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Terms in this set (95)Assessment Collecting information about the person; a step in the nursing process Evaluation To measure if goals in the planning step were met; a step in the nursing process.
Goal That which is desired for or by a person as a result of nursing care. Implementation To perform or carry out nursing interventions (nursing measures or nursing actions) in the care plan; a step in the nursing process. Medical Diagnosis Describes a health problem that can be treated by nursing measures; a step in the nursing process. Nursing Intervention An action or measure taken by the nursing team to help the person reach a goal; nursing action, nursing measure. Nursing Process The method nurses use to plan and deliver nursing care; its 5 steps are assessment, nursing diagnosis, planning, implementation, and evaluation. Nursing Care Plan A written guide about the person's nursing care; care plan. Nursing Diagnosis Describes a health problem that can be treated by nursing measures; a step in the nursing process. Objective Data Information that is seen, heard, felt, or smelled by an observer; signs. Observation Using the senses of sight, hearing, touch, and smell to collect information. Planning Setting priorities and goals; a step in the nursing process. Signs See "Objective Data". Subjective Data Things a person tells you about that you cannot observe through your senses; symptoms. Symptoms See "Subjective Data". BMs Bowel Movements CAA Care Area Assessment CMS Centers for Medicare & Medicaid Services IDCP Interdisciplinary Care Plan MDS Minimum Data Set OASIS Outcome and Assessment Information Set RN Registered Nurse Which is a step in the nursing process? Evaluation The nursing process Is the method nurses use to plan and deliver nursing care. What happens during assessment? Information is collected. Which is a symptom? Pain Which is a sign? Dry skin Which should you report at once? The person complains of sudden, severe pain. The person can no longer move a body part. What do you do? Report it at once. Measures in the care plan are carried out. This is Implementation Which statement about the nursing process is true? You are responsible for it. Which statement about care conferences is true? The person can refuse suggested actions. The care plan is The measures to help the person. To communicate delegated tasks to you, the nurse uses An assignment sheet. Which is a nursing diagnosis? Chronic pain Your role in the nursing process involves Reporting observations. These are things a person tells you about that you cannot observe trough your senses; symptoms. Subjective Data This is to perform or carry out measures in the care plan; a step in the nursing process. Implementation The method RNs use to plan and deliver nursing care is the Nursing Process Another name for subjective data is Symptoms A written guide about the person's care is the Nursing Care Plan This is collecting information about the person; a step in the nursing process. Assessment Another name for objective data is Signs This describes a health problem that can be treated by nursing measures; a step in the nursing process. Nursing Diagnosis Information that is seen, heard, felt, or smelled is Objective Data A step in the nursing process that is used to measure if goals in the planning step were met is called Evaluation This is setting priorities and goals; a step in the nursing process. Planning This is an action or measure taken by the nursing team to help the person reach a goal. Nursing Intervention This is that which is desired in or by the person as a result of nursing care. Goal Using the senses of sight, hearing, touch, and smell to collect information is Observation The identification of a disease or condition by a doctor is a Medical Diagnosis Which of these is not a step in the nursing process? Objective Data The nursing process focuses on The person's nursing needs When you observe by using your senses, you Assess the person. Which of these is an example of objective data you can collect? You are taking Mrs. Jensen's blood pressure and you notice her skin is hot and moist. When you take Mr. Young's blood pressure, you notice it is 50 points higher than when you took it in the morning. You Tell the nurse at once. A minimum data set (MDS) is used For nursing center residents The MDS is updated Only once a year. A nursing diagnosis Describes a health problem that can be treated by nursing measures. When a nurse uses the nursing process, the person is given As many nursing diagnoses as are needed. Planning involves all of these except Measuring whether all goals are met. A problem-focused is held When one problem affects the person's care CMS requires a comprehensive care plan. It is a written guide about the person's care What part of the nursing process is being carried out when you give personal care to a person? Implementation Nurses will measure if goals in the planning steps are met during Evaluation Bowel Movements BMs Care Area Assessment CAA Center for Medicare and Medicaid Services CMS Interdisciplinary Care Plan IDCP Minimum Data Set MDS Outcome & Assessment Information Set OASIS Registered Nurse RN When you make observations while you give care, what senses are used? 1. Seeing Is the abdomen firm or soft? Bowels Is the person sensitive to bright lights? Eyes Are sores or reddened areas present? Skin What is the frequency of the person's cough? Respirations Can the person bathe without help? ADL Can the person swallow food and fluids? Appetite What is the position of comfort? Pain or Discomfort Does the person answer questions correctly? Ability to Respond Does the person complain of stiff or painful joints? Movement An assessment and screening tool completed when the person is admitted to a long-term care center is called Minimum Data Set An MDS is updated before each Care Conference A new MDS is completed Every year When planning care, needs that are required for life and survival must be met before All other needs. Name the two resident care conferences used in long-term care. 1. Interdisciplinary Care Plan The assignment sheet tells you about 1. Each person's care needs. The nurse uses your observations for Nursing Diagnosis and Goals You may help develop the Care Plan You perform nursing actions and measures in the Implementation step Your observations are used for the Evaluation step When you learn skills and practice until you are comfortable performing the skills, it show you take Pride in learning your job well. To encourage independence and to help the person feel involved in his or her care, you can 1. Listen to the person When you keep your assignment sheets with you at all times and place them in the wastebasket for shredding at the end of your shift, it shows that you take pride in protecting the Privacy and security of protected health information. 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The client is discharged from the hospital and a licensed practical nurse is assigned for the nursing care of the client at home. This is an example of: 2 answers Which phase of the nursing process involves setting priorities and goals?The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
Is to perform or carry out measures in the care plan?CNA Terms Chapter 8. What is the order of the planning step components within the nursing process?What is the order of the planning step components within the nursing process? Prioritize nursing diagnoses->establish goals and outcomes->select interventions->create a plan of care.
Which step of the nursing process is when the nurse uses their sense of sight?Observation requires the nurse to use all their senses (sight, touch, smell, hearing) to learn about the patient.
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It is used to measure if goals in the planning step were met; a step in the nursing process.
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