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Exit HESI INFO BANK Rationale 2023
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Exit HESI INFO BANK Rationale 2023 Maslow's Hierarchy of Needs 1. Physiological 2. Safety 3. Love/Belonging 4. Esteem 5. Self-actualization ABCs Airway Breathing Circulation Nursing Process Assessment Diagnosis (Analysis) Planning Implementation Evaluation *1. Complete As...

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  • September 13, 2023
  • 13
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

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  • exit hesi info bank rationale 2023 maslows hier

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  • HESI
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Exit HESI INFO BANK Rationale 2023

Maslow's Hierarchy of Needs

1. Physiological
2. Safety
3. Love/Belonging
4. Esteem
5. Self-actualization

ABCs

Airway
Breathing
Circulation

Nursing Process

Assessment
Diagnosis (Analysis)
Planning
Implementation
Evaluation




*1. Complete Assessment
2. Assess/Analyze Data
3. Identify Problems
4. Determining Priority Nursing Diagnoses
5. Establish Goals & Expected Outcomes
6. Discuss Plan of Care with Patient before Implementation
7. Plans and Implement Interventions
8. Evaluation.

Assessment

The first step of the nursing process; a priority and a valuable skill that RNs possess.

Diagnose

The second step of the nursing process.
ANALYZE assessed data to identify the PROBLEM
(BEFORE establishing Diagnostic Statement)!

Planning

, The third step of nursing process; setting of priorities THEN goals (outcomes).

*Discuss plan of care with patients before interventions take place.

GOALS (part of Planning)

ALWAYS make the "The Client...." the subject; vital in documentation!

i.e - "THE CLIENT will not lose anymore skin"

Short Term Goals vs Long Term Goals (part of planning)

STG - Should be realistic & attainable within 7-10 days; i.e "The Client will eat 50% of six small meals
each day by 1 week."

LTG (Outcome) - broad; i.e "The client will demonstrate progressive weight gain toward the ideal
weight."
or
"The client will be >95% SaO2 on Room Air"

Intervention

The fourth step of the nursing process; implementation of planned action.

Evaluation

The fifth step of nursing process; deciding if nursing measures worked or were effective, and whether
goal was met.

If outcome was not met, what should the nurse FIRST do?

1. NOTE which actions were NOT implemented
2. Revise Expected Outcome
3. Identify New Nursing Diagnosis

DOCUMENTATION (Narrative Nursing Notes)

Documentation of subjective & objective data in precise, descriptive, clear, SPECIFIC, and accurate
information/depiction of events without judgmental inference

i.e S1 murmur auscultated in supine positon.

i.e young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal
area, approx. 1 cm deep with tissue bridging. States boyfriend is abusive.

Documenting Education

Should include the content taught AND statement from the client's
displaying understanding after teaching; written in: "he/she will...."

Subjective Data

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