EVCC NURS 110 Test #4, Part 1 With 100% Correct Answers 2023

EVCC NURS 110 Test #4, Part 1 With 100% Correct Answers 2023 Nursing Process ADPIE The way a nurse thinks to organize, prioritize care, and cultivate a habit of thinking at the bedside. ADPIE Assessment, Diagnosis, Planning, Intervention, Evaluation Assessment Immediate concern and used to arrive at nursing dx Diagnosis - problem 3 step (problem/label = constipation) RELATED TO (related factors/etiology/cause = abdominal surgery, pain meds, decreased ambulation, hypoactive bowel sounds, etc.) AS EVIDENCED BY (defining characteristics/S & Sx = hypoactive bowel sounds x4Q, nausea, pain 7/10) What is the patient's problem? why did they get what they got? How do I know the pt has a problem? Diagnosis - Risk 2 step (risk label = falls) AS EVIDENCED BY (risk factors = unsteady gait, age acute confusion, etc.) Has not yet occurred so there are no defining characteristics Diagnosis - Health Promotion Readiness to learn... Planning Identify and select goal for patient 3 elements - pt focused, measured by 1/5 senses, specific time frame Intervention take action, nurse focus, "will assess", and reassess as needed Assess and consult - 1 intervention each Problem focused Intervention related factors need to be modified or eliminated, also manage symptoms Risk focused Intervention need to remove or modify risk factors Health focused Intervention need to support pt and/or maximize desire Evaluation How effective was the intervention? Evaluate goal, assessment data, and interventions State if the goal was met and what you will do next Problem focused evaluation Evaluate pt goals, assess data, and assess effectiveness of nursing intervention Risk focused evaluation Evaluate changes in patients condition Heath focused evaluation Evaluate effectiveness of supportive nursing intervention and goals Dyspareunia painful sex GU female health Hx Include the stage of menopause Postmenopausal is 1 year with no period - if report of vaginal bleeding or spotting requires further workup GU male health hx Include any trouble peeing Prostate issue signs - nocturia, frequent urges, blood in urine/semen, pain, trouble peeing Include TSE - males 20+, once a month, during shower, looking for any bumps JVD or swollen feet Check Scrotum polyuria excessive urination olguria too little urination 30 mL/hr in adult Report this immediately - Indicates impaired blood flow to kidneys or impending renal failure GU assessment Health Hx an