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Assessment and Fundamentals > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Six Phases of Nursing Process

A
  1. Assessment
  2. Diagnosis
  3. Outcome Identification
  4. Planning
  5. Implementation
  6. Evaluation
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2
Q

Assessment

A

A collection of data about an individual’s health state

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3
Q

Subjective

A

What the patient says

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4
Q

Objective

A

What is observed about the person

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5
Q

Database

A

Subjective data, objective data, patient record, and laboratory studies

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6
Q

Diagnostic Reasoning

A

The process of analyzing health data and drawing conclusions to identify diagnoses

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7
Q

Four Major Components of Diagnostic Reasoning

A
  1. Attending to initially available cues
  2. Formulating diagnostic hypothesis
  3. Gathering data relative to the tentative hypothesis
  4. Evaluating each hypothesis with the new data collected
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8
Q

Cue

A

A piece of information, a sign or symptom, or piece of laboratory data

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9
Q

Hypothesis

A

A tentative explanation for a cue or a set of cues that can be used as a basis for further investigation

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10
Q

Nursing Process

A

The standards of practice in nursing

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11
Q

Components of Assessment

A

Collect data, evidence-based assessment, document relative data

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12
Q

Components of Diagnosis

A

Compare clinical findings, interpret data, validate diagnoses, document

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13
Q

Components of Outcome Identification

A

Identify expected outcomes, individualize to patient, make culturally appropriate, make realistic and measurable, include a timeline

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14
Q

Components of Planning

A

Establish priorities, develop outcomes, identify interventions, document plan of care

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15
Q

Components of Implementation

A

Safe and timely manner, evidence-based interventions, collaborate with colleagues, health teaching/promotion, document implementation

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16
Q

Components of Evaluation

A

Progress toward outcomes, include patient and significant others, use ongoing assessment, make sure it is systematic, ongoing, and criterion-based

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17
Q

First Level Priority

A

Emergent, life-threatening, immediate

Example: establishing an airway

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18
Q

Second Level Priority

A

Requires prompt intervention to prevent deterioration

Examples: mental status change, acute pain, elimination problems, abnormal lab values, infection risks

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19
Q

Third Level Priority

A

Important to patient’s health but can be addressed after first and second level
(Example: obesity)

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20
Q

Collaborative Problems

A

When the approach to treatment involves multiple disciplines

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21
Q

Evidence-Based Practice

A

Conviction that all patients deserve to be treated with the most current and best practice techniques

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22
Q

Four Components of Evidence-Based Practice

A
  1. Evidence-based research and theories
  2. Physical examination and assessment of patient
  3. Clinical expertise
  4. Patient preferences and values
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23
Q

Complete (Total Health) Database

A

Includes a complete health history and a full physical exam

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24
Q

Focused/Problem-Centered Database

A

Limited to a short-term problem, collect a “mini” database, concerns mainly one problem, cue complex, or body system

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25
Q

Follow-Up Database

A

Reevaluating identified problems at regular and short intervals

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26
Q

Emergency Database

A

Urgent, rapid collection of crucial information with a swift diagnosis

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27
Q

Holistic Health

A

Consideration of the whole person; mind, body, and spirit

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28
Q

Holistic Model Assessment

A

Includes lifestyle behaviors, culture and values, family and social roles, self-care behaviors, job-related stress, and more

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29
Q

Verbal Communication

A

Words, vocalizations, tone of voice

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30
Q

Nonverbal Communication

A

Body language, can be more reflective than true feelings

31
Q

Four Internal Factors for Communication

A
  1. Liking others
  2. Empathy
  3. Ability to listen
  4. Self-awareness
32
Q

Four External Factors for Communication

A
  1. Ensure privacy
  2. Refuse interruptions
  3. Physical environment
  4. Dress/Note-taking
33
Q

Three Steps of Interview

A
  1. Introductions
  2. Working Phase
  3. Summary
34
Q

Interviewing Parent or Caregiver

A

Be patient, avoid judgmental behavior, refer to child by name, be mindful of nonverbal communication

35
Q

Dealing with an Infant (0-12mos)

A

Nonverbal communication is primary
Respond quickly to changes
Use gentle handling

36
Q

Dealing with a Toddler (12-36mos)

A

Child develops communication skills
Telegraphic speech (noun and verb)
Provide simple explanations
Give one direction at a time

37
Q

Dealing with a Preschooler (3-6 years)

A

They take things literally
Use short, simple explanations
Utiliza animism and imaginations

38
Q

Dealing with a School-Aged Child (7-12 years)

A

Able to tolerate and understand others’ viewpoints
Objective and realistic
Important to be nonjudgmental
Interview child and caregiver together but ask child first

39
Q

Dealing with an Adolescent

A

Do not overcompensate
Be respectful and give validation
Communicate honestly
Adolescent first, problem second

40
Q

Dealing with the Older Adult

A

Address by proper surname
Avoid “elderspeak”
Prepare for a long interview
Consider physical limitations

