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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
Follow-Up Database
Reevaluating identified problems at regular and short intervals
26
Emergency Database
Urgent, rapid collection of crucial information with a swift diagnosis
27
Holistic Health
Consideration of the whole person; mind, body, and spirit
28
Holistic Model Assessment
Includes lifestyle behaviors, culture and values, family and social roles, self-care behaviors, job-related stress, and more
29
Verbal Communication
Words, vocalizations, tone of voice
30
Nonverbal Communication
Body language, can be more reflective than true feelings
31
Four Internal Factors for Communication
1. Liking others 2. Empathy 3. Ability to listen 4. Self-awareness
32
Four External Factors for Communication
1. Ensure privacy 2. Refuse interruptions 3. Physical environment 4. Dress/Note-taking
33
Three Steps of Interview
1. Introductions 2. Working Phase 3. Summary
34
Interviewing Parent or Caregiver
Be patient, avoid judgmental behavior, refer to child by name, be mindful of nonverbal communication
35
Dealing with an Infant (0-12mos)
Nonverbal communication is primary Respond quickly to changes Use gentle handling
36
Dealing with a Toddler (12-36mos)
Child develops communication skills Telegraphic speech (noun and verb) Provide simple explanations Give one direction at a time
37
Dealing with a Preschooler (3-6 years)
They take things literally Use short, simple explanations Utiliza animism and imaginations
38
Dealing with a School-Aged Child (7-12 years)
Able to tolerate and understand others' viewpoints Objective and realistic Important to be nonjudgmental Interview child and caregiver together but ask child first
39
Dealing with an Adolescent
Do not overcompensate Be respectful and give validation Communicate honestly Adolescent first, problem second
40
Dealing with the Older Adult
Address by proper surname Avoid "elderspeak" Prepare for a long interview Consider physical limitations
41
Interview with Hearing Impaired
Use cues to recognize hearing loss Ask preferred method of communication Face them and speak slowly Utilize nonverbal cues and written communication
42
Interview with Acutely Ill
Identify main area of distress Ask family/friends Make them comfortable
43
Interviewing Under the Influence
Ask simple, direct questions Appear nonthreatening Avoid confrontation
44
If Asked Personal Questions...
Supply appropriate information | Be aware of ulterior motives
45
Interviewing Sexually Aggressive People
Establish professionality | Communicate intolerance
46
Interviewing Someone Who is Crying
Allow person to cry and express feelings | Acknowledge their expressions
47
Interviewing Someone Who is Angry
Ask about their anger and listen
48
Dealing with Threats of Violence
Try to defuse the situation Leave door open Don't turn your back on patient Act calm
49
Interviewing Someone with Anxiety
Take time to listen
50
Interviewing Regarding Gender
Ask about culturally relevant aspects Mind modesty Knock and announce before entering
51
Interviewing Regarding Sexual Orientation
Do not marginalize Know the state laws Do not make assumptions Be nonjudgmental
52
Health Literacy
Encompasses factors beyond basic reading such as using quantitative information and understanding verbal instructions
53
Oral Teaching
Keep it simple Explain benefits Present needed information Use active voice
54
Written Materials
Must be at a 5th grade reading level or below 12-point font Supply pictures
55
Health History Sequence
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
Biographic Data
Includes name, address, phone number, age and birth date, birthplace, gender, marital status, race, ethnic origin, and occupation
57
Source of History
Record who furnishes information Judge the reliability (reliable always gives same answers) Note if person appears sick or well (sick may communicate poorly)
58
Reason for Seeking Care
Brief, spontaneous statement from patient that includes one or two signs or symptoms
59
Symptom
Subjective sensation that patient feels
60
Sign
Objective abnormality that you detect from physical exam or labs
61
Present Health/History of Present Illness
Well Person: brief statement of general health | Sick Person: chronological record of the reason for seeking care from when symptoms started to now
62
Six Critical Characteristics of Symptoms
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
Past Health
``` Childhood Illnesses Accidents/Injuries Serious/Chronic Illnesses Hospitalizations Operations Obstetric History Immunizations Last Exam Date Allergies Current Medication ```
64
Family History
Highlights diseases and conditions that may put patient at risk
65
Family History if Patient is New Immigrant
Biographical Data Spiritual Resources Past Health/Immunizations Health Perception
66
Review of Systems
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
Functional Assessment
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
14 Categories of Functional Assessment
``` 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
Developmental Competence (Children)
``` Same as Past Health but includes: Prenatal Status Labor Postnatal Status Developmental History Nutritional History ```
70
Assessment of Adolescent
HEEADSSS 1. Home environment 2. Education/employment 3. Eating 4. Activities 5. Drugs 6. Sexuality 7. Suicide/depression 8. Safety
71
Alcohol CAGE Test
Cut down drinking (ever been asked to?) Annoyed by criticism? Guilty about drinking? Eye openers (drinking in the morning)
72
Transpersonal Caring
Acknowledges unity of life and connections that move in concentric circles of caring
73
Caring Model
Philosophical and moral/ethical foundation for professional nursing
74
Caring Science
Encompasses a humanitarian, human science orientation to human caring processes, phenomena, and experiences

Assessment and Fundamentals (6 decks)

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