Nursing Assessment, Data Analysis, and Planning Essentials

Flashcards covering planning theory, patient assessment in various care settings, prioritization of needs, and clinical documentation according to nursing theory.

Short-term goals

Goals that are achievable within $7 \text{ to } 10 \text{ days}$ or before discharge.

Long-term Goal

Goals that take many weeks or months to achieve and often relate to rehabilitation.

Expected outcome

A statement of the goal a patient is to achieve as a result of nursing interventions.

Interventions (Nursing orders)

Actions designed to alleviate problems and achieve expected outcomes, including medications and ordered treatments individualized to personal needs.

LPN/LVN in Home Health Care

When doing private duty, they perform daily assessments and maintain necessary documentation, reporting changes to the RN Supervisor.

Physiologic needs

Needs for basic survival, such as airway and circulation, which take precedence over other problems.

Safety problems

Issues that take priority after physiologic needs are met.

Holistic approach

An approach where the nurse keeps psychosocial needs in mind while working on physical problems.

Care plan update frequency

The plan of care should be reviewed and updated once every $24 \text{ hours}$.

Change-of-shift report

Provides clues as to the priority of each action to be implemented.

Nursing diagnosis statement

Indicates actual health status or risk of a problem, causative/related factors, and specific defining characteristics (signs and symptoms).

Etiologic Factors

The cause of the problem.

Signs

Abnormalities that can be verified by repeat examination and represent objective data.

Symptoms

Data the patient says is occurring that cannot be verified by examination; these are subjective data.

Defining Characteristics

Signs and symptoms that must be present for a particular problem statement to be valid for a patient.

Functional health patterns assessment

An assessment approach formulated by Mary Gordon.

Focused assessment

An assessment that focuses specifically on a single problem.

The opening

The first stage of an interview during which rapport is established with the patient.

The body

The stage of an interview during which necessary questions are presented.

The closing

The final stage of an interview during which information is summarized.

Face Sheet

A component of the medical record review that included physician's orders and admission details.

Physical Assessment Techniques

The systematic use of inspection, auscultation, palpation, and percussion.

Normal heart sounds

Determined during assessment as normal $S_1$ - $S_2$.