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Assisting with the Nursing Process
A written guide about the care a person should receive is the | Comprehensive care plan |
The method nurses use to plan and deliver nursing care is the nursing | process |
Collecting information about a person is | assessment |
______________ is measure is taken by the nursing team. It helps a person reach a goal. | nursing intervention |
You make many observations when giving care. You should use your senses to | collect information about a person |
The nursing process focuses on the | person's nursing needs |
____________________ is the first step of the nursing process. | assessment |
If the nursing process is used correctly | nursing care is organized and has purpose |
Nursing diagnoses and medical diagnoses are the same. | False |
Information that you can see, hear, feel, or smell is | objective data |
Fever is a | sign |
Yellow urine is a | sign |
Itching is a | symptom |
Tingling is a | symptom |
Symptoms are __________ data. | subjective |
With every resident contact____________________is collected | new informaiton |
The Minimum Data Set [MDS] is required by | OBRA |
The MDS is | an assessment and screening tool |
The planning step of the nursing process involves | setting goals and priorities |
A nursing intervention | is a nursing action or a nursing measure |
The comprehensive care plan contains | goals for care |
The comprehensive care plan may be part of the Kardex. | True |
Heart attack is not a nursing diagnosis. | True |
Care is given during the _______________ step of the nursing process. | implementation |
Goals are aimed at the person’s highest level of well-being and function. | True |
__________ step in the nursing process involves measuring if the goals set were met. | evaluation |
The nursing process changes as the person’s needs change. | true |
The nurse communicates delegated tasks to you by using | an assignment sheet |
The resident has the right to take part in his or her care planning. | true |
The nursing process is on-going. It never ends. | True |
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
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style
factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions
or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and
long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Implementation
Nursing care is
implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.