Unit 2 Exam Study Guide - Chapter 10 Person centered care...

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Chapter 10 Person centered care is the most important not the tasks (patient ask for pain meds. Assess how pt doing and communicate respect compassion and care.) When developing a nursing plan of care and associated client outcomes, the nurse recognizes which of the following? Select all that apply. Outcome setting and planning should be comprehensive and involve planning in the initial phases, ongoing, and discharge. The plan of care should be individualized and setting outcomes helps to individualize a plan of care. Long- and short-term outcomes should be included in the plan of care and clients and their families should be involved in the creation. Perfusion. Body delivering blood to cap refill Nursing Process Problem – What is wrong (no experience making cake from scratch) Find the big problem. Assessment- findings of the problem (never made cake from scratch) Related to (what’s causing it) As evidenced by (as clearly shown by) assessment finding (mass in RLQ) Nursing diagnosis – (Constipation “related to” decreased water intake “AEB” abdomen distended and mass noted.) Outcome- The goal for patient (princess cake is made from scratch by birthday) Intervention- Things that will help solve the problem (research, and practice) Evaluation- was outcome met (princess cake was made from scratch by birthday) As evidenced by (as clearly shown by) (signs and symptoms)
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Assess step in nursing process Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. Assessment should be documented accurately, completely, concisely, factually, and timely. For the nurse to document a factual assessment, the client’s behaviors should be documented and not the nurse’s interpretation of the behaviors. If patient has surgery the next day high temp verbalize to the physician If patient says no pain but show non-verbal signs of pain validate the data or any discrepencies. Types of Assessments Initial assessment - preformed after admission. Purpose is to establish complete database for problem identification. Focused assessment – Focus on problem or pain (specific identified problem) Emergency assessment – quick and life threatening Time lapsed assessment – Broken in time; (home health care) Collecting patient data is a vital step in the nursing process. Collect only data helpful to planning care. Assessments help alert the nurse to changes in the patient’s response to health and illness and suggests necessary changes of the plan of care. Nursing physical assessment focuses on the patient and their functional abilities Interview
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Interview Phases : preparatory, introductory, working, termination When conducting an interview ; the nurse should sit at eye level, introduce herself, and state her position. This sends the message that the nurse accepts responsibility and is willing to be accountable. Verify the client's name and ask what he would like to be called.
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