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95 Cards in this Set
- Front
- Back
Which component of the nursing process?
Conducting initial interview |
Assessing
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Which component of the nursing process?
Collect nursing health history. |
Assessing
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Which component of the nursing process?
Perform physical assessment |
Assessing
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Which component of the nursing process?
Document assessment data. |
Assessing
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What is the primary purpose of assessing?
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To create a database for the client
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When you make a clinical judgment, you are really performing which component of the nursing process?
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Diagnosing
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Which component of the nursing process?
Analyze the data base. |
Diagnosing
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Which component of the nursing process?
Derive conclusions based on the analysis of the client's data base |
Diagnosing
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Which component of the nursing process?
Assign diagnostic labels |
Diagnosing
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Which component of the nursing process?
Determine causative factors |
Diagnosing
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Which component of the nursing process?
Formulate a diagnostic statement, including defining characteristics |
Diagnosing
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Which component of the nursing process?
Establish priorities |
Planning
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Which component of the nursing process?
Establish goals |
Planning
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Which component of the nursing process?
Formulate outcome criteria |
Planning
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Which component of the nursing process?
Identify nursing interventions |
Planning
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Which component of the nursing process?
Formulate a plan of care |
Planning
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Which component of the nursing process?
Organize interventions |
Implementing
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Which component of the nursing process?
Perform interventions |
Implementing
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Which component of the nursing process?
Review outcome criteria |
Evaluating
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Which component of the nursing process?
Collect data related to outcome criteria |
Evaluating
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Which component of the nursing process?
Compare data to outcome criteria and determine whether outcomes were attained |
Evaluating
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Which component of the nursing process?
Summarize inferences regarding evaluation outcome |
Evaluating
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Which component of the nursing process?
Take appropriate action based on the outcome of evaluations |
Evaluating
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(def)
a clinical judgment about an individual, family, or community |
Nursing diagnosis
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A nursing diagnosis is a clinical judgment that is a response to ________ and ________ health problems / life processes.
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Actual and Potential
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A proper nursing diagnosis provides the basis for what?
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the selection of interventions that will achieve outcomes that the NURSE is accountable for
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Describe what a "Wellness Nursing Diagnosis" is?
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a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness
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What 2 cues must be present for an individual or group to have a wellness diagnosis?
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1. a desire for a higher level of wellness
2. effective present status or function |
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A Wellness Nursing Diagnosis will begin with what specific label?
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"Readiness for Enhanced"
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The following nursing diagnosis is an example of what type of diagnosis?
"Readiness for Enhanced Community Coping" |
Wellness Nursing Diagnosis
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What is the primary differences between a nursing diagnosis and a medical diagnosis?
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A nursing diagnosis describes a patient's response to a disease or a condition. It is dynamic (can change as the client's response changes).
A medical diagnosis describes a specific disease. It will remain constant throughout the duration of the illness. |
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What is the purpose of using standard terminology (NANDA definitions) when preparing a nursing diagnosis?
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To facilitate communication among nurses
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A client's database is derived from both the health history and the physical examination. Why would you want to use both sources when determining your nursing diagnoses?
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To promote holistic care of the client
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A nursing diagnosis provides direction for what?
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the planning of independent nursing interventions
(Nursing Diagnoses should be treated by nursing interventions, not medical interventions. A proper diagnosis should be able to be treated with a proper "nursing" intervention) |
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How do nursing diagnoses promote professional accountability and autonomy?
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they define and describe the independent area of the nursing practice
(there is an NANDA list of approved diagnoses that nurses can treat) |
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Diagnosing is a process of ________ and _________.
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analysis and synthesis
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(def)
the portion of the diagnostic process that involves the separation of information into components |
analysis
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(def)
the portion of the diagnostic process that involves taking information and putting it together to form a whole |
synthesis
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What is the purpose of using Gordan's functional health patterns and a head-to-toe physical assessment?
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to gather and organize information
(to organize the data) |
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Inferences are made how?
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by comparing the data obtained to standards
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When comparing the data you obtain to standards, you are essentially asking what basic question when looking at each piece of information?
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Is this normal or abnormal?
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What are 5 examples of standards that you may compare data with?
