chapter 1 * Flashcards
AIDET stands for
acknowledge, introduce, duration,explain, thank you
A IN AIDET examples would be
knock, ask for and wait until permission given to enter, address patient and family by name. make eye contact, assess/fix, ask is there anything I can do for you before I leave.
I in AIDET examples would be
introduce yourself, your role, skill set, manage up others positively
D in AIDET examples would be
under promise over deliver, give them a time expectation that will absolutely be met, thinking of the patient perception of how long something will take always keep your promise
E in AIDET examples would be
explain step-by step what will happen next. give explanation of purpose “why” ask patient and family if they have any questions
T in AIDET examples would be
thank the patient for communication cooperation check is there anything else you can do before you leave.
SOAP stands for
Subjective data, Objective data, Assessment, and Planning.
Give an example of S in SOAP.
Subjective data
Give an example of O in SOAP.
Objective data are derived from the physical assessment, client records, and reports.
SBAR stands for
S situation B background A assessment R recommendation
Healthy People 2020 topics are:
physical activity, nutrition, tobacco use, alcohol and substance abuse, sexual and reproductive health, mental health, injury and violence prevention, occupational safety and health, environmental health, oral health, emerging issues, preventive services
Give an example of A in SOAP.
Assessment refers to conclusion drawn from the date.
Give an example of P in SOAP.
Planning indicates the actions to be taken to resolve problems or address client needs.
The letters APIE refers to
Assessment, Problems, Intervention, and Evaluation.
definition of Evidence Based Practice
an approach to decision making, intervention, and nursing care that requires integration of clinical expertise with the best evidence from systematic research and regard for the concerns and choices of the client
(abd) is the standard abbreviation for
Abdomen
(ADL) is the standard abbreviation for
Activities of daily living.
absence of disease is
health
WHO defines health as
a state of complete physical, mental,and social well-being. this is a holistic approach
health assessment is defined as
a systemic method of collecting data about a client for the purpose of determining the client’s current and on going health status, predicting risks to health and identifying health promoting activities
what is a systematic method of collecting data
health assessment
does the interview use objective data?
no, subjective
define interview
subjective data is gathered that includes health history and focused interview. data comes from primary and secondary sources
during the interview where does the information come from?
primary and secondary sources
what is subjective data?
information that the client experiences and communicates to the nurse.
what are 5 examples of subjective data?
- pain
- dizziness
- nausea
- itching sensation
- feeling nervous
is pain subjective or objective data
subjective
what is included in the health history
biographic data, perceptions about health, past and present history about illness or injury, family history, health patterns, and practices
what does the focused interview allow the nurse to do?
clarify points, obtain missing info, and follow up on cues
a hands on examination of the client is
physical assessment
what is objective data?
observed or measured by the professional nurse.
Give some examples of objective data
seen, felt, heard or measured by the nurse
Past documentation, charts, diagnostic reports or lab testing is all what type of data?
Secondary sources that are objective
Define client record
legal document used to plan care, communicate information between and among health care providers and to monitor quality of care
5 things a document must be is
- accurate
- confidential
- appropriate
- complete
- detailed
BP
blood pressure
CBC
complete blood count
CNS
Central Nervous System
CVA
Costovertebral angle
Dx
Diagnosis
Ht
height
Hx
History
LMP
last menstrual period
mg
milligram
P
pulse
RR
respirations rate
T
temperture
VS
vital signs
WBC
white blood cell
Wt
Weight
Confidentiality means?
that information sharing is limited to those directly involved in client care
Anterior (ventral)
Toward the front
Cephalad
toward the head
Distal
farthest from the center or medial line
Deep
below the surface
Extenal
outside of
Medial
closer to the midline
Superior
upper
supine
face up
Posterior (dorsal)
toward the back
Caudad
toward the feet
Proximal
closet to the center or a medial line
Superficial
on or above the surface
Internal
inside of
Lateral
inside of
inferior
lower
Prone
face down
Interpretation of findings can be defined as?
making determinations about all of the data collected in health assessment process
Communication refers to
the exchange of information, feelings, thoughts, and ideas
Communication occurs through ____ means and ____ methods?
nonverbal means and verbal methods
Examples of nonverbal means are
facial expression, gestures, and body languages
Examples of verbal methods are
spoken or written communication
Holism can best be described as?
the overall factors that affected physical, spritrual and emotional well being
The interpretation of findings include 8 things that are:
- knowledge 2. communication 3. holistic approach 4. developmental factors 5. psychologic and emotional factors 6. family factors 7. cultural factors 8. environmental factors
Examples of internal environmental factors
emotional state, response to medication and treatment and physiologic or anatomic alterations
External environmental factors examples are
inhaled toxins, irritants, noise light motion
The nursing process is a _____, ___, _____ and _____ process used by the nurse for planning and providing care for the client
systematic, rational, dynamic and cyclic
5 steps of the nursing process are
assessment, diagnosis, planning, implementation and evaluation
What type of approach is the nursing process
client centered
Step 1 of the nursing process is
assessment
Assessment is:
the collection, organization and validation of subjective and objective data
What type of data is collected during the assessment step?
subjective and objective data
Step 2 of the nursing process is
Diagnosis
What is the basis for planning and implementing nursing care?
nursing diagnosis
3 types of nursing diagnoses are identified by NANDA. They are
actual problems, risk for problems and wellness issues
what are the 4 components of the NANDA diagnosis
diagnostic label, definition, defining characteristics and risks or related factors
How are NANDA diagnoses formulated?
