Plan of Care - ANSWER 1: Gather health history.
2- Perform a physical examination.
3. Document data.
4- evaluate and understand data.
5- Develop therapy.
ANSWER: objective data observed, felt, heard, or measured.
Symptoms - Answer subjective data perceived and reported by the customer
assessment - ANSWER when the nurse collects relevant data and information
regarding the health care consumer's health
, ANSWER when the nurse analyzes the assessment data to evaluate actual or
prospective diagnoses, problems, or issues.
ANSWER when the nurse produces a plan that prescribes tactics to achieve
predicted, measurable goals.
implementation - ANSWER when the nurse carries out the defined plan and
organizes care delivery.
Evaluation - ANSWER when the nurse assesses progress toward achieving
goals and results.
Establish a baseline. ANSWER: Why is data documentation important?
thorough - ANSWER health assessment that includes a detailed history and
physical examination at the start of care.
- Health Promotion
- Disease Prevention
- evaluate for problems related with identified risk factors.
Problem-based ANSWER health evaluation limited to a single problem or
concern.
- Typically utilized in walk-in clinics or emergencies.
episodic - ANSWER health exam following up on previously recognized
problems.
- an ongoing state.
- Regular clinic appointments.
shift - ANSWER health assessment done each shift by the nurse to identify
changes from baseline.
screening - ANSWER health evaluation centered on disease detection
- health fair or physician's office
main - ANSWER health promotion reducing illness development by supporting
a healthy lifestyle.
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