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Nursing diagnosis -ANSWERS--Analyze data
-Identify health problems, risks, and strengths
-Formulate diagnostic statements
Planning -ANSWERS--Prioritize problems and diagnoses
-Formulate goals and designed health outcomes
-Identify nursing interventions
Implementation -ANSWERS--Reassess the patient
-Determine the nurse's need for assistance
-Implement nursing interventions
-Supervise delegated care
-Document nursing activities
Evaluation -ANSWERS--Collect data related to outcomes
-Complete data with outcomes
-Relate nursing actions to patient goals/outcomes
-Draw conclusions about problem status
-Continue, modify, or end the patient's care plan
Focused assessment -ANSWERS--Gathers specific details about the presenting concern to either
confirm or rule out abnormalities
,Time-lapsed assessment -ANSWERS--To reevaluate the patient's status and identify whether
the condition has improved, worsened, or stayed the same
Emergency assessment -ANSWERS--To ensure the patient has a patent airway, is breathing, and
has adequate circulation
-To identify the primary cause of the problem
Types of data -ANSWERS--Subjective-What the patient says (sometimes patient's family)
-Objective-What the nurse collects or observes (physical assessment, medical records, patient
sometimes)
Health interview -ANSWERS-A health *interview* is a structured interaction between you and
the patient. The *rules* governing this interaction should be *clearly outlined and agreed on*
by you and the patient at the start of the interview. Your mutual *goal* is the *patient's
optimal health*.
-Provides opportunity for communication, gathering information, and form a therapeutic
relationship with the patient
Assessment tools -ANSWERS--Stethoscope
-Blood pressure cuff
-Thermometer
-Etc
-4 of 5 senses
Four senses to use -ANSWERS-Sight- Colour of patient's skin, presence of abnormal movement,
patient's level of consciousness, patient's response to touch
Smell-Unique smells
Touch-Changes in skin temperature or fluid volume
Sound
, 5 vital signs -ANSWERS-1. temperature
2. pulse
3. respirations
4. blood pressure
5. oxygen saturation
(6. pain)
ways to measure temperature -ANSWERS--Orally
-Rectally
-Tympanic membrane
-Temporal artery
-Axillary
Causes of clinical alteration in temperature -ANSWERS--Infection
-Inflammatory response
-Deteriorating patient status
-Thermoregulatory disorders
Normal respiration rate -ANSWERS-12-20 breaths per minute
Bradypnea -ANSWERS--Abnormally slow breathing
-Less than 10 breaths/minute
Tachypnea -ANSWERS--Rapid breathing
-More than 24 breaths/minute, shallow