Exam 2 Study Guide NUR2115 Fundamentals of nursing exam 2 study guide Kissairy Gomez perez Rasmussen summer ‘19 Module 4 – clinical judgement and nursing process The nursing process - is a systematic method that directs the nurse and patient, as together they accomplish the following: (1) assess the patient to determine the need for nursing care, (2) determine nursing diagnoses for actual and potential health problems, (3) identify expected out- comes and plan care, (4) implement the care, and (5) evaluate the results.• Systematically collect patient data (assessing) • Clearly identify patient strengths and actual and potential problems (diagnosing) • Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning) • Execute the plan of care (implementing).
An example of the nursing process in action:
Assessing You are checking on a patient who had abdominal surgery yesterday and hear that the patient has considerable pain: “It kept me up all night.” The patient has been reluctant to ask for any pain medication, fearing effects of the drug. “I don’t want to become a junkie.” The patient’s blood pressure and pulse rate are slightly elevated.Diagnosing You analyze the data just described and write the nursing diagnosis: Unrelieved pain related to a fear of taking pain-relieving medications. The patient agrees that this is becoming a problem.Outcome Identification and Planning You decide to work with the patient to achieve the outcome: By 3:00 pm, patient reports sufficient relief of pain to enable him to rest and to get out of bed to go to the bathroom. The patient wants to accomplish the outcome. You identify teaching as the primary nursing intervention.Implementing After asking the patient about his experiences with pain- relieving medications, you explain that although many of these drugs are addictive when abused, there is no harm if they are taken as prescribed postoperatively. You also explain that it is important for him to experience enough pain relief to be able to cough and deep breath, ambulate, and do other things important to his recovery. You suggest that the medication will be most effective if taken before his pain peaks 1 / 3
Exam 2 Study Guide NUR2115 and becomes intense. You administer the prescribed medication for pain when the patient indicates that he is willing to give it a try.Evaluating After enough time has elapsed for the medication to take effect, you check back with the patient to evaluate whether he has obtained relief and met his outcome. If the patient is satisfied and you both feel that comfort is no longer a problem, you terminate the plan of care for this diagnosis. If the patient still feels pain or is dissatisfied with the medication, each of the preceding steps of the nursing process is re-evaluated, and necessary changes are made in the plan of care.Nursing process continues… Assessing is the systematic and continuous collection, analysis, validation, and communication of patient data, or information.Assessing - Preparing for data collection • Collecting data • Indentifying cues and making inferences • Validating data • Clustering related data and indentifying patterns • Reporting and recording data Types of assessments
Nursing assessments include:
comprehensive initial assessment focused assessment emergency assessment time-lapsed assessment Initial assessment The initial assessment is performed shortly after the patient is admitted to a health care agency or service.Focused Assessment In a focused assessment, the nurse gathers data about a specific problem that has already
been identified. Helpful questions include:
• What are your signs and symptoms? • When did they start? • Were you doing anything different than usual when they started? • What makes your symptoms better? Worse? • Are you taking any remedies (medical or natural) for your symptoms? 2 / 3
Exam 2 Study Guide NUR2115 Emergency Assessment When a physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life- threatening problems. A long-term care facility resident who begins choking in the dining room, a bleeding patient brought to the emergency department with a stab wound, an unresponsive patient in the rehabilitation unit, and a factory worker threatening violence are all candidates for an emergency assessment.Time-lapsed Assessment The time-lapsed assessment is scheduled to compare a patient’s current status to the baseline data obtained earlier. Most patients in residential settings and those receiving nursing care over longer periods of time, such as home- bound patients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the plan of care. This assessment can be comprehensive or focused Collecting DATA
There are two types of data: subjective and objective.
Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, or chilly, and experiencing pain. Subjective data also are called symptoms or covert data.Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient. Examples of objective data are an elevated temperature reading (e.g., 101°F), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or overt data Sources of data Patient - The patient is the primary and usually the best source of information.Family and Significant Others - Family members, friends, and caregivers are especially helpful sources of data when the patient is a child or has limited capacity to share information with the nurse.Patient Record - Records prepared by different members of the health care team provide information essential to comprehensive nursing care.Assessment Technology - Nurses can also gain valuable data about patients from technologies such as cardiac and respiratory monitors.Methods of data collection The nursing history and physical assessment are primary components of data collection
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