Module 1-c Flashcards
Physical Assessment
Subjective/Objective findings when doing a head to toe physical assessment on a patient. Least invasie to most invasive.
Components of a physical assessment
Inspect, Auscultate, Percuss, Palpate
Basic History and a physical assessment
1.Biographical data, 2.Reason for seeking health care, 3.Hx of present health care concern, 4.Medical Hx, 5.Family Hx 6. Lifestyle
Nursing Process (systemic, dynamic,interpersonal,outcome oriented, universally acceptable)
Communication in the Nursing ProcessSystemic method for organizing and delivering nursing care. Framework for nursing practice. Patient centered, helps the nurse manage care scientifically, holistically, and creatively.
Assessing
collection of pt data, validation, and communication of pt data.
Diagnosing
analysis of pt data to ID pt strengths and health problems that independent nursing intervention can prevent or resolve.
Outcome ID and planning
Specification of !) pt outcomes to prevent, reduce, or resolve the problems ID’d in the nursing diagnoses, 2) related nursing interventions
Implementing
carrying out the plan of care.
Evaluating
Measuring the extent to which the patient has achieved the outcomes specified in the plan of care.ID factors that positively/negatively influenced outcome achievement. Revising the plan if necessary.
Characteristics of data
(good data) is Purposeful, Complete, Factual/Accurate, Relevant
Objective data (observable/ measurable)
age, weight, height vital signs. “posterior, left midcalf is warm and red” , :pt observed fidgeting with bed covers, facial features are tightly drawn
Subjective data (perceptions/feelings)
pain scale, symptoms “ my leg hurts when I walk”, I am so afraid”
Methods of data collection
Observation, Interview, and Physical Assessment
Components of Nursing HX
PT profile (demographics, reason for seeking care, health habits/patterns, current state of health, body systems, pain, PMH/PSH, Meds, allergies, vacs, Health status, Participation, personal resources, perception of health status, Developmental ,family, enviromental, physchosocial, Expectations of providers, Educational needs & willingness to learn, Potential for injury
Phases of the Interview Process
Preparatory (reading chart, taking report)
Introduction (meeting the pt, exchanging names)
Working (longest part of the process)
Termination (end of the process, summarize w/ the pt, look to the future)
Validation of data
Act of confirming or verifying. Purpose is to :free from error, bias, misinterpretation, question discrepancies, determine accuracy, address lack of objectivity.
Analysis of data
Recognize significant date ( Hypertension), recognize patterns/clusters, ID strengths and problems, ID potential complications, reach conclusion, partner w/ the pt.
Analyzing data ( standards or “norms”)
Rule, Measure, Pattern, Model, Compares same class or catrgory. (related to/ as evidenced by)
Comparing data to standards (analysis phase)
changes in normal patterns- deviation from population norm- nonproductive behavior-developmental lag or dysfunction
Analyzing data
Recognize significant data ( high temp, VS, etc…) , Recognize patterns or clusters (productive coughing/ smoking 1 pack per day for 15 yrs.)
Medical vs Nursing Diagnosis
MEDICAL DIAGNOSIS (ID’s disease, describes problems & directs TX, remains the same as long as the disease is present.) NURSING DIAGNOSIS (focus on IDing unhealthy responses to health/illness. problems treated by nurse in scope of nursing. may change day to day as the pt responds)
Types of Nursing Diagnoses
5 TYPES 1. Actual, 2.Risk, 3.Possible, 4.Wellness, 5. Syndrome.
ACTUAL (nursing diagnosis)
4 components …label, definition, defining characteristics, & related factor. (I.E. Imbalanced nutrition is greater than body requirements. (label), intake of nutrients exceeds metabolic needs (definition), weight 20% over ideal (defining characteristics), R/T excessive intake in relation to metabolic need (related factors)
RISK (nursing diagnosis)
risk for impaired skin integrity
POSSIBLE ( nursing diagnosis)
possible low self esteem
WELLNESS (nursing diagnosis)
readiness for enhanced health maintenance
SYNDROME (nursing diagnosis)
post-trauma syndrome
Components of a nursing diagnosis
Directs your nursing diagnosis/interventions. 3 components 1. Problem (ID’s what is unhealthy, suggests pt outcomes, independent nursing intervention. 2. Etiology (ID’s factors, based on collected data, directs interventions. 3. Defining Characteristics (subjective/objective data, real or potential and tangible)
Examples of nursing DX statements
Problem- frequent liquid stools, Etiology-R/T increased intake of high fiber foods. Defining characteristic- as manifested by liquid stools 5 x/day for 2 weeks.
Outcome, Identification, and Planning
Pt goals (aim or end, expected conclusion, developed by RN/PT, derived from problem statement) Outcomes prevent, reduce, or eliminate the problem & must support overall goals
Short term goals
Short, 8 hr shift, complete quick
Long term goals
longer, greater than a week, may be discharge gaols
Etiology of a Problem & Nursing Measures
Problem statement, etiology of a problem, standards of care, interventions (TX based on clinical judgment)
Nursing Intervention Classification (NIC)
list of nursing interventions (comprehensive, validated, and facilitate ID of appropriate interventions)
Dependent Nursing Interventions (Actions)
Physician initiated (Dr orders)
Independent Nursing Interventions (Actions)
Nurse initiated ( RN prescribes interventions)
Interdependent Nursing Intervention (Actions)
Collaborative interventions (performed jointly by RN and other members of the healthcare team)
Types of outcomes
Cognitive (increased pt knowledge), Psychomotor (pt achieves a new skill), Affective (change in pt values/beliefs), Physiologic ( physical changes)
Expected Outcomes and evaluation process
Measurable, ID factors (success/failure), document findings, modify nursing plans as needed.
Plan of care evaluation
Terminate, Modify, Continue
Nursing guidelines for legal documentation
Complete, reflects nursing process, observations of behavior, avoid generalizations, note problems, medical visits, responses, factual info
Documentation (timing)
agency policy and frequency, type of entry/information, time of execution, military time, never document before doing. Approved abbreviations only.
