301 chap 2, 3 , 4, and 21 Flashcards
More than one health problem occurring at the same time
Comorbitidity
A set of interrelated concepts that represents a certain way of thinking about something
Model
Five steps of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
The nursing interview AND physical assessment become part of the
Patient database
Nurse assistants are allowed to collect data such as
Temperature, height, weight
Data gathered by a physical assessment or laboratory tests
Objective data
Assessment tool for figuring out if someone can do the more sophisticated tasks like shopping
Lawton scale
Assessment tool used mostly in palliative care
Karnofsky
Form for data collection that is especially useful for identifying medical problems
Body systems (medical) framework
Includes vital signs such as blood pressure, pulse so trends over time can be seen clearly
Graphic flow sheet
primary vs secondary data: patient’s chart
secondary
primary vs secondary data: another healthcare provider
secondary
primary vs secondary data: something the patient says
primary
primary vs secondary data: something you find on the patient
primary
the first step in the process of analyzing and interpreting data?
Identify significant data
the __ phase begins when you meet the client and introduce yourself and your role in the relationship
orientation phase
The goal of this phase is to establish rapport and trust through the use of verbal and nonverbal communication
orientation phase
kind of interviewing, which is used to obtain factual, easily categorized information
directive interviewing
During a physical examination, you take a client’s pulse and blood pressure, auscultate his lungs, and palpate his neck. Which zone of the client’s personal space have you entered while performing these assessments?
intimate
“Problem r/t ___ as manifested by (AMB) signs or symptoms.”
etiology
“Problem r/t etiology ___ signs or symptoms.”
AMB
“___ r/t etiology as manifested by (AMB) signs or symptoms.”
Problem
To ___ the message, instead of just requesting further explanation from the client regarding a statement, go ahead and suggest your interpretation and ask whether it is correct
validate
___ means using your own words to summarize the message you received from the client
Restating
___ messages helps ensure that you have accurately interpreted the information. It involves expressing a lack of understanding of the client’s statement and requesting further explanation
Clarifying
Record cues, not ___
inferences
Performance scale is used primarily in palliative care settings to assess functional abilities at the end of life
Karnofsky
What are the two components of “caring” in the full-spectrum nursing concepts
Self-knowledge and ethical knowledge
what is typically left out of a collaborative problem
etiology
___ status would be assessed in a comprehensive assessment but not in an initial assessment
Emotional
A client’s marital status would be recorded as part of the ___ assessment, which focuses on static data—data that are not likely to change often—such as demographic data (marital status, occupation)
initial
A normal resting heart rate for adults ranges from __ to 100 beats a minute
60
The Joint Commission requires that agencies designate when each patient is to be ____
reassessed
The component of care “___” is striving to understand what an event (e.g., an illness) means in the life of the patient
Knowing
The component of care “__ __” is doing what the patient would do for himself if he could (e.g., bathing)
Doing for
The component of care “___” is supporting the patient through coping with life changes and unfamiliar events, such as hospitalization
enabling
The component of care “___” is being emotionally present for the patient (e.g., making eye contact, actively listening)
being with
___ is a technique whereby you acknowledge that there may be some truth to a criticism but you remain the judge of your own action
Fogging
When you use ___ inquiry, you request clarification of one’s criticism of you
negative
full spectrum nursing involves 3 things: t___, d___, and c___ and ___ situation
thinking doing caring and patient situation
cognitive processes used in complex thinking operations such as problem-solving are critical thinking ___
skills
different than critical thinking skills, ___s are more like feelings
attitudes
critical thinking attitude: dont believe everything you’re told
independent thinking
critical thinking attitude: love to learn new things
intellectual curiosity
critical thinking attitude: are that you don’t know everything
humility
critical thinking attitude: try to understand the feelings of others
empathy
critical thinking attitude: examine things even when it’s uncomfortable
courage
critical thinking attitude: don’t settle for quick easy answers
perseverance
critical thinking attitude: make impartial judgements
fair-mindedness
reflective, creative thinking about patient care
clinical reasoning
critical thinking model: awareness of the total situation
contextual awareness
critical thinking model: applying standards of good reasoning to your thinking
inquiry based on credible sources
critical thinking model: imagining alternatives
considering alternatives
critical thinking model: recognizing assumptions
analyzing assumptions
critical thinking model: questioning your rationale
reflecting skeptically
knowledge that enables you to apply your theoretical knowledge to patients
practical knowledge
component of caring: striving to understand what an event means in the life of the patient
knowing
component of caring: being EMOTIONALLY present for patient
being with
component of caring: do what the patient can’t do for himself
doing for
component of caring: supporting the patient through coping with life changes and unfamiliar events (such as being hospitalized)
enabling
component of caring: having faith in the patients ability to get through the change
maintaining belief
The JC requires that agencies have assessments that are written, ___, and used to identify ___
comprehensive
priorities
The JC requires that agency policy designates when patients are to be ___ and which disciplines can make which ___
released
assessments
The JC requires that all patients are assessed for
