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Nurse Role of Lecture (Misty)


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An actual nursing diagnosis contains 3 parts: what are they?
1. Problem (NANDA format)
2. Etiology ("related to")
3. Defining characteristics (AEB)
True or False:
If a nursing diagnosis contans "at risk for," then there will be no signs or symptoms, or "AEB."
An "at risk for" diagnosis contains 2 parts: what are they?
1. Problem (NANDA format)
2. Etiology ("related to")
A wellness diagnosis has only one part: what is it?
Problem (NANDA format)
The "planning" phase of the nursing process requires the nurse to perform four important functions: what are they?
1. Set priorities, in order of importance
2. Establish client goals
3. Select nursing interventions
4. Determine resources
In setting priorities, the nurse's #1 priority is what?
Keep the patient alive! (Breathing, Circulation and Safety)
"A specific aim planned by the nurse AND the client to assist the client in achieving maximal level of wellness" is the definition of what?
Goal Setting
When setting goals, we should remember the acronym S.M.A.R.T. What do these letters stand for?
S = specific
M = measurable
A = attainable
R = realistic
T = timed
When setting goals, the nurse should avoid which words in order to ensure that the goals are specific and measurable?
"Pt. will be free of..."
Goals should begin with what statement?
"The client will..."
Goals should answer what 3 questions?
Goals should always match what?
the Nursing Diagnosis
What are the 4 factors involved in selecting the appropriate nursing interventions?
1. Defining characteristics of the nursing dx.
2. Research associated with interventions
3. Client's acceptance of disease, health cond., handicap, etc.
4. Least amount of risk/discomfort for the client
According the the Nurse Practice Act, the RN will do what regarding pt. education?
"Promote and participate in client education, based on health needs."
What should a nurse include in educating a client who will be undergoing chemotherapy?
hair loss
decrease in energy
side effects
survival chances (if appropriate)
What should a nurse include in educating new parents who are about to take their baby home?
car seat safety
breast feeding
What should a nurse include in educating a newly diagnosed diabetes patient?
1. explain the disease process of diabetes
2. explain signs/symptoms of complications
3. explain what to do if glucose gets too high/low
4. how to use glucometer
5. diet
The term "survival skills" usually refers to whom?
Newly diagnosed diabetics
This semester, our role as student nurses will include what five principles?
1. Demonstrating effective communication
2. Providing things for the pt.
3. Competency in clinical skills
4. Critical thinking in assessment
5. Applying the nursing process to clinical situations
The key principle of Nursing I was "formulating the nursing diagnosis." What is the key principle of Nursing II?
What types of tasks can be delegated to unlicensed hospital personnel (CNA, etc.)?
* ADL's
* Baths
* Bed changes
* Data collection
* Recording pain scale
What are the "4 C's" of Delegation?
1. Clear
2. Concise
3. Correct
4. Complete
What are the "4 rights" of Delegation?
1. Right task
2. Right person
3. Right communication
4. Right feedback/follow-up
What does "Accountability" refer to in the role of the nurse?
1. Knowing the rules / regulations of being an RN
2. How supplies are used
The nurse should always chart as if he/she were charting for whom?
A jury
On a Flow Sheet, the "Time" column is used to record what?
The actual time of the assessment
How often should a nurse make entries in the Narrative Notes?
At least every 2 hours
Documentation such as "visiting with family," or "watching TV," are examples of what?
Fillers - those things that a nurse charts when he/she can't think of anything else to chart
Instead of using "fillers," what would a nurse chart INSTEAD of "client is sleeping quietly?"
"Checked on client at xx:xx (time), to assess IV site."
When performing a neuro check, what should be assessed and documented?
* Level of Consciousness
* Alert & Oriented x 3
* Mental status
* Motor function
* Sensory function
When auscultating in a cardio assessment, what should the nurse listen for?
* Extra (split) sounds
* Murmurs
* Rate
* Regular/irregular rhythm
Besides auscultating, what other things are included in a cardio assessment?
* Telemetry #
* Rhythm
* Pulse
* Capillary refill
* Periphery (is skin wet/dry)
* Pt. status
* Pacemaker settings (capture/non-capture)
What should be DOCUMENTED in a cardio assessment?
* Rate
* Rhythm
* Telemetry
* Auscultation
* Abnormalities in skin periphery
* Cyanosis
* Pt. status
* Pacemaker settings (capture/non-capture)

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