Using the PES statement
PES stands for (in the NANDA diagnoses)
P is the problem , E the Etiology, S signs and symptoms
step 3 of the nursing process is
Planning
3 parts of the planning process are
- setting priorities 2. stating client goals, and 3. selecting strategies to address the diagnoses
The nurse uses the diagnostic statements to develop ______ and _______.
goals and interventions
The goal is stated in terms of ________ includes a _____ ______, and is derived from the _____ part of the diagnosis
the expected client outcomes includes a time frame and is derived from the first part of the diagnosis
Step 4 is what of the nursing process
Implementation
what happens in the implementation phase of the process
the care plan is put into action
Step 5 of the nursing process is
Evaluation
Evaluation refers to
if the goal has been achieved within the stated time frame
Critical thinking is a ___ skill
cognitive skill
Define critical thinking
a process of purposeful and creative thinking about resolutions of problems or the development of ways to manage situations.
Critical thinking is more than ____ _____; it is a way to apply _____ and cognitive skills to the complexities of client care.
problem solving, it is a way to apply logic
5 essential elements of critical thinking are
collection of information, analysis of the situation, generation of alternatives, selection of alternatives and evaluation
what is the first of the 5 essential elements in critical thinking
collection of information
what does collection of information involve (5)
- identifying assumptions, 2. organizing data collection, 3. determining the reliability of the data,4. identifying relevant vs. irrelevant data, and 5. identifying inconsistencies in the data
the second skill of collection of information is?
data collection
Data collection involves both ____ and ____ data
subjective and objective data
The third skill of collection of information is
determining the reliability of the data
what is the best source of information especially historic for information
the client
What is the fourth critical thinking skill
determine the relevance of the information in relation to the client’s current, evolving or potential condition or situation
What is the fifth skill of the collection of information assessment
identifying inconsistencies is the last skill
What is the second element of critical thinking
analysis of the situation
what 5 skills are linked to the second element of critical thinking
- distinguish data as normal or abnormal, 2. cluster related 3. identify patterns in the data 4. identify missing information 5. draw valid conclusions
what is alopeia
hair loss
when critically thinking the nurse will cluster information by sorting and categorizing information into groupings. These techniques are:
cue, symptoms, body systems or health practices
what are the two skills associated with critical thinking in regards to element of generations of alternatives
articulating options and establishing priorities
what are the two skills associated with critical thinking in regards to selection of alternatives
articulate options and establish priorities
the last element of critical thinking is
evaluation
what are the two types of teaching
informal teaching and formal teaching
what are the three conditions represent the three types of nursing diagnoses in the NANDA taxonomy
teaching that occurs as a natural part of a client encounter.
define informal teaching
occurs as a natural part of a client encounter. it may be to provide instructions, to explain a question or procedure or to reduce anxiety
Define formal teaching
occurs in response to an identified lecturing need of an individual or group or community. Teaching plans are part of the formal process
what are the 6 parts of the teaching plan
the identified learning need, the goal, objectives, content, teaching strategies and rationales, and evaluation
what are some cognitive verbs
apprasies, changes, composes, concludes, converts, creates, criticizes, defines, designs, diagrams, discriminates, explains, generates, matches, modifies, names, reorganizes, separates, solves, states, subdivision, summarizes
what are some affective verbs
acts, adheres, describes, discusses, displays, explains, greets, justifies, modifies, presents, proposes
what are some psychomotor verbs
assembles, calibrates, changes, demonstrates, dismantles, fixes, makes, manipulates, operates
what type of teaching methods are cognitive?
one-on-one discussion, explanation, lecture, group discussion, case study, role-play, printed material, media audiovisual presentation, computer-assisted instruction
what type of teaching methods are affective?
one-on-one discussion, group discussion, role-play, media audiovisual presentation, computer-assisted instruction
what type of teaching methods are psychomotor?
demonstration, practice, media audiovisual presentation, computer-assisted instruction
what are the roles of the professional nurse?
Teacher,caregiver, nurse researcher, nurse practitioner, clinical nurse specialist, nurse administrator, nurse educator
what are the four types of data collected in a patient assessment
objective, subjective, reflective and introspective
