AND CORRECT ANSWERS REVIEW
◉ elimination. Answer: act of removal of materials from the body; in
the digestive system, the removal of indigestible materials as feces
◉ Mobility Needs. Answer: Considerations for clients with physical
limitations.
◉ hygiene. Answer: conditions and practices that promote health
◉ Circulation/Perfusion. Answer: The supply of nutrients and
oxygen moving from the heart to the cells, organs and tissues via the
blood vessels
◉ Skin Integrity. Answer: Maintaining healthy skin to prevent
breakdown.
◉ Nursing Process. Answer: five-step systematic method for giving
patient care; involves assessing, diagnosing, planning, implementing,
and evaluating
,◉ Nursing Process: Assessment. Answer: Collection of data from
multiple sources
Review of clinical record
Interview
Health history
Physical examination
Functional assessment
Cultural and spiritual assessment
Consultation
Review of the literature
◉ nursing process: diagnosis. Answer: The purpose of the
diagnosing step is:
Identify how an individual, group, or community responds to actual
or potential health and life processes.
Identify factors that contribute to, or cause, health problems
(etiologies).
Identify resources or strengths on which the individual, group, or
community can draw to prevent or resolve problems.
,◉ NANDA. Answer: North American Nursing Diagnosis Association,
purpose is to define, refine, and promote a taxonomy of nursing
diagnostic terminology of general use to professional nurses.
◉ 3 parts of nursing diagnosis. Answer: PES
Problem - ex. acute pain
Etiology - R/T tissue trauma
Signs/Symptoms - AEB abdominal wound, rating of pain 8/10, facial
grimacing, ^BP, moaning, guarding.
◉ Nursing process: planning. Answer: -establish priorities
-develop outcomes
-set timelines for outcomes
-identify interventions
-integrate evidence-based trends and research
-document plan of care
◉ How do you format the statement in planning?. Answer: SMART
goal
◉ Nursing smart goals. Answer:
, ◉ Nursing process: Intervention. Answer: Check vital signs before
and after activity
•Monitor labs and diagnostic reports (i.e ECG)
•Assess level of fatigue and the precipitating causes
•Provide assistance with self care and pace activities with periods of
rest
•Administer medications as per MD orders and measure
effectiveness of drug therapy
•Provide nutritional support
◉ Nursing process: Evaluation. Answer: - Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation
- Include patient and significant others
- Use ongoing assessment to revise diagnoses, outcomes, plan
- Disseminate results to patient and family
◉ ADPIE. Answer: • Assessment: 1st step, subjective and objective
data
• Diagnosis: analysis, formulation of nursing diagnosis
• Planning: prioritizing problems, determining goals, plan of care
• Implementation: nursing action (rather than medical action)
• Evaluating: comparing outcomes, communicate and document
findings