Lecture Exam 3 for accelerated nursing program at LCC
Assessment, Outcome Identification, Nursing Diagnosis, Planning, Implementation, Evaluation, Interventions
Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, Evaluation
Assessment, Planning, Nursing Diagnosis, Outcome Identification, Implementation, Evaluation
Label
Related factors
Defining Characteristics
All the above
Signs and symptoms
Etiology
Signs and symptoms
Subjective and objective
Etiology
A and B
All the above
Risk for fluid volume deficit
Fluid volume deficit
Acute pain
Impaired airway clearance
C/o sharp discomfort to RLQ of abd
Tissue trauma from abd surgery
Tylenol #3 eases pain from 7/10-1/10
Grimacing when getting out of bed
Absent bowel sounds
Felling "bloated"
Abd distention
Surgical manipulation of the bowel
Acute confusion
Impaired memory
Risk for acute confusion
Disturbed thought processes
Awareness
Attention
Memory
Learning
Judgment
Awareness
Attention
Orientation
Awareness
Learning
Memory
Judgment
Awareness
Orientation
Memory
Learning
Sign
Symptom
Syndrome
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Dementia
Delerium
Male
Female
High cholesterol
Tau tangles
HTN
Male
Female
Equal
Affect
Aphasia
Apraxia
Agnosia
Affect
Aphasia
Apraxia
Agnosia
Affect
Aphasia
Apraxia
Agnosia
Reassess the pt
Examine the r/t
Analyze the secondary to factors
Review the DC
Diagnose if the pt is at risk for falls
Ensure that the pts skin is intact
Establish a therapeutic relationship
Identify important data
"I'm not sure that I am going to be able to manage at home by myself"
"I can call a home-care agency if I feel I need help at home"
"What should I do if I have uncontrollable pain at home"
"Will a home helath aide help me with my care at home"
Goal
Problem
Etiology
Implementation
Implementaion
Assessment
Evaluation
Diagnosis
Plan
Evaluate
Diagnose
Implement
Observing
Inspecting
Auscultation
Interviewing
Formulating a plan of care
Identifying the pts potential risks
Designing ways to minimize a pts stressors
Making decisions about the effectiveness of pt care
I am hungry
I feel very warm
I ate half my lunch
I have the urge to urinate
I just went to the urinal and it needs to be emptied
My pain fells like a 5 on a scale of 1 to 5
The dr said I can go home today
I only ate half my breakfast
Implementation
Evaluation
Diagnosis
Planning
Plan
Analyze
Diagnose
Implement
Is dynamic rather than static
Focuses on the role of the nurse
Moves from the simple to the complex
Is based on the pts medical problem
Teacher
Advocate
Surrogate
Counselor
Data
Problem
Rationale
Evaluation
DC
Outcome criteria
Etiology
Goal
Planning
Diagnosis
Evaluation
Implementation
Physicians history and physical
Social service record
Admission sheet
Progress notes
Diagnosis
Clustering
Collection
Assessment
Have a lower temp
Be give apirin every 8 hours prn
Be taught how to take an accurate temp
Maintain fluid intake sufficient to prevent dehydration
Establish outcomes
Determine priorities
Take corrective action
Set the time frames for goals
Implementation
Assessment
Diagnosis
Planning
DC
Planned interventions
Diagnostic statement
Related risk factors
Pain of 5 on a 1 to 1 scale
Irregular radial pulse of 50 bpm
Shortness of breath
Dizziness
R/t
Diagnostic label
Secondary factors
Medical diagnosis
Write a pt centered goal
Formulate a nursing diag
Design a plan of nurisng interventions
Determine the significance of the information
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