HA lec 1 Flashcards
Is a process of sharing info and meaning
Communication
Methods of collecting data
Interview
Observation
Physical Assessment
Structured communication intended to obtain subjective data
Interview
Are structured with specific questions and are controlled by the nurse
Directive interview
Are controlled by the patient but the nurse still summarizes the data
Non directive interview
Types of interview questions
open ended
close ended
Phases of interview
Introductory
Working
Termination
Is the time to iuntroduce yourself to your patient
Introductory
Is often where data collection occurs
Working phase
Is the end of the interview process
Termination
Entails deliberate use of senses
Observation
Provides objective data base
Physical assessment
Is a process which results to diagnostic statement
Diagnosis
A statement of a patients potential or actual health problem which nurses, by virtue of their education and experience are capable and licensed to treat (Gordon, 1976)
Nursing Diagnosis
It is a clinical judgement about an individual (NANDA 1990)
Nursing Diagnosis
Prescribes a disease or a pathology of specific organs or body system
Medical Diagnosis
Describes an actual, risk, or human response to health problem that nurses are responsible for treating independently
Nursing diagnosis
parts of a complete nursing diagnosis
Problem
Etiology
Signs and symptoms
Is a mental formulation of a proposed method of doing or making something
Planning
Are activities that the nurse plans and must be implemented to help a patient achieve the goals
Nursing interventions
Types of nursing interventions
Developmental
supplemental
facilitative
Enhances patients capabilith for self care
developmental
nurse doing things for the patient because he lacks technical knowledge or has a physical disability
Supplemental
Nurse rmoves barriers to care
Facilitative
Types of nursing function
Independent
dependent
collaborative
It involves determining the effectiveness of your plant
Evaluation
To identify not only actual but potential health problems
Health history
Types of health history
Complete
Focused
Includes biographical data
Complete
Focuses on an acute problem
focused
Types of physical assesment
Complete
Focused
includes general survey: vital sign measuremnents; height and weight etc
Complete physical assessment
Assess only the parts of the body that relate to that problem
Focused physical assesment
Blueprint of nursing process
Nursing care plan