41
Q

Interview with Hearing Impaired

A

Use cues to recognize hearing loss
Ask preferred method of communication
Face them and speak slowly
Utilize nonverbal cues and written communication

42
Q

Interview with Acutely Ill

A

Identify main area of distress
Ask family/friends
Make them comfortable

43
Q

Interviewing Under the Influence

A

Ask simple, direct questions
Appear nonthreatening
Avoid confrontation

44
Q

If Asked Personal Questions…

A

Supply appropriate information

Be aware of ulterior motives

45
Q

Interviewing Sexually Aggressive People

A

Establish professionality

Communicate intolerance

46
Q

Interviewing Someone Who is Crying

A

Allow person to cry and express feelings

Acknowledge their expressions

47
Q

Interviewing Someone Who is Angry

A

Ask about their anger and listen

48
Q

Dealing with Threats of Violence

A

Try to defuse the situation
Leave door open
Don’t turn your back on patient
Act calm

49
Q

Interviewing Someone with Anxiety

A

Take time to listen

50
Q

Interviewing Regarding Gender

A

Ask about culturally relevant aspects
Mind modesty
Knock and announce before entering

51
Q

Interviewing Regarding Sexual Orientation

A

Do not marginalize
Know the state laws
Do not make assumptions
Be nonjudgmental

52
Q

Health Literacy

A

Encompasses factors beyond basic reading such as using quantitative information and understanding verbal instructions

53
Q

Oral Teaching

A

Keep it simple
Explain benefits
Present needed information
Use active voice

54
Q

Written Materials

A

Must be at a 5th grade reading level or below
12-point font
Supply pictures

55
Q

Health History Sequence

A
  1. Biographic data
  2. Reason for seeking care
  3. Present health/History of present illness
  4. Past history
  5. Medication reconciliation
  6. Family history
  7. Review of systems
  8. Functional assessment
56
Q

Biographic Data

A

Includes name, address, phone number, age and birth date, birthplace, gender, marital status, race, ethnic origin, and occupation

57
Q

Source of History

A

Record who furnishes information
Judge the reliability (reliable always gives same answers)
Note if person appears sick or well (sick may communicate poorly)

58
Q

Reason for Seeking Care

A

Brief, spontaneous statement from patient that includes one or two signs or symptoms

59
Q

Symptom

A

Subjective sensation that patient feels

60
Q

Sign

A

Objective abnormality that you detect from physical exam or labs

61
Q

Present Health/History of Present Illness

A

Well Person: brief statement of general health

Sick Person: chronological record of the reason for seeking care from when symptoms started to now

62
Q

Six Critical Characteristics of Symptoms

A
  1. Provocative or Palliative
  2. Quality or Quantity
  3. Region or Radiation
  4. Severity Scale 1-10
  5. Timing or Onset
  6. Understand Patient’s Perception
63
Q

Past Health

A 
Childhood Illnesses
Accidents/Injuries
Serious/Chronic Illnesses
Hospitalizations
Operations
Obstetric History
Immunizations
Last Exam Date
Allergies
Current Medication
64
Q

Family History

A

Highlights diseases and conditions that may put patient at risk

65
Q

Family History if Patient is New Immigrant

A

Biographical Data
Spiritual Resources
Past Health/Immunizations
Health Perception

66
Q

Review of Systems

A
  1. Evaluates past/present health state of each body system
  2. Double-checks in case significant data was omitted from Present Health
  3. Evaluate health promotion practices
67
Q

Functional Assessment

A
  1. Measures a person’s self-care ability in the areas of general physical health or absence of illness
  2. Measures a person’s present functional status and monitors changes over time
68
Q

14 Categories of Functional Assessment

A 
Self-Esteem
Activity/Exercise
Sleep/Rest
Nutrition/Elimination
Interpersonal Relationships
Spiritual Resources
Coping/Stress Management
Personal Habits (tobacco, alcohol)
Alcohol
Illicit/Street Drugs
Environmental/Hazards
Intimate Partner Violence
Occupational Health
Perception of Health
69
Q

Developmental Competence (Children)

A 
Same as Past Health but includes:
Prenatal Status
Labor
Postnatal Status
Developmental History
Nutritional History
70
Q

Assessment of Adolescent

A

HEEADSSS

  1. Home environment
  2. Education/employment
  3. Eating
  4. Activities
  5. Drugs
  6. Sexuality
  7. Suicide/depression
  8. Safety
71
Q

Alcohol CAGE Test

A

Cut down drinking (ever been asked to?)
Annoyed by criticism?
Guilty about drinking?
Eye openers (drinking in the morning)

72
Q

Transpersonal Caring

A

Acknowledges unity of life and connections that move in concentric circles of caring

73
Q

Caring Model

A

Philosophical and moral/ethical foundation for professional nursing

74
Q

Caring Science

A

Encompasses a humanitarian, human science orientation to human caring processes, phenomena, and experiences

Assessment and Fundamentals (6 decks)

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