Chap 5&6- The Nursing Process & Assessment SKills

Question 1

WHat is the nursing process?

Answer 1

Patient centered, goal oriented, systematic, problem solving approach that serves as a guide for professional nursing practice

Question 2

Nursing Process Phases

Answer 2

(ADPIE)
Assessment
Diagnosis
Planning
Implementation
Evaluation

Question 3

First Phase of Nursing Process

Answer 3

Assessment- Collection of data, getting info from patient, identify chief complaint(s); assess their whole situation from all aspects; establish pt’s baseline

Question 4

How do you gather information for an assessment?

Answer 4

Observe. Interview. Physical examination. Intuition. Obtaining dx/lab data

Question 4

Any info the patient gives you directly is called

Answer 4

subjective information

Question 5

tests, lab results, vital signs are examples of what kind of information

Answer 5

objective

Question 6

Why is intuition in nursing important?

Answer 6

It tells you to ask more questions

Question 7

Why is it important to know your patient’s norm/baseline?

Answer 7

So you can identify abnormalities.

Question 8

comprehensive and initial assessment that is done to gather all info about a patient; typically the longest

Answer 8

Admission assessment

Question 9

assessment done once patient’s problem is identified; each time pt is seen, assessment is done on the focus/ problem identified

Answer 9

focus assessment

Question 10

assessment done several weeks after initial assessment

Answer 10

time lapsed assessment

Question 11

A skill of assessment; pieces of information to put together about pt’s health stat; can be objective or subjective

Answer 11

cues; cue clustering- putting them together

Question 12

When observing a patient, nurse should use ___ and be ____ while observing? When does observation again?

Answer 12

all their senses and be non judgemental- OBSERVATION BEGINS IMMEDIATELY!!

Question 13

What are the clinical skills used in assessment?

Answer 13

Observation
Interviewing
Physical Examination

Question 14

4 Phases of Interviewing
“PIMc No P”

Answer 14

Preparatory- familiarize of pt sitaution before….
Introductory- introducing yourself and the patient to how to utulize the room/instruct etc
Maintenance- working phase, both nurse and pt working to meet the set goals
Concluding- focus is on reviewing goals attained, expressing concerns related to this phase.

Question 15

The parts of assessment that utilize all nurses sense

Answer 15

observation and the physical examination

Question 16

What is a primary source? What is a secondary source? (of data)

Answer 16

primary source- always the patient
secondary source- aside of the patient (Family, sig others, other Healthcare prof, health records, and lit reviews

Question 17

Four techniques used in physical examination portion of the assessment are… (and the silent technique ;)

Answer 17

IPsquared-AI
Inspection ( LOOOK)
Palpation (touch, press- dont PUSH Me)
Percussion (tapping)
Auscultation (body sounds - bowel-lung- <3)
Intuition/ GUTS! (ask that question!)

Question 18

There is no difference between a nursing dx and a medical dx.

Answer 18

FALSE