Module 1 Flashcards
Is a critical thinking process that professional nurses used to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.
Nursing process
A systematic method of providing care to clients
Nursing process
A systematic method of planning and providing individualized nursing care
Nursing process
It is a written guidelines for client care
Nursing care plan
It is organized so nurse can quickly identify nursing actions to be delivered, it also coordinates resources for care
Nursing care plan
It enhances the continuity of care and organizes information for change of shift report
Nursing care plan
Critical thinking has ability to
-identify a problem
-analyze it
-develop a response
-follow through
Critical thinking is based on
-experience
-knowledge
-intuition
What are the nursing process
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
It is the first step in determining a patient’s health status, collecting, validating, organizing and recording data about the patient health status.
Assessment
What is the purpose of assessment
-establish a database concerning a client physical, psychosocial and emotional health
-identify health promoting behavior
-potential health problems
What are the four types of assessment
- Initial comprehensive assessment
- Problem focused assessment
- Emergency assessment
- Time-lapsed assessment/ongoing assessment
This type of assessment is called admission assessment it is performed when client enters a healthcare from healthcare agency, evaluate the client health status and identify functional health pattern that are problematic and provide in-depth comprehensive database which is critical for evaluating changes in the client’s health status in subsequent assessment
Initial comprehensive assessment
A type of assessment that collects data about problem that has already been identified, has narrower scope and shorter time frame.
Problem focused assessment
A type of assessment that takes place in the life threatening situations and preservation of life is top priority. It also focuses on few essential health patterns and is not comprehensive.
Emergency assessment
What are the examples of emergency assessment
- Airway
- Breathing and circulatory problems
- Abrupt change in self concept or suicidal thoughts
It is a type of assessment that takes place after initial assessment to evaluate any changes in the client’s functional health.
Time lapsed assessment or ongoing assessment
What are the examples of time lapsed assessment
- Periodic output patient clinic visit
- Home health visit
- Health and developmental screening
What are the two activities during assessment
- Collecting data
- Verifying/validating data
This data involves gathering information about the patient, considering the physical, psychological, emotional, socio-cultural and spiritual factors that may affect his or her health status.
Collecting data
This data makes sures your information is accurate.
Verifying/validating data
What are the types of data
- Subjective data (interview)
- Objective data
Data from clients point of view that includes feelings, perception and concern.
Subjective data
What are the examples of subjective data
-vertigo
-pain
-nausea
-anxiety
-weakness
-fatigue
This data is called signs which is observable and measurable data obtained through physical examination and laboratory and diagnostic testing.
Objective data
What are the examples of objective data
-bp
-temperature
-reddish urine
-jaundice
What are the sources of data
- Primary source (client)
- Secondary source (family members, other healthcare providers and medical records)
A process which result to a diagnostic statement of nursing diagnosis
Diagnosing
A clinical act of identifying problems, the diagnose in nursing, analyze assessment information and derive meaning
Diagnosis
What is the purpose of diagnosis
Identify the patients healthcare needs and to prepare diagnostic statement
It refers to formulating and documenting measurable, realistic, patient focused goals
Outcome identification
What is the purpose of outcome identification
- Provide individualized care
- Promote patient satisfaction
- Plan care that is realistic and measurable
- Allow involvement of supporting people
It involves determining beforehand the strategies of course of actions to be taken before implementation of nursing care.
Planning
What is the purpose of planning
- Identify the patient goal and appropriate nursing intervention
- Direct patient activities
- Promote continuity care
- Focus charting requirements
- Allow for delegation of specific activities
It is where you’re putting your plan into action
Implementation
What is the purpose of implementation
-carry out planned nursing intervention to help the patient attain goals and achieve optimal level of health
It includes determining outcomes of achievements and identify variables or factors that affecting outcomes achievement
Evaluation
It is where to decide where two continue or modified terminate plan continue, a step of nursing process that measures the client’s response to nursing actions and the clients progress towards achieving goals.
Evaluation
What is the purpose of evaluation
-to appraise the extent to which goals and outcome criteria of nursing care have been achieved
A purposeful conversation between nurse and patient, consist of asking question designed to elicit subjective data (what person says about himself or herself)
Interview
What is the purpose of interview
- Gather, organize, complete and accurate data about patients health state including the description of chronology of any science and symptoms of illness
- Establish report and trust
- Teach the client about health state
- Build report for more nurse patient relationship
- Begin teaching for health promotion and disease prevention
A process of communication where it is done through verbal and nonverbal communication and is true spoken or written words (vocalization)
Sending
It is done underless conscious control does it is more accurate expression of one’s inner thoughts and feelings
Nonverbal
What are the examples of nonverbal
-gestures
-facial expressions
-posture
A process of communication that the words and gestures must be interpreted in a specific contents to have meaning
Receiving
What are the factors that affect communication
- Internal factors
- External factors (physical setting of interview)
What are the examples of internal factors
-liking others
-empathy
-ability to listen
What are the examples of external factors
-ensures privacy
-refuse interruptions
-physical environment
-dress
-note taking
-video and tape recording
It is the best for assessing breath and other body odors
Intimate zone (0 to 1 1/2 feet)
It is where you do physical assessment
Personal distance (1 1/2 to 4 feet)
It is where you do interview
Social distance (4 to 12 feet)
It is where you do help teaching in a community
Public distance (12 feet or more)
