ANSWERS WITH COMPLETE SOLUTIONS GRADED A++
Initial Assessment
Planning phase that is developed by the nurse who performs the nursing history and
physical assessment. Addresses each problem listed in the prioritized nursing
diagnosis.
Identifies appropriate patient goals and related nursing care
ongoing planning
■ Carried out by any nurse who interacts with patient
■ Keeps the plan up to date, manages risk factors, promotes function
■ States nursing diagnoses more clearly
■ Develops new diagnoses
■ Makes outcomes more realistic and develops new outcomes as needed
■ Identifies nursing interventions to accomplish patient goals
Dishcharge Planning
■ Carried out by the nurse who worked most closely with the patient
■ Begins when the patient is admitted for treatment
■ Uses teaching and counseling skills effectively to ensure that home care behaviors
are performed
competently
Guidelines for Discharge Planning
, ● Assess and identify health care needs, Set goals with patient, Teach patient and
family, Provide home health care referrals, Evaluate discharge planning effectiveness.
Admissions To Hospital
○ Admission sheet becomes part of the medical record.
○ Bracelet is placed on the wrist of the patient.
○ A nursing interview and physical assessment are conducted.
○ A room is prepared for patient
○ Information Obtained on the Admission Sheet
Information Obtained on the Admission Sheet
■ Name, address, and date of birth of patient
■ Gender and marital status
■ Name of admitting physician
■ Name of nearest relative
■ Occupation and employer
■ Financial status for health care payment
■ Religious preference
■ Date and time of admission/admitting diagnosis
■ Identification number
Considerations When Delegating Nursing Care
■ Patient's condition
■ Complexity of the activity
■ Potential for harm
■ Degree of problem solving& innovation necessary