Chapter 5-Assessment, Nursing Diagnosis and Planning
What are four measurable vital signs?
Temperature Pulse rate Respiration Blood pressure
Nonverbal communication is an ___________form of communication.
objective
True or False: Extensive assessments are done every shift when a patient is in a Long Term Care facility.
False. Reassessments are done per facility policy or if there is a change in the patient's condition.
Name three different approaches to assessment (data collection).
Gordon's Functional Health Patterns Focused assessment Basic needs assessment based on Maslow's hierarchy of needs
Name four techniques used in a physical exam.
Inspection Auscultation Palpation Percussion
What does a nursing diagnosis indicate in a patient?
It indicates their actual health status or the risk of a problem developing, causative or related factors and signs and symptoms.
Define "expected outcome" in relation to the Planning phase of the Nursing Process.
It's a specific statement regarding the goal the patient is expected to achieve. It should be realistic, attainable and have a defined time line.
How does a nursing diagnosis differ from a medical diagnosis?
Nursing diagnoses deal with human response to health problems that the nurse is licensed and competent to treat. Medical diagnoses deal with a disease or medical condition.
When prioritizing nursing diagnoses what needs take precedence?
Physiologic needs. Airway being the highest priority of the physiologic needs.
What are the interventions in the nursing process supposed to accomplish?
They are there to eliminate problems and achieve expected outcomes. Example: administering a blood pressure med to keep a patient's blood pressure within normal range.
What type of communication is considered subjective?
Verbal
For a patient receiving home health care, the initial assessment is performed by ________.
an RN. After that assessments can be done by an LPN with any changes being reported to the RN in charge.