Chapter 1 Flashcards
Healthy People initiatives
Premise that individual health is closely related to health in the community
United States Department of Health and Human Services (USDHHS)
Strategy intended to eliminate preventable disease, achieve health equity, create environments that promote health, and promote healthy development and behaviors at every age
Evidence-Based Practice
Integrates best available evidence, nursing expertise, and preferences and values of individuals, families and communities
Agency for Healthcare Research and Quality (AHRQ)
Health
The absence of disease
Wellness
A state of life that is balanced, personally satisfying, and characterized by the ability to adapt and participate in activities that enhance quality of life
Health (WHO Definition)
A state of complete physical, mental, and social well-being
Roy and Andrews definition of health
A process and state of being and becoming whole and integrated in a way that reflects person and environment mutuality
Orem definition of health
A state of a person as characterized by soundness or wholeness of developed human structures and mental and bodily functioning that requires therapeutic self-care
Leininger definition of health
A culturally defined, valued, and practiced state of well-being reflective of the ability to perform role activities
Nightingale definition of health
A state of well-being and use of every power the person possesses to the fullest extent
Health Assessment
A systematic method of collecting data about a patient
Scope of focus must be more than problems presented by patient.
The Interview
Subjective data gathered
Primary and secondary sources
Information that the patient experiences and communicates to the nurse
The Health History
Purpose of obtaining information about the patient’s health in his or her own words and based on their perceptions
Provides cues regarding patient’s health and guides further data collection
Most important aspect of data collection process
The Focused Interview
Enables nurse to clarify points, obtain missing information, and follow up on verbal and nonverbal cues
Nurse applies knowledge and critical thinking when asking specific and detailed questions related to symptoms, feelings, or events.
Physical Assessment
Hands-on examination of the patient
Objective data
Observed or measured by the professional nurse
Can be constant or variable
Documentation
Essential to consistency in health care
Used to communicate information between and among health professionals. Must be accurate and consistent (language)
Patient record: Legal document used to plan care, monitor care quality
HIPPA states that documents must be confidential
Contains narrative notes (words, paragraphs) and can be charted by SOAP or ADPIE.
Holistic approach
Considering more than the physiologic health status of a patient
All factors that impact a patient’s well-being
Interpretation of findings
Developmental factors (Age, Intellect, Developmental tasks or handicaps) Psychologic and emotional factors (Anxiety, Self-esteem, Depression, Grieving) Cultural factors (Language, Expression, Emotional and physical well-being, Health practices) Internal factors (reaction to medication, emotional state) External factors (toxins, inhalants)
Assessment
The collection, organization, and validation of subjective and objective data
Begins when nurse first meets patient
Diagnosis
Use of critical thinking and application of knowledge from the sciences and other disciplines to analyze and synthesize data
Composed of four components: (Diagnostic label, Definition, Defining characteristics, Risks or related factors)
If problem is actual, three-part statement; if a risk, two-part
Planning
Priority setting
Stating patient goals or outcomes
Selecting nursing interventions
Implementation
Putting the nursing interventions into action
Promotes patient’s achievement of goals or outcomes
Evaluation
Comparing the patient status to the stated goals or outcomes
A single nursing diagnosis may generate more than one patient goal.
Critical Thinking
Process of purposeful and creative thinking about resolutions of problems or the development of ways to manage solutions
Cognitive skill
Enables nurse to make judgments about patient care based on careful collection and interpretation of patient data
Collection of Information
Identifying assumptions Organizing data collection Determining reliability of data Identifying relevant versus irrelevant data Identifying inconsistencies in data
Analysis of the Situation
Distinguishing data as normal or abnormal Clustering related data Identifying patterns in data Identifying missing information Drawing valid conclusions
Generation of Alternatives
Articulating options
Establishing priorities
Selection of Alternatives
Developing outcomes
Developing plans
Includes all actions required by patient independently or in coordination with healthcare professionals to achieve outcomes
Role of the Professional Nurse
Teacher Caregiver Patient advocate Manager of patient care Each situation requires critical thinking and the nursing process.
Teacher
Acquires knowledge required for health maintenance or improvement
Prevents illness or injury
Manages therapies
Makes decisions about health and treatment
Informal teaching: Occurs as a natural part of the encounter
To provide instructions, explain a question or procedure, or reduce anxiety
Formal teaching: Occurs in response to teaching plans for an identified learning need of an individual, a group, or a community
