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NURS320 > Module 6 > Flashcards

Module 6 Flashcards

1
Q

Assessing

A

Systematic and continuous collection, analysis, validation, and communication of patient data

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2
Q

Data does what for us on assessment?

A

reflects how health functioning is enhanced by health promotion or compromised by illness and injury

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3
Q

Database

A

includes all the pertinent patient information collected by the nurse and other healthcare professionals

ensures the nurse to partner with patients to make a comprehensive and effective care plan

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4
Q

Medical Assessment

A

targets data pointing to pathologic conditions / exact conditions

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5
Q

Nursing Assessments

A

focus on the patients response to a health problem and how to prevent those responses

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6
Q

In assessment, the primary source of information is the ____

A

patient

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7
Q

How is critical thinking linked to assessment?

A

You have to assess systematically and comprehensively to ID nursing and medical concerns

Detect bias and determine credibility of information sources

Distinguish normal from abnormal findings and ID risks for abnormal findings

Make judgements about data significance

Determine what is relevant and what is not

ID assumptions and inconsistencies, checking accuracy and reliability, and recognizing missing information

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8
Q

Characteristics of a Nursing Assessment

A 
Purposeful
Prioritizing
Complete (holistic and meaningful to issue)
Systematic
Factual and Accurate
Relevant
Recorded in a Standard Manner
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9
Q

4 Types of Nursing Assessments

A

Comprehensive / Initial
Focused
Emergency
Time-Lapsed

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10
Q

Initial comprehensive assessment

A

done shortly after admittance

needs to establish a complete database for problem ID and care planning

performed by the nurse to collect data on all aspects of patient health

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11
Q

Focused Assessment

A

performed during initial assessment or as a routine data collection

performed to gather data on specific problems already ID, or ID new or overlooked problems

Done by the nurse to collect SPECIFIC PROBLEM DATA

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12
Q

Emergency Assessment

A

When a physical or psychological crisis is present

done to ID life threatening problems

done by nurses to gather data on a LIFE THREATENING PROBLEM

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13
Q

Time Lapsed Assesment

A

Performed to compare a patients current status to baseline data obtained earlier

Reassesses health status and allows for necessary revisions in a care plan

Done by the nurse to collect data about current health status of the patient

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14
Q

What factors determine assessment priorities?

A
  1. Health Orientation (potential and actual risks that influence wellness)
  2. Developmental Stage (compare what is happening when hospitalized to what occurs outside setting)
  3. Culture (big role in patient care)
  4. Need for Nursing (ex: focus on the problem they have, not irrelevant things)
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15
Q

Characteristics of Good Assessment Data Gathered

A 
Purposeful
Prioritizing
Complete
Systematic
Factual and Accurate
Relevant
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16
Q

Objective Data

A

observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

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17
Q

Subjective Data

A

information perceived only by the affected person

ex: pain, dizziness, anxiety

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18
Q

Potential Sources of Assessment Data

A

Patient Family and Sig others

Patient records

PMH, Physical exam, progress notes

consultations

reports of lab and other diagnostic studies

reports of therapies by other health are professionals

nursing and other health care literature

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19
Q

Problems related to data collection?

A

Inappropriate database organization

omission of needed data

inclusion or duplication of misinterpreted, irrelevant, or erroneous data

Failure to establish rapport or partnership with patient

Recording and interpretation of data rather than observed behavior exactly

failure to update database

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20
Q

When should data be verified?

A
  1. When there is a discrepancy between what the person says, and what the nurse observes
  2. When the data seems to lack objectivity
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21
Q

The skill of nursing observation involves determining…

A
  1. Patients current responses (emotional and physical)
  2. patients current ability to manage care
  3. immediate environment and its safety
  4. the larger environment (hospital or community)
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22
Q

4 Phases of a Nursing Interview (assessment stage)

A
  1. preparatory phase
  2. Introduction
  3. Working phase
  4. termination
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23
Q

How is the Nursing Interview different from the Communication stages?

A

There is a preparatory stage in the nursing interview

24
Q

Preparatory Phase

A

getting printed information to assure you know it, clearing mind of anxiety and bias, visualizing yourself as the optimal caregiver

25
Q

Introductory Phase

A

talking comfortably and introducing yourself

26
Q

Working Phase

A

active listening, obtaining information, observation work

27
Q

Termination Phase

A

asking for a summary of the most important concerns, mentioning to say if they have anything to add later one, being open to more information

28
Q

Purpose of a Nursing Physical Assessment

A
  1. Appraisal of Health Status
  2. ID health problems
  3. Establishment of a database for nursing interventions
29
Q

2 Parts of the Nursing Physical Assessment

A
  1. ROS

2. Physical Assessment

30
Q

Ways to validate inferences

A

Physical exam with proper equipment and procedure

use clarifying statements

sharing inferences with other team members - communicate

checking findings with research reports

comparing cues to knowledge based of normal function

checking consistency of cues

31
Q

How does the phases of assessment set the stage for diagnosis?

A

Collecting data, ID cues and inferences, Validating data, clustering related data into patterns, and reporting & recording make up ASSESSMENT –> which leads to CLINICAL REASONING (analyze, synthesize, reflect, make judgment, draw conclusion) –> which leads to the DIAGNOSIS

32
Q

How should documentation of data occur?

