Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
52 Cards in this Set
- Front
- Back
|
Test
|
test
|
|
|
ANDPIE
5 Steps in the Nursing Process |
Assessment
Nursing Diagnosis Planning Implementation Evaluation |
|
|
Assessment
|
Collecting information about the person;
|
|
|
Nursing Diagnosis
|
Describes a health "problem" that can be treated by nursing measures.
A human response to a medical prblem - A Problem List NOT A MEDICAL DIAGNOSIS |
|
|
Planning
|
Setting priorities and goals
|
|
|
Implementation
|
DO IT - To perform or carry out nursing measures in the care plan
|
|
|
Evaluation
|
To measure if goals n the planning step were met
DID YOUR IMPLEMENTATION WORK? |
|
|
Goal
|
That which is desired for or by a person as a result of nursing care
|
|
|
Medical Diagnosis
|
The identification of a disease, condition or a treatment by a doctor
|
|
|
Nursing Care Plan
or Care Plan |
A written guide about the person's nursing care
|
|
|
Nursing Intervention
|
An action or measure taken by the nursing team to help the person reach a goal
|
|
|
Nursing Process
|
The method nurses use to plan and deliver nursing care; its five steps are...
|
|
|
5 Steps of the Nursing Process
|
ANDPIE
Assessment Nursing Diagnoses, planning, implementation, and evaluation |
|
|
Signs and Symptoms
|
Signs - Objective Data
Symptoms - Subjective Data |
|
|
Subjective Data
|
Things a person tells you about that you cannot observe through your senses
These are symptoms. Example: I feel nausious |
|
|
Objective Data
|
Information that is seen, heard, felt, or smelled by and observer
These are Signs Example: Vomit... it can be measured |
|
|
Oberservation
|
Using the senses of sight, hearing, touch,and smell to collect information.
Examples: sit, stand, walk, vitals, cold, warm, breath sounds, odors from elimination |
|
|
ADL
|
Activities of Daily Living
|
|
|
CAA
|
Care Area Assessment
|
|
|
IDCP
|
Interdisciplinary Care Planning
|
|
|
MDS
|
Minimum Data Set
|
|
|
NANDA-I
|
North American Nursing Diagnosis Association International
|
|
|
OASIS
|
Outcome and Assessment Informaton Set
|
|
|
OBRA
|
Omnibus Budget Reconciliation Act of 1987
|
|
|
RN
|
Registered Nurse
|
|
|
Examples of Assesment
|
Health History
Family's Health History (genetic) An RN will examine Body Systems and Mental Status |
|
|
Observations to Report at Once
9 |
Box 7-1 in book
Persons inability to respond Change in mobility Complaints of pain Difficulty Breathing Abnormal Respirations Difficulty Swallowing Vmitting Bleeding Vitals out side of normal range |
|
|
Basic Observations
10 |
Ability to Respond
Movement Pain or Discomfort Skin Eyes, Ears, Nose, and Mouth Respiration Bowels and Bladder Appetite Activities of Daily Living |
|
|
NANDA-I
10 Examples |
1. Anxiety
2. Dry Eye - or Risk for 3. Feeding - Self-Care Deficit 4. Infection - Risk For 5. Sleep Pattern - Disturbed 6. Cardiac Output - . . .. .........increased/decreased 7. Lifestyle:Sedentary 8. Pain:Acute / Chronic 9. Coping: Defensive, . . Ineffective 10. Fear |
|
|
Care Conference
|
an RN may conduct a care conference to share information and ideas about the person's care.
|
|
|
Example of a Nursing Diagnosis
|
Insomnia due to staying in hospital / noisy enviroment
|
|
|
Example of Goal
|
Patinet will report a restful sleep by 6/29/2012
|
|
|
Example of Intervention
|
Clse the door to patients room
Turn off TV or radio or low volume Ask staff to reduce unnecessary noise Turn off unneeded equipment |
|
|
c/o
|
Complains of
|
|
|
What are our resources for Assesment
2 |
Patient
and everything else (family, history, DR.) |
|
|
How do you create a care plan
4 |
1. Patient Directed (willed)
2. Measurable ex: ambualate 250' x 1 asst without distress Bid by 10/5/12 3. Time Frame 4. Realistic |
|
|
A Care plan is made for what amount of time?
2 |
Short Term
or Long Term |
|
|
Can a care plan state how the patient will feel in the future?
|
No, it's subjective
Can not use good bad ok and Yes, you can use the pain scale because it is objective. |
|
|
NA's role in the Care Plan
|
The process never ends...
Once the plan has been Evaluated -Where are they now? You start the process again ANDPIE |
|
|
REVIEW QUESTIONS...
Which is not a step in the A. Nursing Process B. Observation C. Assessment D. Planning E. Implementation |
A. Observation
|
|
|
The Nursing Process Involves
A. guidelines for care plans B. is a care conference C. Triggers D. is the method nurses use to plan and deliver nursing care |
D. is the method nurses use to plan and deliver nursing care
|
|
|
What happens during Assessment?
A. Goals are set? B. Information is collected C. Nursing measures are carried out D. Progress Evaluated |
B. Information is collected
|
|
|
Which is a Symptom?
A. Redness B. Vommitting C. Pain D. Pulse rate 78 |
C. Pain
|
|
|
Which is a sign?
A. Nausea B. Headache C. Dizziness D. Dry Skin |
D. Dry Skin
|
|
|
Which should you report at once?
A. a bowel movement B. complaints of sudden pain C. does not like their food E. complains of stiff painful joints |
B. Complaints of sudden pain
|
|
|
Which should you report at once?
A. The person and not move a body part? B. Answers questions correctly? C. The person has breath odor D. The person walked to the dining room |
A. The person and not move a body part?
|
|
|
Measures in the nursing plan are carried out... this is.
A. A nursing diagnosis B. Planning C. Implementation D. Evaluation |
C. Implementation
|
|
|
Which statement about the nursing process is true?
A. It is done without the person's input. B. You are responsible for it C. It is used to communicate the persons care. D. Steps can be done in any order. |
C. It is used to communicate the persons care
|
|
|
The Care Plan is?
A. Written by the doctor B. The measures to help the person C. The same for all persons D. Also called the Kardex |
B. The measures to help the person
|
|
|
What is used to communicate the nursing tasks delegated to you?
A. The care plan B. The Kardex C. An assignment sheet D. Care conferences |
C. An assignment sheet
|
|
|
Which is a Nursing Diagnosis?
A. Cancer B Heart attack C. Kidney failure D. Chronic pain |
D. Chronic pain
|
|
|
Kardex
|
A type of card file that summarizes information found in the medical record - drugs, treatments, diagnoses, routine care measures, equipment, and special needs
|