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1. normal health patterns
2. normal vital signs 3. laboratory values 4. growth and development 5. Erickson's developmental stages |
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The process of determining the relatedness of data and grouping the data is known as what?
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Clustering Data
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Clustering data increases the accuracy of what?
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inferences
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What are the 4 guidelines you should follow when clustering data?
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1. search for abnormal cues
2. look for patterns in the database 3. use references to compare the client's cues with defining characteristics and etiologic factors of accepted nursing diagnoses 4. make an inference about the data cluster and label with a tentative diagnostic label |
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What is the next step in developing a diagnosis after you have developed a tentative diagnostic label?
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Verify the interpretation with the client.
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Upon discussion of the tentative diagnostic label with the patient, the nurse and patient can make what (4) possible conclusions?
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1. No problem exists
2. No problem exists, but a potential problem is present 3. A problem exists that the nurse can treat 4. A problem exists that the nurse cannot treat and must be referred. |
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After discussing your interpretation of data with the client and determining a conclusion based off of your interaction with the client, what is your next step?
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Finalizing the diagnostic statement
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(def)
the part of the nursing diagnosis statement which is a description of the client's health problem (actual or risk) for which nursing therapy is given |
diagnostic label
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(def)
the part of a nursing diagnosis statement which refers to the etiology or contributing factors |
Related factors
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What are the 3 purposes of "related factors" within the diagnostic statement?
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1. identify one or more probable causes of the health problems/diagnostic label
2. give direction to the nursing intervention 3. individualize the nursing diagnosis |
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(def)
cluster of signs and symptoms/clinical criteria that support the presence of the diagnostic category label |
Defining characteristics
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In formulating a nursing diagnosis, what is the next step after you have determined your related factors and defining characteristics?
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You complete your nursing diagnosis
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When completing your nursing diagnosis, what determines if you will use a two-part or three-part statement?
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You will use a two-part statement for risk diagnosis. (PE - will consist of the problems/diagnostic label and the etiology/related-to factors)
You will use a three-part statement for actual diagnoses. (PES- will consist of Problem/diagnostic label, Etiology/Related-to factors, and Signs and symptoms/defining characteristics) |
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Correct the following diagnostic label and explain the reasoning for the correction:
"needs suctioning" |
"Risk for aspiration"
- "needs suctioning" would be an intervention, not a diagnostic label. Diagnostic labels must come from the NANDA approved list |
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Correct the following Nursing Diagnosis:
Risk for injury due to change in mental status |
Risk for injury R/T change in mental status
(never use the term due to) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Impaired skin integrity R/T infrequent turning. |
Impaired skin integrity R/T immobility.
(Never imply negligence or blame in a nursing diagnosis) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Spiritual distress R/T strict rules necessitating church attendance. |
Spiritual distress R/T inability to attend services.
(Never write a diagnosis with a value judgment, which means including your personal values and beliefs) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Rapid respirations R/T increased airway secretions. |
Ineffective Breathing Pattern R/T increased airway secretions.
(Never use a sign/symptom as your diagnostic statement. Use the NANDA list of diagnostic statements) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Risk for ineffective airway clearance R/T Emphysema |
Risk for ineffective airway clearance R/T accumulation of lung secretions.
(a medical diagnosis is never used UNLESS it is secondary to. Your R/T should always be something that can be treated by a nursing intervention.) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Anxiety R/T cardiac monitoring. |
Deficient knowledge: purposes and need for cardiac monitoring R/T lack of exposure to information.
(identify the client's response to equipment or treatment, not the equipment or treatment itself) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Offer bedpan frequently R/T of diarrhea. |
Diarrhea R/T intolerance to milk-based foods.
(your statement should never include your interventions.) |
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Correct the following diagnostic label and explain the reasoning for the correction:
Pain and anxiety R/T difficulty ambulating. |
- Anxiety R/T difficulty in ambulating.
- Impaired physical mobility R/T discomfort in (R) knee. (There should only be one problem in a diagnostic statement. Write out each separately) |
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True/False:
There should only be one related factor in a diagnostic statement. |
False- Although you can only have one problem, you can have one or more related factors.
