1. Goal ANSWER: 1 When the nurse considers the nursing process, the word "identify" is to "recognize" as the word "do" is to which of the following words? 1. Plan ANSWER: 4 A nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? 1. Observing ANSWER: 4 A nurse is caring for a patient with a urinary elimination problem. Which are accurately stated goals? Select all that apply. 1. "The patient will be taught how to use a bedpan while on bedrest." ANSWER: 3 + 5 3- This is a correctly worded goal. Goals must be patient-centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. Which human responses identified by the nurse are examples of objective data? Select all that apply. 1. Irregular radial pulse of 50 beats per minute ANSWER: 1,2,3 Which patient statements provide subjective data? Select all that apply. 1. "I'm
not sure that I am going to be able to manage at home by myself." ANSWER: 1, + 5 1- Knowing one's own abilities is subjective information because it is the patient's perception and can be verified only by
the patient. A nurse is interviewing a patient at the change of shift. Which patient statements reflect subjective data? Select all that apply. 1. "When I lift my head up off the bed I feel like vomiting." ANSWER: 1 + 3 A patient is transferred from the emergency department to a medical-surgical unit at 6:30 p.m. The nurse arriving on duty at 8 p.m. reviews the patient's clinical record. Which information documented in the clinical record reflects the evaluation step of the nursing process? 1. Productive cough ANSWER: 3 This statement reflects an evaluation of the patient's response to ambulation. The nurse assesses a patient and collects a variety of data. Identify the human responses that are subjective data. Select all that apply. 1. Nausea ANSWER: 1 + 3 A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is directly related to this concept? 1. Defining characteristics ANSWER: 3 The etiology (also known as related to or contributing factors) are the conditions, situations, or circumstances that cause the development of the human response identified in the problem statement of the nursing diagnosis. A nurse concludes that a patient's elevated temperature, pulse, and respirations are significant. Which step of the nursing process is being used when the nurse comes to this conclusion? 1. Implementation ANSWER: 4 During the analysis step of the nursing process, data are critically explored and interpreted, significance of data is determined, inferences are made and validated, cues and clusters of cues Cues Whether verbal or nonverbal, it is an indirect signal that a patient uses to try to alert the doctor to a question or concern. Students also viewedSafety20 terms Kccarroll09 FOUNDATIONS OF NURSING: Chapter 5 Nursing Process…85 terms medic0757Plus Critical thinking and nursing process27 terms joselynv_94 *Chain of Infection24 terms greatS_Willis4 Sets found in the same folderNursing Process Critical Thinking103 terms Carolina_Pauta Chapter 5: Nursing Process & Critical Thinking34 terms Shanu_LoyaPlus Nursing Process/Critical Thinking223 terms emeraldsky7 Chapter 4 - Tissue40 terms kemelypaola Other sets by this creatorCH.30 Health Promotion for Infant, child…59 terms Abbottce8Plus HEALTH PROMOTION AND PREGNANCY40 terms Abbottce8Plus ATI MEDSURG Q'S65 terms Abbottce8Plus SENSORY13 terms Abbottce8Plus Recommended textbook solutionsPharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 388 solutions
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In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met expected outcomes quizlet?In the five-step nursing process, the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes.
What phase of the nursing process identifies nursing actions designed to help a patient achieve a goal?Planning (the identification of nursing actions designed to help a patient achieve a goal occurs during the Planning step of the Nursing Process).
What are the 5 stages of the nursing process?The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment. ... . Diagnosis. ... . Outcomes / Planning. ... . Implementation. ... . Evaluation.. |
During which of the five steps in the nursing process does the nurse determine whether outcomes of care are achieved quizlet?
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