Fundamentals: Chapter 16 Flashcards
Define the Nursing Process
A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.
How often does a nurse apply the nursing process?
each time you meet a patient
What is the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns?
assessment
What provides the basis for planning and implementing nursing interventions and evaluating the outcomes of care?
clearly defining your patients’ problems
What are the two steps of the nursing assessment?
- Collection of information from a primary source (the patient) and secondary sources (e.g., family members, health professionals, and medical record)
- The interpretation and validation of data to ensure a complete database
What is the purpose of the assessment?
to establish a database about the patient’s perceived needs, health problems, and responses to these problems
Why is critical thinking a vital part of the assessment?
It allows you to see the big picture when you form conclusions or make decisions about a patient’s health condition.
What is information that you obtain through use of the senses?
cue
What is your judgment or interpretation of the information you obtain through use of the senses?
inference
What are the 11 functional health patterns?
Health perception
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Sleep-rest pattern
Cognitive- perceptual pattern
Self perception-Self concept pattern
Role-relationship pattern
Sexuality-reproductive pattern
Coping-stress tolerance pattern
Value-belief pattern
Who can provide subjective data?
only the patients
What is subjective data?
the patients’ verbal descriptions of their health problems
What data is usually included in subjective data?
feelings
perceptions
pt. self report of symptoms
What is objective data?
observations or measurements of a patient’s health status.
What is the difference between subjective data and objective data?
A nurse uses subjective data (from patient) to guide objective observations.
What is usually your best source of information?
the patient
What is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness.
patient-centered interview
What are the 4 steps for an initial patient-centered interview?
- Setting the stage
- Gathering information
- Collecting the assessment/nursing health history
- Terminating the interview
Which phase of an interview is setting the stage?
Orientation
Why do we use open-ended questions?
They prompt patients to describe a situation in more than one word which leads to a discussion in which patients actively describe their health status
How can the interviewer reinforce interest in what the patient has to say?
Good eye contact and listening skills
When would an interviewer use closed-ended questions?
To help the interviewer acquire specific information about health problems such as symptoms, precipitating factors and/or relief measures
What does an assessment with cultural competence involve?
A conscientious understanding of your patient’s culture so you can offer better care within differing value systems and act with respect and understanding without imposing your own attitudes and beliefs.
When does a nurse gather a nursing health history?
During either the initial contact or early contact with the patient.
What is the term for symptoms that patients experience along with their primary symptoms?
concomitant symptoms (i.e nausea + pain)
What is the systematic approach for collecting the patient’s self-reported data on all body systems?
review of symptoms (ROS)
How does a nurse validate assessment data?
compare the data with another source to determine accuracy
What is the last part of a complete assessment?
Data documentation
What are the 4 types of nursing assessment?
Comprehensive initial
Focused
Emergency
Time-lapsed
