KNECHT CH 12

For a nursing care plan to be a useful, realistic tool for the nursing staff, _____ must be established
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Terms in this set (27)
For a nursing care plan to be a useful, realistic tool for the nursing staff, _____ must be established
Priorities
Nurses often use _____ ____ of needs to assist in prioritizing client needs
Maslow's hierarchy
In prioritizing client needs, attention is paid first to problems related to food, air, water, ______ , elimination, rest and pain
temperature
This begins on admission and continues with each client encounter
data collection
Information that is based on the client's opinion. Some refer this as symptoms, more difficult to measure in an actual assessment
Subjective
Information that the nurse can verify; it is AKA "signs".
check, observe, monitor, weigh, measure, smell, touch, and hear
Objective
This involves questioning any information that does not match your data collection. Differentiate between subjective/objective data.
Compare findings w/ the RN and other staff involved w/ the client...
Verifying information
This includes assisting the RN to develop nursing diagnoses, outcomes, and interventions
Planning
Goals must be realistic, measurable, and _________
time referenced
An educated guess on the part of the nurse as to how long it will take to attain the outcome
time referenced
Nursing ______ identify specifically what the nurse will do to assist the client to reach desired client outcomesinterventionsInterventions are also called nursing approach, nursing action, or nursing care. Interventions focus on the _____ _______ (R/T) portion of the nursing diagnosis. They tell nursing personnel who, what, where, when, and how muchrelated toThe key for all your activity, regardless of your position and the agency involved, is to use the care plan as the basis of your nursing actions and reportingImplementationUse the ____ _____ as your guideline when reporting to the RN and offer information on any changes you have notedCare PlanIn a/an ____ _____ setting , your primary responsibility will be to use the established care plan as a guideline for providing direct care, continuing data collections, making verbal reports to the RN, and chartingacute careIt is more likely you will be working in a long=term care or a community based setting and functioning in the role of an LPN/LVN charge nurse, responsible for managing client care, under the ____ of the RNsupervisionThe nursing process: 2000 and beyond Data collection Planning Implementation EvaluationDPIETHe LPN/LVN acts in a more dependent role when participating in the planning and evaluation phase of the nursing process but acts in a more _________ role when participating in the data collection and implementation phasesIndependentNursing Interventions ClassificationNICNursing Outcomes ClassificationNOCNorth American Nursing Diagnosis Association InternationalNANDA-IThe nursing process has impacted the nursing profession. How did the origination of the nursing process in the 1950s change the course of nursing? a. It provided a reasoning model b. It provided a specificity model c. It provided a quality model d. It provided a critical thinking modeldSome RNs and instructors have questioned the value of teaching SPN/SVNs nursing process and critical thinking. Which statement provides a valid reason for including both in the SPN/SVN curriculum? a. Knowledge of the nursing process and critical thinking encourages postgraduate education so that one day the LPN/LVN can be an RN b. LPNs/LVNs and RNs collaborate, assisting the client to meet their outcomes. A common language and though process provides an organized way of understanding what is to be done. c. Learning the nursing process and critical thinking provides the opportunity to be working on both LVN and RN levels of nursing at the same time. d. Learning the nrsg process and critical thinking provides a cookbook method of learning & provides time to deal w/ job stressesbAn LPN/LVN is working w/ an RN in a LTC facility. Which request by the RN will you refuse to do because it is beyond the LPN/LVN scope of practice? a. "Update Ms. Frederic's plan of care, and we will discuss it as soon as i get back from lunch." b. "Catheterize Mrs. Jones as soon as you can & report total output to me ASAP." c. "Check Mr. Neap's pressure sore on his right hip for changes since his admission." d. "Assist Sally (RN) by doing an assessment of our new admission on the south wing."dThe LPN/LVN observes a client demonstrate signs of aspiration & choking while eating a piece of meat. Which of the following is the best action w/in the LPN/LVN scope of nursing practice? a. Ask someone to get help as you move quickly toward the client to perform a Heimlich maneuver. b. Ask another client to straighten up the client while you go to get an RN or other qualified staff member c. Immediately call the client's health care provider for permission to perform the Heimlich and mention you are an SPN/SVN d. Because you do not know if this client has a DNR on the chart, send someone to check?aAn LVN is admitting a client to the nursing unit. Which of the following is an important reason for verifying data? (SATA) a. Client & family account of what happened differ. b. You believe that persons of this culture are dishonest c. Client complains of fever, but the forehead feels cool d. You note that the client's body language & words match e. Client indicates that they have no pain but they grimace when you touch their left lega, c, eA new client has arrived, & the RN has asked you to begin data collection while she finishes taking the health care provider's orders. Prioritize the following steps: a. Identify the client b. Measure vital signs c. Introduce yourself to the client d. explain what you are planning to do e. Report information to the RN and ask for further instructionsa, c, d, b, e