pain
Nurses can delegate someone getting height, weight, etc but the nurse must __ the data, conduct the ___, and complete the assessment
data, interview
assessment completed when the client first comes to the agency
initial
assessment performed as needed, at any time after the initial database is completed
ongoing
performed to get data about an actual, potential, or possible problem
focused assessment
assessment that provides in depth info about an area of client functioning
special needs
Katz is an assessment tool that gives you 1 point for these 6 areas
bathing continence dressing feeding toileting transfer
nursing health history covers some of the same topics as the medical history, but for different
reasons
conceptual term: something that indicates which info is significant
framework
Maslow’s list
Physiological Safety Love/belonging Esteem Cognitive Aesthetic Self actualize
Maslow, need for affection
Love and Belonging
Maslow, need to feel good about yourself
esteem
Maslow, need for knowledge
cognitive
Maslow, need for order and beauty
aesthetic
Maslow, need grow and change, reach potential
self-actualize
in documentation, should be used sparingly and only if agency approved
acronyms
When recording patient’s words, only use the most
important part
Record __s not ____s
cues not inferences
diagnostic reasoning is aka Diagnostic ___
process
the basis for planning client-centered goals and interventions
Dx
Dx is the reasoning process used in ___ing assessment data
interpreting
Dx contains both __ and __
problem and etiology
___ ___ in a sense forms the body of knowledge that is unique to nursing
diagnostic labels
nursing Dx is stated in terms of human responses to
disease and other stressors
nursing Dx can be a problem or
strength
you can’t predict a patient’s nursing Dx just by knowing the
medical Dx
a medical Dx can have __ nursing Dx
multiple
All patients who have a certain disease are at risk for the ___ complications
same
a collaborative problem is always a ___ problem
potential
If you can prevent the complication with independent ___ interventions alone, then it is not a collaborative problem
nursing
the thinking process that enables you to make sense of assessment data.
diagnostic reasoning
diagnostic reasoning is aka a____
analysis
In nursing, an etiology is always an ___ because you can never actually observe the link between etiology and problem
inference
NANDA categorizes diagnoses into 13 __ and 47 __
domains, classes
a word or phrase that represents a pattern of related cues and describes a problem or wellness response
diagnostic label
Explains the meaning of the label and distinguishes it from other similar labels
definition
the cues (signs and symptoms) that allow you to identify a problem or wellness diagnosis are called
defining characteristics
cues, conditions that are in some way associated with the problem
related factors
An individual’s etiology will ___ include all the related factors that NANDA lists for the Dx
not
things that increase the vulnerability: ___ factors
risk factors
during the diagnostic process, the first step is to identify a ___ that fits the cue cluster
domain
during the diagnostic process, the second step is to choose the
class
the etiology will help you individualize nursing care because etiologies are __ to the individual
unique
a label that represents a collection of several nursing Dxs
syndrome Dx
you may need to add a second part of the etiology using the words “secondary to.” This part is usually the
disease
in actual practice, you would not write an etiology for a ___ problem
collaborative
as a general rule, the problem suggests goals and the etiology suggests __
interventions
the __ is the opposite of the unhealthy response
goal
the aim of nursing ____s is to remove the factors contributing to the problem
interventions
as a rule, avoid using the word “___” in a problem statement
need
The ___ of the communication describes the actual subject matter, words, substance of the message
content
__ refers to the act of sending, receiving, interpreting, and reacting to a message.
process
process of selecting words, symbols, etc to transmit the message
encoding
the verbal and or nonverbal information the sender communicates
message
the medium used to send the message
channel
interpretation is aka
decoding
once message is rec’d, he may be stimulated to send
feedback
literal meaning of the word
denotation
tone of voice
intonation
older adults may be affected by sensory ___ such as hearing loss
alterations
the area immediately surrounding people (within 18 inches)
intimate distance
18 inches to 4 ft. appropriate when communicating caring or concern
personal distance
4 to 12 ft. Used in more formal interactions
Social distance
Over 12 ft
public distance
communication style that forces others to lose
aggressive approach
the expression of a wide range of positive and negative thoughts and feelings
assertive communication
in assertive communication, the expressions are direct, honest, and
nonjudgemental
good communication uses “_” statements
“I”
Use “____” to help you accept criticism without becoming defensive
fogging
in communicating it can help to use __ inquiry
negative inquiry
A therapeutic relationship focuses on
improving the health of the client
Therapeutic communication is client centered communication directed at achieving
client goals
the goal of the orientation phase is to establish ___ and ___
rapport and trust
Orientation phase ends when the relationship has been
defined
the bulk of the therapeutic communication occurs in the __ phase
working phase
empathy, respect, genuineness, concreteness, confrontation are the 5 characteristics of
therapeutic communication
valuing your client and being flexible for them
respect
difficulty expressing or interpreting messages
aphasia
means using your own words to summarize the message you received from the client
restating
asking the client whether you are making the correct interpretation
validating
Helps the patient explore a topic of importance. The nurse selects one topic for further discussion from among several topics presents by the patient
focusing
Let the patient know that a message was unclear and seeks specific info to make it clearer
clarification