A

SAME DAY

Do immediately when critical changes occur in health status

Enter initial database into record the same day as admission while summarizing objective and subjective data concisely, comprehensively, and in a way that can be retrieved easily

Use good grammar and standard abbreviations

When possible, use patients own words

avoid non specific terms subject to individual definition/interpretation

33
Q

When assessing and documenting data is is important for the nurse to…

A

have their primary ethical responsibilities in mind for privacy, confidentiality, and professionalism

Be familiar with HIPAA and institutional policies

34
Q

Nursing Diagnosis

A

a clinical judgment / describe patient problems a nurse can treat independently

35
Q

NANDA I

A

group making nursing diagnosis guidelines

36
Q

Purpose of the Diagnosis step of the nursing process

A

ID how someone, group, or community responded to actual or potential health and life processes

ID factors that contribute to, or cause, health problems (etiologies)

ID resources or strengths on which the individual, group, or community can draw to prevent or resolve problems

37
Q

Nursing concerns and responsibilities related to diagnosis

A

Recognizing safety and infection risks and addressing them ASAP

ID human responses to things and how treatment impacts a patients life while promoting optimal health

Anticipating possible complications and trying to prevent them

Initiating urgent interventions if needed

38
Q

What is “Predict, Prevent, Manage, Promote”

A

We must PREDICT the most common and most dangerous complications

Make immediate actions to PREVENT

MANAGE them if they cannot be prevented

Promote optimum function, independence, and sense of well being by ensuring safety and learning needs are met

39
Q

3 Types of Diagnoses

A

Nursing
Medical
Collaborative Problem

40
Q

Medical Diagnosis

A

describe problems for which the physician directs the primary treatment

41
Q

Collaborative Problems

A

managed by using physician-prescribed and nursing-prescribed interventions

ex: Medical Diagnose Cancer –> Radiotherapy as surgical treatment –> diagnostic study in exploratory test

42
Q

Diagnostic and Clinical Reasoning tips

A

Be familiar with nursing diagnosis and health problems through literature

trust clinical expertise and judgement, but be willing get help when needed

respect intuition but dont have 0 evidence

recognize your bias & keep an open mind

43
Q

Skills Needed To Work In Partnership

A

respect and care when speaking

effective listening

respect the opinions and views of others

know how to validate perceptions w patients and families

44
Q

4 Steps of Data Interpretation and Analysis

A

Recognizing Significant Data (compare to standards) –> Recognize patterns or clusters –> ID strengths and problems and potential complications –> Reach a conclusions

45
Q

Possible Results when reaching conclusions?

A

No Problem

Possible Problem

Acute or Potential nursing Diagnosis

Clinical problem other than nursing diagnosis

46
Q

3 components of the Nursing Diagnosis

A

Problem - Etiology (r/t) - Defining Characteristics (AEB)

What is unhealthy r/t Factors maintaining unhealthy state AEB subjective and objective data signaling existence of problem

47
Q

Types of nursing diagnoses

A

Problem focused
risk
health promotion

(with defining characteristics and related factors stated too)

48
Q

Problem focused nursing diagnosis

A

patient has a problem

ex: impaired bed mobility r/t left side paralysis
ex: sleep deprivation r/t pain

49
Q

Risk nursing diagnosis

A

Diagnosis of a risk for something due to something

ex: Risk for skin integrity r/t incontinence
ex: RIsk for ineffective breathing pattern r/t dyspnea

50
Q

Health promotion nursing diagnosis

A

Readiness for ____

ex: Readiness for enhanced nutrition

51
Q

Ways to validate the nursing diagnosis?

A

Is my database sufficient, accurate, and supported by research? (do I have everything)

Does data synthesis demonstrate a pattern?

Are the subjective and objective data characteristics of the problem defined?

Is my nursing diagnosis based on EBP and clinical expertise?

It the diagnosis able to be prevented, reduced, or resolved by independent nursing action?

Is my degree of confidence above 50% that other qualified practitioners would formulate the same diagnosis?

52
Q

Keep in mind what while documenting on EHR

A

view ongoing risks and problems others have ID’ed

Decide on the doc, new N diagnosis based on assessment findings

facilitate communication of ACTUAL problems with other healthcare providers

Use N diagnosis to make decisions on what mutual goals of the patient are

determine and document when N diagnosis are resolved

53
Q

Benefits of the nursing diagnosis

A

Individualized patient care

Defining domain of nursing to health care administrators, legislators, and providers

Seeking funding for nursing and reimbursement for nursing services

54
Q

Limitations of the nursing diagnosis

A

If used incorrectly, misdiagnosis occurs

Nursing practice may be restricted

55
Q

Common errors when writing a nursing diagnosis?

A

Writing in terms of needs and response

Making legally inadvisable statements

ID a problem response that isnt necessarily unhealthy or that cannot be changed by us

ID environmental factors rather than patient ones

Reversing clause order

having both clauses say the same thing

including value judgements

Including medical diagnosis in the diagnostic statement

56
Q

When writing a nursing diagnosis be…

A

simple, do not overcomplicate

57
Q

Sources of Error for the Nursing Diagnosis

A

premature diagnosis from incomplete databases

erroneous diagnosis from inaccurate database or analysis

Routine diagnosis from failure to tailor data collection and analysis to that patients unique needs

Omission errors

NURS320 (12 decks)

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