For Example: Impaired Nutrition: more than body requirements R/T limited physical activity and increase in fat and calories in diet. |
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When planning your care, the diagnoses you have identified are ranked by order of what?
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importance - higher priority items are placed at the top
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What framework is often used to help determine priority of diagnoses?
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Maslow's hierarchy of needs
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Would the following have a high, intermediate, or low priority:
Ineffective airway clearance |
High Priority
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Needs that required immediate attention are ranked a ______ priority.
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High
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Needs that involve non-emergency, non-life threatening situations would be ranked a ______ priority.
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Intermediate
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Needs that may not be directly related to a specific illness or prognosis, but may affect their future well-being would be ranked a _____ priority.
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low
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When establishing your client's Expected Outcome, you will include both goals and outcome criteria. Describe each.
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Goals = broad statements reflecting resolution of the diagnostic label/problem
Outcome criteria = specific, measurable, observable statements that reflect the resolution of the defining characteristics |
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True/False:
An expected outcome is realistic in relation to the client's present and potential capabilities. |
True
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True/False:
An expected outcome is attainable in relation to the resources available to the client. |
True
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True/False:
An expected outcome is vague and may explain positive and negative outcomes. |
False-
An expected outcome is clear, concise, and in positive terms |
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True/False:
An expected outcome should include a time estimate for attainment. |
True
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Who should formulate the expected outcome?
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When possible, both the nurse and client should formulate the expected outcome.
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What is the overall purpose of an expected outcome?
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It is used to provide direction to nursing interventions and measure the validity of the interventions.
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True/False:
An expected outcome is essentially a nursing intervention. |
False- an expected outcome would be the result of a nursing intervention. They are not one in the same.
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(def)
specific actions the nurse takes that are designed to assist the client to achieve expected client outcomes |
Nursing interventions
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Nursing interventions are individually tailored to meet the specific needs of a client. They should be designed to resolve what?
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the "related factors"
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True/False:
Nursing interventions should only include your actions (care), never assessing, assisting, or teaching |
False-
Include nursing interventions that are assessing, assisting, and teaching |
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Nursing interventions reflect the prescribed care that is required to do what (3) things?
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- monitor a problem (assessing)
- prevention of a problem - treatment/resolution of a problem |
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What is the goal of nursing interventions if the nursing diagnosis is "Risk for..."?
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They should provide protection or precautionary measures
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The verbs used in a nursing intervention are specific ones that direct what?
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They direct the nurse's actions (for example, assess, instruct, place, observe, etc.)
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How would YOU guarantee that others are able to follow your care plan when you are not available?
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Make sure that your nursing interventions are specific! Use specific times, frequencies, amounts, etc.
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Nursing interventions can be what (3) types?
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1. Physician-Initiated
2. Nurse-Initiated 3. Collaborative |
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What is wrong with the following nursing intervention:
Provide hydrogen peroxide mouthwash for client. |
It is not specific. A correctly stated nursing intervention would be -
Provide 50mL of hydrogen peroxide mouthwash for the client every 2 hours while awake. |
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True/False:
As a student, it is not important to understand the rationale behind a nursing intervention as long as you implement it properly. |
False- you should be able to identify rationales for all nursing interventions. You can find rationales in your text books, notes, care plan books, etc.
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What are critical pathways and computerized care plans?
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standard plans of care developed to set daily care priorities for specific diagnoses, promote timely achievement of outcomes, and reduce the length of hospital stays.
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(def)
a system of organizing client information to develop a comprehensive plan of care |
Care Map
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_________ is simply carrying out the plan of care.
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Implementing
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What are the 4 components of evaluating the plan of care?
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1. Review outcome criteria
2. collect data related to the outcome 3. compare data collected with the outcome to determine if they were attained 4. Make inferences and take appropriate action if needed. |
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(def)
nursing interventions performed when implementing the medical regimen, such as giving medications and treatments |
Physician-Initiated interventions
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(def)
nursing interventions that evolve form the nursing diagnosis and do not require a physician's order |
Nurse-Initiated interventions
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(def)
Nursing orders that are performed by nurses in collaboration with other members of the health team |
Collaborative interventions
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