Care Planning
What phrase is used to begin a patient outcome in a care plan?
"Patient will..."
How many inches is considered to be an excessive amount of abdominal fat in males?
> 40
What kind of assessment is used when time is a factor and treatment must begin immediately?
Emergency assessment
What are the 3 types of nursing diagnoses?
1. Actual 2. Risk 3. Health Promotion
When lightly palpating, what are you looking for? (2)
1. Expression of pain 2. Masses
What 3 phrases can a care plan evaluation begin with?
1. Goal met 2. Goal not met 3. Goal partially met
What are the 3 types of implemented interventions?
1. Independent 2. Dependent 3. Collaborative
What information must be provided when noting an order? (4)
1. Name 2. Dose 3. Route 4. Frequency
What three things take place during the Assessment portion of ADPIE?
1. Observation 2. Interview 3. Physical Assessment
What are the 3 parts of an ACTUAL nursing diagnosis?
1. Problem 2. Etiology 3. Signs and Symptoms
What are the 7 components of health history?
1.Biographical Information 2.Chief Complaint 3.Present Health Concern/Illness 4.Past Health History 5. Family History 6. Review of Systems 7. Patient Profile
What BMI indicates being overweight?
25+
How many nursing measures/interventions are necessary to be noted in a care plan?
3-5
What BMI indicates obesity?
30+
What BMI indicates poor nutrition?
< 18.5
How many inches is considered to be an excessive amount of abdominal fat in females?
> 35
A medicine order is considered a ______ order.
Dependent
Oxygen, labwork, dietary needs, etc are examples of:
Dependent Interventions
How can you tell if someone has a pressure ulcer when touching it?
Does not blanch(turn white)
When does a comprehensive asssessment occur?
During admission only
Where can care plans be documented/stored?
Electronically or on paper
What quadrant should you start with when listening to bowl sounds?
RLQ
What does R/T mean?
Related To
If a patient is brought in and is staring with no focus, what may you assume is wrong?
Seizure (Focal seizure)
SMART stands for:
Specific, Measurable, Attainable, Realistic, Timely
A patient comes in, unable to properly form words. What may be wrong?
Stroke, resulting in aphasia
Is pain considered subjective or objective? Why?
Subjective. Pain levels are different per person and cannot be measured through observation.
Which does a nurse not perform: a genital exam on women or a genital exam on men?
Woman - Nurses do not do internal exams.
Are care plans a part of the permanent record?
Yes
Is oxygen considered a drug?
Yes
What does C/O mean?
Complains Of
When listening to bowel sounds, what part of the GI system should you listen to?
Colon/Large Intestine
What is the acronym that qualifies patients for an emergency assessment?
ABCD
What acronym is used for the five-step nursing process?
ADPIE
The ABCDs of life support are ______
Airway, Breathing, Circulation, Deficit
What does AEB mean?
As Evidence By
What does PRN mean?
As Needed
What does ADPIE stand for?
Assessment, Diagnosis, Planning, Implementation, Evaluation
When does a focused assessment occur?
At the beginning of each shift
With the GI system, do you palpate or auscultate first?
Auscultate
The assessment technique used to listen to sounds produced by air or fluid within body structures is called ______.
Auscultation
_____ involves organizing patient assessment data into groupings with similar underlying causes.
Clustering
Respiratory therapy, rapid response, lab, etc are examples of _____ care.
Collaborative care
Making sure that a patient has their call bell is called a _____ order.
Independent
What is the standard order of assessment techniques?
Inspection, Palpation, Percussion, Auscultation
What comes first during an assessment?
Interview
In females, what 3 nutrients are most at-risk for deficiency?
Iron, folate, calcium
What kind of diagnosis format must be used in a care plan?
North American Nursing Dianosis Association (NANDA)
What are the 3 parts of a patient interview?
Orientation phase, Working phase, and Termination phase
The assessment technique used when lightly or deeply touching structures of the body is called ______.
Palpation
Financial resources, education, culture, and self-concept fall under which category of health history?
Patient profile
The assessment technique that uses sound to examine different body organs is called _____.
Percussion
What is the "Rationale" section used for in a care plan?
To explain why you chose a specific nursing intervention
Why do you auscultate the GI system before palpating?
Touching would change the GI sounds
______ is a form of emergency assessment.
Triage
Auscultation of the mitral valve is used to indiciate _____.
heart rate
