NURS 231 Exam 3 Questions With Verified Answers Graded A+ 2024/2025
medical assessment
data collected targets pathology or a pathological condition/disease
nursing assessment
focus on the patient's response to health problems
assessment characteristics
purposeful, prioritized, comple...
NURS 231 Exam 3 Questions With Verified
Answers Graded A+ 2024/2025
medical assessment
data collected targets pathology or a pathological condition/disease
nursing assessment
focus on the patient's response to health problems
critical thinking perspectives
systematically and comprehensively, detect bias and determine credibility of sources, normal vs
abnormal, relevant vs irrelevant, identify assumptions and inconsistencies
types of assessment
initial assessment, focused assessment, time-lapsed assessment
initial assessment
admission assessment, baseline data
focused assessment
relates to a specific problem
emergency assessment
rapid focused assessment conducted in crisis
time-lapsed assessment
for comparison
signs
things the nurse can see, feel, smell, touch, hear
symptoms
described by the patient
sources of assessment data
patient, family and significant others, patient record, assessment technology, other health care
professionals, nursing and other health care literature
nursing diagnosis
actual or potential health problems that can be resolved or prevented by nursing interventions,
always changing
,medical diagnosis
identifies diseases or conditions and remains as long as the disease or condition is present
problem-focused nursing diagnosis
a clinical judgment concerning an undesirable human response to a health condition/life process,
identifies what is unhealthy about the patient and what the patient would like to change in their
status
examples of medical diagnosis
COVID-19, concussion, type 2 diabetes mellitus, rheumatoid arthritis, pregnancy
examples of nursing diagnosis
impaired gas exchange, acute conduction, risk for hypoglycemia/hyperglycemia, chronic pain, fatigue
plan of action
setting priorities, identifying outcomes, selecting evidence-based interventions, communication
types of planning
initial planning, ongoing planning, discharge planning
when implementing
make sure patient is ready physically and mentally, anticipate everything you will need before
beginning, anticipate the unexpected, promote self-care, delegate when safe and appropriate to
unlicensed assistive personnel, often there are protocols and standards in place, always be evaluating
the nursing care plan
evaluation
when the nurse and the patient together measure how well the outcomes in the care plan have been
achieved
elements of evaluation
collecting the data to determine if outcomes were met, interpreting and summarizing findings,
documenting, ending, continuing, or changing the care plan
three parts of care plan evaluative statement
date, whether the outcome was met, evidence to support the decision
documentation
written or electronic legal record of all pertinent interactions with the patient
reporting
, the oral, written, or computer-based communication of patient data to others
patient record
compilation of a patient's health informaiton
patient health record
legal document, must reflect accurate information, documents the care provided, the property of the
healthcare provider, patient is entitled to a copy of the record in most states
purpose of documentation
legal, reimbursement, research, communication and quality improvement
not documented
not done
poorly documented
poorly done
incorrectly documented
potentially fraudulent
what to record in documentation
facts, observed behavior, services rendered, results of diagnostic procedures and tests, time given,
route, and patient response to medication, precautions and preventative measures used, referral and
consultation requests, efforts to seek clarification
documentation DO's
read and act upon progress notes of the previous shift, be specific, be objective, document each of
your observations, document complete assessment data, document interventions and status of
patient following any intervention
documentation DON't's
use vague expressions, record a symptoms without including what you did about it, use shorthand
abbreviations unless they are approved, give excuses, record for someone else, record care ahead of
time
charting by exception
use of predetermined standards and norms to record only significant assessment data
source-oriented records and narrative charting
recording of patient care in descriptive form
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