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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
2. Hearing
3. Touch
4. Smell
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
2. Problem Focused Care Plan
The assignment sheet tells you about
1. Each person's care needs.
2. Nursing unit tasks to perform.
3. What measures and tasks need to be done.
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
2. Ask about their preferences
3. Tell the nurse about your observations
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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