What is subjective data?
Data obtained from the patient verbally. They are SYMPTOMS.
Examples = headache, tingling in the feet, pain,
... [Show More] nauseated
What is objective data?
Info obtained through the senses and hands-on physical examination. They are SIGNS.
Examples = vital signs, physical examination findings (bruises), results of diagnostic tests, patient inability to support themselves, number of visitors
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What is the initial goal of the patient interview?
Find out the patient's major complaints, performs a physical examination, and determine the patient's overall health status.
When/how often do you assess patients during your shift?
After the admission assessment, each patient should be visited and assessed during the first hour of each shift. Perform a head-to-toe examination, which should take about 10 minutes.
What is NANDA-I?
North American Nursing Diagnosis Association-International.
Formulates diagnostic labels. The list of diagnostic labels is used to form the first part (stem) of the nursing diagnoses used in nursing care plans and is revised every 2 years.
What does a nursing diagnosis consist of?
It is a statement that indicates the patient's actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms).
What is the construction of a nursing diagnosis?
Problem + Etiology (cause) + signs and symptoms
What is an etiology factor?
Cause of the problem.
What is a sign?
Abnormalities that can be verified by repeat examination and are objective data.
Example = bruise
What is a symptom?
Factors the patient has said are occurring that cannot be verified by examination; they are subjective data.
Example = headache
How are nursing diagnosis prioritized?
Priorities of care are set so that the most important interventions for the high-priority problems for each patient are attended first. Then, as time permits, the lower-priority problems are considered.
Once the nursing diagnosis have been formulated, they are ranked according to their importance. This order can be guided by the hierarchy of needs adopted from Maslow, by the patient's beliefs regarding the importance of each problem, and by what is most life threatening or problematic for the patient.
True or false?:
Physiological needs (basic survival needs) take precedence over everything. One of the first rules concerning priorities of care is that the airway ALWAYS comes first.
True
A __________ is a broad idea of what is to be achieved through nursing intervention.
goal
What are short-term goals?
Goals that are achievable within 7 to 10 days or before discharge.
What are long-term goals?
Goals that take weeks or months to achieve.
What are expected outcomes?
Derived from goals. It is a specific statement regarding the goal the patient is expected to achieve as a result of nursing intervention.
It should be realistic and attainable, have a defined time line and be a collaboration with the patient and health care professionals involved with the patient's care.
What is an assessment?
Gathering info about patients and their needs using a variety of methods. During this phase of the nursing process, data are systematically obtained, organized into a logical database and documented.
Who performs an assessment?
A RN is designated as the staff member who must perform the initial admission assessment of each patient. However, the LVN is often asked to assist with this task and participates in carrying out the plan by continuing to collect data.
What are the 3 basic stages of an interview?
1. The opening, when rapport is established with the patient
2. The body of the interview, when the necessary questions are presented
3. The closing segment
What info is documented in the face sheet?
Age, sex, martial status/significant other, religion, occupation, residence, next of kin and address, allergies, insurance status.
What info is documented in physician's orders?
Admitting diagnosis, date of admission; current orders regarding diet, activity, frequency of vital signs measurement, daily weight, treatments, medications, diagnostic tests ordered, IV fluids, therapies ordered.
What info is documented in nurse's notes?
Patient status during the last 24 hours.
What info is documented in physician's progress notes?
Findings from the last 2 days; status of problems.
What info is documented in medication administration record (MAR)?
Medications received, frequency of PRN medications, allergies.
What info is documented in physician's patient history and physical?
Current complaint, chronic problems, physical finding abnormalities, allergies, impressions.
What info is documented in surgery operative report?
Procedure done, organs removed, type of incision, drains or equipment in place, blood loss, problems during surgery.
What info is documented in pathology report?
Presence of malignancy or infection
What info is documented in current diagnostic tests?
Abnormal findings, CBC, UA, blood chemistries, x-ray films, culture and sensitivity, other tests.
What info is documented in nursing admission history and assessment?
Reason for hospitalization, average number of cigarettes smoked per day, average amount of alcohol consumer per day, last bowel movement, special diet requirements, use of aids or prostheses (hearing aid, eyeglasses), medications taken regularly, identification of significant other, previous hospitalizations or surgeries, baseline vital signs, physical abnormalities.
Inspection = ?
looking
Auscultation = ?
listening
Palpation = ?
touching
Percussion = ?
thumping
True or false?:
Usually the LVN collects data for the RN, who finalizes the assessment.
True
________ are pieces of data or info that influence decisions.
cues
How does a nursing diagnosis differ from a medical diagnosis?
A nursing diagnosis defines the patient's response to illness, while a medical diagnosis labels the illness. [Show Less]