Patient Assessment and Prioritization

<p>Breathing (A)</p> Signup and view all the answers

<p>Additional laboratory test results (D)</p> Signup and view all the answers

<p>Evidence supporting the efficacy of interventions (A)</p> Signup and view all the answers

<p>Identify significant patient problems or conditions (A)</p> Signup and view all the answers

<p>Patient's ability to pay for treatment (D)</p> Signup and view all the answers

<p>High levels of nutritional deficiency (A)</p> Signup and view all the answers

<p>Forcing the patient to discuss their feelings (B)</p> Signup and view all the answers

<p>Realistic and patient-centered approaches (A)</p> Signup and view all the answers

<p>To validate nursing actions and their impact on patient outcomes (A)</p> Signup and view all the answers

<p>Repositioning a patient (D)</p> Signup and view all the answers

<p>Seek clarification (A)</p> Signup and view all the answers

<p>A nurse working with a physical therapist to optimize patient mobility (B)</p> Signup and view all the answers

<p>Rooted in scientific research and proven methods (B)</p> Signup and view all the answers

<p>What actions should be taken immediately to address the patient’s needs? (C)</p> Signup and view all the answers

<p>Dependent intervention (D)</p> Signup and view all the answers

<p>Achievable with available resources (C)</p> Signup and view all the answers

<p>Review the care plan and ensure qualifications (A)</p> Signup and view all the answers

<p>Measuring the achievement of specified goals (A)</p> Signup and view all the answers

<p>Blood Pressure (BP) (A)</p> Signup and view all the answers

<p>The caregiver's knowledge of medication doses (C)</p> Signup and view all the answers

<p>A gastrointestinal infection (D)</p> Signup and view all the answers

<p>Increase in appetite and hydration (D)</p> Signup and view all the answers

<p>Implementing alternative therapies (D)</p> Signup and view all the answers

<p>Identifying potential causes of symptoms (D)</p> Signup and view all the answers

<p>Fever indicating an infection (C)</p> Signup and view all the answers

<p>Bilingual communication barriers (D)</p> Signup and view all the answers

<p>Physical symptoms and vital signs (D)</p> Signup and view all the answers

<p>By adapting care plans based on patient-specific information. (D)</p> Signup and view all the answers

<p>Information obtained from family members. (B)</p> Signup and view all the answers

<p>Using a mix of subjective and objective assessment techniques. (B)</p> Signup and view all the answers

<p>It provides a structured approach that informs decision-making at each stage. (A)</p> Signup and view all the answers

<p>It integrates the best available research with clinical expertise and patient values. (C)</p> Signup and view all the answers

<p>Ignoring discrepancies within data. (A)</p> Signup and view all the answers

<p>Throughout all stages, from assessment to evaluation. (A)</p> Signup and view all the answers

<p>Subjective data may be influenced by personal biases and perceptions. (C)</p> Signup and view all the answers

<p>To assess the effectiveness of nursing interventions and adjust care as needed. (B)</p> Signup and view all the answers

<p>Openness to alternative perspectives and ongoing reflection. (A)</p> Signup and view all the answers

The nursing process is a systematic framework used to guide patient care. It involves five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Clinical judgment is the thinking and decision-making process that nurses use during the nursing process to tailor care to individual patients.

Assessment is the first step of the nursing process. It involves gathering, organizing, validating, and documenting client data to form a complete picture of their health status.

Data collection is the process of gathering information about a patient. This includes observing, interviewing the patient, and reviewing their medical records.

Subjective data represents what the patient tells you about their condition. Examples include pain level, feelings, beliefs, or thoughts.

Objective data is information that you observe or measure yourself during the assessment. This can include vital signs, physical exam findings, or lab results.

Primary data is information directly gathered from the patient during a physical assessment or interview.

Secondary data comes from medical records, other healthcare providers, or family members. It's information gathered from sources other than the patient.

Organizing data involves taking all the information gathered during assessment and structuring it in a meaningful way. This helps make sense of the patient's situation and identify patterns.

Prioritization involves deciding which patient needs are most urgent and require immediate attention. It involves using clinical judgment to determine the order of care.

Actions nurses can take independently, without a provider's prescription. Examples: repositioning a client, providing emotional support.

Actions prescribed by a physician or advanced practice nurse, carried out by the nurse. Examples: medications, treatments, IV therapy.

Actions performed in collaboration with other healthcare team members. Examples: working with physical therapists, physicians, etc.

A standardized plan of care that outlines the expected course of treatment for a specific condition or procedure.

A set of instructions or guidelines designed to ensure consistent, safe, and effective care for specific situations or conditions.

The 'doing' and 'delegating' of planned interventions. Includes documenting nursing actions.

Reviewing the care plan, ensuring qualifications, and seeking clarification for unclear orders before implementing interventions.

Determining which interventions are most appropriate for the patient's needs and priorities.

Deciding the order of nursing actions based on urgency and importance.

Assessing when to report events or concerns to the healthcare team, manager, or other relevant personnel.

A comprehensive assessment is a detailed evaluation that covers all aspects of a patient's health status, including their physical, mental, and social well-being. It is typically performed when a patient is first admitted to a healthcare facility.

A focused assessment is directed at a specific body system, symptom, or concern. It is typically used when a patient presents with particular symptoms or requires follow-up after a previous assessment.

Ongoing assessments are conducted regularly to monitor a patient's progress and identify any changes in their condition. These assessments can be brief or comprehensive, depending on the patient's needs.

Analyzing cues involves applying your nursing knowledge and skills to interpret the patient's findings, recognizing patterns, and considering potential causes or diagnoses.

Prioritizing problems involves ranking patient concerns based on urgency, potential consequences, and patient preferences. This ensures you address the most critical needs first.

The ABCDE approach helps prioritize patient care by addressing life-threatening issues first. A stands for airway, B for breathing, C for circulation, D for disability (neurological status), E for exposure (environmental factors).

Generating solutions involves formulating a plan of care based on the patient's assessed needs. This includes identifying appropriate interventions, evidence-based practices, and potential risks.

Hypotheses are potential explanations for the patient's condition. They are based on your assessment findings and your nursing knowledge.

Outcomes are the desired results of your nursing interventions. They should be specific, measurable, achievable, relevant, and time-bound.

Interventions are the actions you take to address the patient's needs and promote positive outcomes. They should be evidence-based and tailored to the individual patient.

A process where the nurse and patient work together to measure how well the patient has achieved their goals.

Specific, measurable, achievable, relevant, and time-bound statements describing the desired outcome.

Assessing whether a goal has been fully met, partially met, or not met at all.

Collecting information about a patient's condition that helps determine if their health is improving.

Evaluating the effectiveness of interventions by observing their impact on the patient.

Considering potential diagnoses based on a patient's symptoms.

Deciding on the best interventions based on the prioritized diagnosis.

Evaluating if both the patient and caregiver understand the care plan.