Assessing (ch 12) Flashcards
Nursing process
Purpose of nursing process: To diagnose and treat human responses to actual or potential health problems
Nursing history
Identifies the patients health status , strengths, health problems, health risk, need for nursing care
Initial assessment
Preformed shortly after the patient is admitted to a healthcare agency or service
Purpose if initial assessment
Establish complete database for problem identification and care planning
Focused assessment
Gathers information about a specific problem that has already been identified also identify new or overlooked problems
Emergency assessment
Identify life threatening problems
Time-lapsed assessment
scheduled to compare a patients current status to baseline taken earlier
Minimum data set
Specifies the information that must be collected from every patient and a structured assessment form to organize or cluster this data
Subjective data
Information perceived only by affected person
Objective data
Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
Observation
Conscious and deliberate use of the five senses to gather data
Interview
Planned communication
Physical assessment
Examination of the patient for objective data that may define the patients condition and help the nurse in planning care
Review of systems (ROM)
Nursing physical assessment involves the examination of all body systems
Validation
Act of confirming or verifying: purpose of validating is to keep data as free from error, bias, and misinterpretation as possible
Diagnosis
- Identify how an individual, group or community responds to actual or potential health and life processes
- Identify factors that contribute to or cause health problems
- Identify resources the individuals, group or community can draw to resolve problem
Health problem
Condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness
Nursing diagnosis
Actual or potential health problems that can be prevented or resolved by independent nursing intervention
Medical diagnosis
Identify diseases
Collaborative problems
Certain physiologic complications that nurses monitor to detect onset or changes in status
Cue
Used to denote significant data or data that influence this analysis
Models for organizing or clustering data
Human needs ( Maslow) Functional health patterns (Gordon) Human response patterns (unitary person) Body system model
Standard
Generally accepted rule
Data cluster
Grouping of patient data or cues that points to the existence of a patient health problem
Actual nursing diagnosis
Represents a problem that has been validated by the presence of major defining characteristics
Risk nursing diagnosis
Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation
Possible nursing diagnosis
Statements describing a suspected problem for which additional data are needed
Wellness diagnosis
Clinical judgements about an individual, group, or community, in transition from a specific level of wellness to higher level of wellness
Syndrome nursing diagnosis
Comprise a cluster of actual or risk nursing diagnosis that are predicted to be present because of a certain event or situation
Goal
An aim or an end
Patient outcome
An expected conclusion to a patient health problem
Expected outcomes
Used to refer to the more specific, measurable criteria used to evaluate the extent to which a goal has been met
Initial planning
Developed by the nurse who performs the admission nursing history and physical assessment
Standardized care plans
Prepared plans of care that identify the nursing diagnosis, outcomes, and related nursing interventions common to specific population or health problem
Formulation of nursing diagnosis
Problem: identifies what is unhealthy about patient
Etiology: identifies factors maintaining the unhealthy state
Symptom: patient reports
Ongoing planning
Carried out by any nurse who interacts with the patient
