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statistics for nursing a practical approach
Fundamentals Of Nursing: Standards And Practices 2nd Edition Sue C. DeLaune, Patricia Kelly Ladner - Solutions
Becomes short of breath with minimal activity.
Unable to eat or sleep for last 3 days.
Client states “nervous about what might be wrong.”
Breathing is rapid and labored.
11. Value-belief pattern: Describes goals and value and belief patterns that underlie decision making.
10. Coping–stress-tolerance pattern: Describes coping pattern and its effectiveness in stress tolerance.
9. Sexuality-reproductive pattern: Describes patterns of satisfaction or dissatisfaction with sexuality;describes reproductive patterns.
8. Role-relationship pattern: Describes pattern of role engagements and relationships.
7. Self-perception–self-concept pattern: Describes self-concept pattern and perceptions of self.
6. Sleep-rest pattern: Decribes pattern of sleep, rest, and relaxation.
5. Cognitive-perceptual pattern: Describes sensory-perceptual and cognitive pattern.
4. Activity-exercise pattern: Describes pattern of exercise, activity, leisure, and recreation.
3. Elimination pattern: Describes patterns of excretory function (bowel, bladder, and skin).
2. Nutritional-metabolic pattern: Describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.
1. Health perception–health management pattern:Describes client’s perceived pattern of health and well-being and how health is managed.
Review of systems: recent signs and symptoms associated with body systems
Activities of daily living: patterns of nutrition, elimination, rest/sleep, and activity/exercise
Sociocultural history: role in family, relationships, occupational history, personal habits, religious beliefs
Psychosocial history: sources of stress, coping mechanisms, self-concept
Developmental level: evidence of accomplishing developmental tasks for age group
Current medications: prescription or over-thecounter medications, including laxatives, birth control pills, pain medications
Allergies: prior allergic reactions to medications, food, or environmental substances
Immunizations/exposure to communicable disease: childhood immunizations or relevant immunizations of adulthood; any known exposure to communicable disease
Client/family medical history: illness or cause of deaths in blood relatives
Previous illnesses, hospitalizations, surgeries:any chronic illness or acute episodes that led to hospitalization or surgery
Perception of health status: client’s view of health
Reason for seeking health care: concern that initiated visit
Demographic information: name, age, gender, marital status
Character: The quality of the feeling or sensation(e.g., sharp, dull, stabbing).
Location: The area of the body in which the symptom(such as pain) can either be pointed to or described in detail.
Activity/exercise: Includes types of exercise and patterns in a typical day or week. If assistance is needed with activities such as walking, standing, or meeting hygienic needs, this information should be noted.
Rest/sleep: Includes the usual number of hours of sleep, number of hours of sleep needed to feel rested, sleep aids used, and the time within the day or night when sleep usually occurs. Any bedtime rituals(especially with children) should also be noted.
Elimination: Includes both urinary and bowel elimination frequency and patterns. Any recent changes or problems in these patterns should be noted.
Nutrition: Includes type of diet and foods eaten and fluids consumed regularly, food preparation, the size of portions, and the number of meals per day. Food preferences and dislikes, as well as the client’s need for assistance in food preparation or eating should also be determined.
Aggravating/alleviating factors: The activities or actions that make the symptom worse or better.
Timing: The onset, duration, frequency, and precipitating factors of the symptom.
Intensity: The severity or quantity of the feeling or sensation and its interference with functional abilities.The sensation can be rated on a scale of 1 (very little) to 10 (very intense).
Promote client comfort.
Make sure that the interview is timed appropriately.
Select an envrionment that is as free of noise and distractions as possible.
Maintain a comfortable room temperature.
Assure adequate lighting.
Relevant literature
Results of diagnostic tests
Interdisciplinary conferences, rounds, and consultations
Medical records
Other health care professionals
Family/significant other
Client
What adaptations for your comfort and care have you and your family made since your return home?
While in the hospital, what did you learn about . . . ?
What type of activities did you do while you were in the hospital?
What kind of diet were you on?
What medications were prescribed for you during that time?
What led up to your most recent hospitalization?
Documented in a usable format
Collected in a systematic manner
Collected using appropriate techniques
Collected from a variety of sources
Relevant to client needs
11. Identify four types of assessment formats
10. Discuss the use of data clustering in organizing the information obtained about the client.
9. Discuss assessment techniques used in the physical examination.
8. Describe the purposes of the physical assessment.
7. Outline the elements of the health history and their importance.
6. Explain the stages of the assessment interview.
5. Describe five methods involved in data collection.
4. Identify examples of nursing and nonnursing models used in collecting and organizing data.
3. Differentiate subjective and objective data.
2. Describe three types of assessment.
1. Identify major purposes of data collection.
The steps in the nursing process are similar to those in the problem-solving method in that problems are identified, information is gathered, a specific problem is named, a plan for solving the problem is developed, the plan is put into action, and the results of the plan are evaluated.
Evaluation, the fifth step in the nursing process, involves deciding whether the client goals have been met, been partially met, or not been met.
The nurse uses psychomotor skills, interpersonal skills, and cognitive skills when performing nursing activities.
Implementation, the fourth step in the nursing process, involves performing or delegating nursing activities.
Planning, the third step in the nursing process, involves prioritizing nursing diagnoses, identifying and writing goals and client outcomes, developing nursing interventions, and recording the plan of care in the client’s record.
Types of nursing diagnoses include: actual, potential(including risk and possible), and wellness.
The second step in the nursing process involves further analysis and synthesis of the data and results in a list of nursing diagnoses.
Both subjective data (information given by the client)and objective data (information collected by the health care provider using the senses) are collected during the assessment process.
Assessment is the first step in the nursing process and involves collecting, validating, organizing, categorizing, and recording data.
The nursing process is composed of five steps: assessment, diagnosis, outcome identification and planning, implementation, and evaluation.
The nursing process is an organized method of planning and delivering nursing care.
Critical thinkers ask questions, evaluate evidence, identify assumptions, examine alternatives, and seek to understand various points of view.
Critical-thinking, problem-solving, and decisionmaking skills are important for use in the nursing process.
The goals and/or the nursing interventions planned were not appropriate for the client.
The time frame was too optimistic.
The goals and expected outcomes were not realistic.
The initial assessment data were incomplete.
Specific interventions are developed
Client-centered long- and short-term goals and outcomes are identified and written.
The list of nursing diagnoses is prioritized.
Imbalanced Nutrition: Less Than Body Requirements related to nausea and vomiting
Risk for Injury (falls) related to unsteady gait
Ineffective Airway Clearance related to excessive and thick secretions and pain secondary to surgery and inability to cough effectively; respirations: 25, shallow, wheezing
Collaborative problems
Wellness conditions
Potential problems (including those where risk factors exist and there are possible problems)
Actual problems
If so, what are some possible sources of the data that are needed?
Are more data needed to answer the question?
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