PNR 104 Exam 2 (Answered) Verified Solution
Steps of the nursing process in order
Assessment, nursing dx, planning, implementation, and evaluation
Assessment and nursing DX
RN's are responsible for this part of the nursing process
Data Collection
LPN's main role in nursing process
Documentation of the plan
Should be constructed right after the admission database is collected. Must be readily
available to each nurse who is assigned to the patient. (Reviewed & updated once
every 24 hrs.)
Problem solving process steps
define the problem clearly, consider all possible alternatives as solutions to the problem,
consider the possible outcomes for each alternative, predict the likelihood of each
outcome occurring, choose the best alternative with the fewest undesirable outcomes.
A medical diagnosis is never included in a nursing diagnosis
True (example: stroke, MI)
Nursing diagnosis =
problem + etiology +signs and symptoms
Etiology
causes of the problem
Defining characteristics
characteristics that must be present for a nursing DX
Constructing a nursing care plan
assess the pt, analyze the data, identify nursing problems, prioritize, make goals, write
expected outcomes, and choose interventions.
purposes of charting
written record of history, treatment, care, claims for reimbursement, and evidence in
court
6 main methods of documentation
source-oriented (narrative) charing, problem oriented medical record charting (POMR)
focus charting, charting by exception, computer assisted charting, and case
management system charting.
source oriented charting (narrative)
narrative notes are phrases and sentences written without any standardized structure.
benefits of this method are that it gives info on pt condition in chronological order,
indicates pt baseline for each shift, and includes aspects of all steps in the nursing
process
POMR
focuses of patient status, emphasizing a problem solving approach. contains 5 steps -
the data base, problem list, plan, progress note, and the discharge summary. This
format is known as a SOAP(IE) note.
s- subjective o - objective a- assessment p- plan i- implementation e- eval
focus charting
, similar to POMR but it substitutes focus for the problem. 3 parts to this form of
documentation are D - data A- action R- response (DAR)
Advantage is that it keeps all relevant data to a problem in one place.
Charting by exception
decreases lengthy narrative entries to reduce repetition of data.
computer assisted charting
electronic health record (EHR)
case management system charting
method of organizing patient care through an episode of illness so that clinical
outcomes are achieved in expected time and kept at a predictable cost. NOT good for
court.
Factors effecting communication
emotions, culture, mood, past experience, attitude
reflection
reflects received message back to the pt, encourages further explanation from patient
focusing
asking a goal directed questions that helps the pt focus on key concerns
ex - "do you have any questions about your chemotherapy?"
Encouraging elaboration
helps the pt describe more fully
ex - "tell me what that felt like"
silence
allows patient time to gather thoughts and sort them out.
therapeutic touch
take into consideration their culture
portuguese may find it reassuring, Koreans and japanese may find it offensive
SBAR
situation, background, assessment, recommendation
effectively communication with a hearing impaired patient
use short simple sentences, maintain a distance of about 2.5-4 ft, never shout, non
verbal communication, short simple sentences
2 main reasons why proper body mechanics are important
1. the body functions best in anatomic position.
2. prevents injury
Hazards of improper alignment
ulcers, cramps, pulmonary edema,
supine position
pt resting on their back, recommended after spinal surgeries
Fowler position
elevating the head of the bed 60-90 degrees
semi-fowler position
30-60 degrees
low-fowler position
15-30 degrees
Fowler's positions may help pt's who
had a stroke and has paresis to swallow food and secretions
Steps of the nursing process in order
Assessment, nursing dx, planning, implementation, and evaluation
Assessment and nursing DX
RN's are responsible for this part of the nursing process
Data Collection
LPN's main role in nursing process
Documentation of the plan
Should be constructed right after the admission database is collected. Must be readily
available to each nurse who is assigned to the patient. (Reviewed & updated once
every 24 hrs.)
Problem solving process steps
define the problem clearly, consider all possible alternatives as solutions to the problem,
consider the possible outcomes for each alternative, predict the likelihood of each
outcome occurring, choose the best alternative with the fewest undesirable outcomes.
A medical diagnosis is never included in a nursing diagnosis
True (example: stroke, MI)
Nursing diagnosis =
problem + etiology +signs and symptoms
Etiology
causes of the problem
Defining characteristics
characteristics that must be present for a nursing DX
Constructing a nursing care plan
assess the pt, analyze the data, identify nursing problems, prioritize, make goals, write
expected outcomes, and choose interventions.
purposes of charting
written record of history, treatment, care, claims for reimbursement, and evidence in
court
6 main methods of documentation
source-oriented (narrative) charing, problem oriented medical record charting (POMR)
focus charting, charting by exception, computer assisted charting, and case
management system charting.
source oriented charting (narrative)
narrative notes are phrases and sentences written without any standardized structure.
benefits of this method are that it gives info on pt condition in chronological order,
indicates pt baseline for each shift, and includes aspects of all steps in the nursing
process
POMR
focuses of patient status, emphasizing a problem solving approach. contains 5 steps -
the data base, problem list, plan, progress note, and the discharge summary. This
format is known as a SOAP(IE) note.
s- subjective o - objective a- assessment p- plan i- implementation e- eval
focus charting
, similar to POMR but it substitutes focus for the problem. 3 parts to this form of
documentation are D - data A- action R- response (DAR)
Advantage is that it keeps all relevant data to a problem in one place.
Charting by exception
decreases lengthy narrative entries to reduce repetition of data.
computer assisted charting
electronic health record (EHR)
case management system charting
method of organizing patient care through an episode of illness so that clinical
outcomes are achieved in expected time and kept at a predictable cost. NOT good for
court.
Factors effecting communication
emotions, culture, mood, past experience, attitude
reflection
reflects received message back to the pt, encourages further explanation from patient
focusing
asking a goal directed questions that helps the pt focus on key concerns
ex - "do you have any questions about your chemotherapy?"
Encouraging elaboration
helps the pt describe more fully
ex - "tell me what that felt like"
silence
allows patient time to gather thoughts and sort them out.
therapeutic touch
take into consideration their culture
portuguese may find it reassuring, Koreans and japanese may find it offensive
SBAR
situation, background, assessment, recommendation
effectively communication with a hearing impaired patient
use short simple sentences, maintain a distance of about 2.5-4 ft, never shout, non
verbal communication, short simple sentences
2 main reasons why proper body mechanics are important
1. the body functions best in anatomic position.
2. prevents injury
Hazards of improper alignment
ulcers, cramps, pulmonary edema,
supine position
pt resting on their back, recommended after spinal surgeries
Fowler position
elevating the head of the bed 60-90 degrees
semi-fowler position
30-60 degrees
low-fowler position
15-30 degrees
Fowler's positions may help pt's who
had a stroke and has paresis to swallow food and secretions
