centered. Rather than simply approaching a patient to take vital signs, the nurse thinks,
"How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals?
How can we better help her?" This demonstrates which characteristic of the nursing
process?
a. Systematic
b. Interpersonal
c. Dynamic
d. Universally applicable in
e. nursing situations
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b,
interpersonal. All of the other options are characteristics of the nursing
process, but the conversation and thinking quoted best illustrates the
interpersonal dimension of the nursing process.
objective data
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information perceptible to the senses; may be verified by another person
(the nurses thought / evaluation. What are the two types of data?
inference
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the judgment reached about a cue
What is in medical records?
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medical history, care plan, assessment, lab results, kardex, orders, graphics ,
demographics, social history
,What does SOAP stand for?
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subjective, objective, assessment, plan
Insurance providers, medicare, medicaid and other agencies require specific
____________________ ______________________. nurses must be aware of regulating agencies and
requirements
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documentation records
What is important to remember about pt-centered care?
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this is what the pt will do, not what the nurse will do
focused assessment
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, assessment conducted to assess a specific problem; focuses on pertinent
history and body regions
FORMULATION OF NURSING DIAGNOSIS: "Wellness" diagnosis
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Describes human responses to health conditions or life processes.
(a healthy preventative dx)
observation:
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conscious and deliberate use of the five senses to gather data
Implement
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carry out the plan of care
List the parts of the nursing diagnosis:
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