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Assessment is
consists of gathering info about patients and their needs using a variety of methods.
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Data is
pieces of info on a specific topic.
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Database is
all the info gathered about a patient and documented.
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LPN/LVN is
often asked to assist with this task and participates in carrying out the plan by continuing to collect data.
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Focused assessment is
concerned with one very specific problem.
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Subjective data is
data obtained from the patient verbally.
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Subjective data examples are
- 1. I have a headache
- 2. I am nauseated
- 3. The sharp pain is in my hip
- 4. Ive been feeling really blue lately
- 5. Ive been lonely since my husband died
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Objective data is
information obtained through the senses and hands-on physical examination.
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Objective data examples are
- 1. Temperature 101.4 F
- 2. 135 mL emesis at 0820
- 3. Bruise on the right hip
- 4. Eyes downcast, flat affect
- 5. Only one visitor seen in room all day
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Interview consists of 3 stages
- 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 of the interview. discuss purpose of the interview
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Assessment is
an ongoing process, you will continue to gather data each time there is an encounter.
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When interviewing an elderly person,
allow more time because the person will prob have a more extensive history and may take a little longer to recall the needed info.
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Chart review is
a data collection tool that assists in obtaining the info needed to intelligently interview the pt or to prepare adequately for the days pt assignment.
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Assessment in Long-Term Care
- 1. for medicare pts every 90 days
- 2. functional assessment is performed ADL's
- 3. personal preference routine
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Assessment in Home Health Care
- 1. initial assessment performed at home by RN
- 2. lvn/lpn will assist in daily assessments and maintain necessary documents
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Cues are
pieces of data or information that influence decisions.
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Inferences are
conclusions made based on observed data.
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Nursing diagnosis
indicates the patient's actual health status or the risk of problem developing, the causative or related factors, and specific defining characteristics(signs and symptoms)
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Medical diagnosis is
never included in the construction of the nursing diagnosis.
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Etiologic factors are
the cause of the problem.
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Signs are
abnormalities that can be verified by repeat examinations and are objective data.
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Symptoms are
data the patient has said are occuring that cannot be verified by examination. symptoms are subjective data.
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Defining characteristics are
those characteristics (signs and symptoms) that must be present for a particular nursing diagnosis to be appropriate for that person.
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Airway
always comes first.
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Physiologic needs
for basic survival take precedence.
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Every nurse must
attempt to look at each pt holistically, keeping psychosocial needs in mind while working on physical problems.
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Goal is
a broad idea of what is to be achieved through nursing intervention.
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Short term goals are
those that are achievable within 7 to 10 days or before discharge.
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Long term goals
make take many weeks or months achieve. often relate to rehab.
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Expected outcome is
a specific statement of the goal the patient is expected to achieve as a result of nursing intervention.
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Expected outcome should be
realistic and attainable and should have a defined a time line.
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Nursing Outcomes Classification is to
- 1. identify, label, validate, and classify patient outcomes and indicators
- 2. field test the classfications for validations
- 3. define and test the measurement procedures to determine if the outcomes are met by the interventions that have been implemented.
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