Flashcards in Exam 3- Nursing process Deck (21):
What is important for a vegan-vegetarian diet?
ESSENTIAL and NONESSENTIAL amino acids!
What is a pt performance criteria?
turn and deep cough..to prevent pneumonia
What is important for the pt and planning their care plan?
Jewish Kosher diet suggestion?
Swiss cheese + ww bread
What sign/symptom would a person who is hyponatremic experience?
If a pt is hypokalemic what food would you give?
If a pt's bowel elimination is oozing out, the pt has what kind of BM?
The fight or flight response releases two hormones: epinephrine (adrenaline) and norepinephrine (noradrenaline) are associated with what group?
If a pt is hypercalcemic and is found to be flacid, what would you test them for?
If a pt's BMI is 18, what is their nutritional status?
UNDERWEIGHT because normal is considered 18.5-24.9
What is the second phase of the nursing process?
Diagnosing, and is an exclusive responsibility for the R.N by the ANA to analyze data
What does a nursing dx do and what must you do to develop a nursing dx?
A nursing dx identifies a client's response to a health problem. It is not a medical dx.
What is a NANDA nursing dx?
world uses same nursing Dx, language to uniform what nurses are doing.
What are the 5 components of a NANDA nursing dx?
1. Diagnostic label
3. Defining characteristics- s, sx, cues
4. Related factors- r/t damaged lungs
5. Risk factors- infection r/t poor tissue perfusion.
What are the 4 components for status of a nursing dx?
1. Actual Dx- pt's prob that is present at time of assessment
2. Health promotion dx- to implement behaviors to improve their health cond.
3. Risk Nursing dx- risk factors to indicate a prob is likely to develop unless a nurse intervenes
4. Wellness dx- human respnse to level of wellness in an individual or community.
Nursing dx versus a medical dx?
Nursing dx- nursing judgement and a nurse is likely to treat.
Medical dx- made by a physician & refers to a cond. that only a physician can treat.
What is the 3 part nursing dx statement?
PES- problem, etiology, signs and symptoms
What is the 3rd part to the nursing process?
What are the 3 types of planning?
1. Initial- first pt contact, dev. of care plan
2. Ongoing- change made in the plan as you evaluate the pt's response to care.
3. Discharge- planning for self-care and continuity of care after pt leaves health care setting.
What are the 5 R's of delegation?
1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision