Quiz 3 & 4: The Nursing Process/Vital Signs/Documentation/Admission, Transfer, Discharge (UNITEK) - Q & A Nursing Process (ADPIE) five-step systematic
... [Show More] method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating Nursing Diagnosis describes a health problem that can be treated by nursing measures; a step in the nursing process Medical diagnosis the identification of a disease or condition by a doctor Medical diagnosis vs nursing diagnosis Medical Diagnosis: is used to evaluate the cause or etiology of disease Nursing Diagnosis: clinical judgments about a person’s response to an actual or potential health state NANDA-I North American Nursing Diagnosis Association International a professional nursing organization that provides standardized language to identify patient problems and plan customized care everywhere. Basically puts everyone on the same page for continuity of care Direct care Deals directly with the patients such as a hospital, nursing home, physician practice, and assisted living facilities. Subjective based on or influenced by personal feelings, tastes, or opinions Objective Factual, related to reality or physical objects; not influenced by emotions, unbiased 5 Purposes for Patient Records 1) Documented Communication 2) Permanent Record for Accountability 3) Legal Record of Care 4) Teaching 5) Research and Data Collection OBRA Omnibus Budget Reconciliation Act of 1987. Purpose is to improve the quality of life of nursing center residents. Nursing Care Plan includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation. Two primary methods of collecting patient data? Interview patient & physical exam Focused assessment assessment conducted to assess a specific problem; focuses on pertinent history and body regions During which phase of the nursing process does the nurse identify the problem? Assessment What will a nurse do during the last phase of the nursing process.... A nurse will evaluate the desired outcomes vs the actual outcomes How do you take temporal lobe Vital Signs differently for an adult and child? (Tympanic Pulse) Adult: lobe (pinna) pulled up and back Child: lobe (pinna) pulled down and back Factors that influence pulse rates Age Exercise Fever, heat Hemorrhage Medications Metabolism Postural changes Pulmonary Conditions Unrelieved severe pain/ chronic pain Factors that affect body temp Exercise Hormonal Influences Daily Variations (diurnal) Stress Environment Food ingestion and liquids (hot and cold) Smoking Celsius to Fahrenheit (C x 1.8) + 32 = F Fahrenheit to Celsius (F - 32) / 1.8 = C [Show Less]