Nuft 202 Exam 2 Flashcards
What is an adverse event?
An adverse event ranges from mild to moderate examples include
a patient fall 
What are the steps included in the implementation process?
personnel
equipment,
Time management
environment,
patient 
Pete P
(Pete Pablo)
Psychomotor
requires the integration of cognitive and motor activities.
For example, when giving an injection, you need to understand anatomy and pharmacology (cognitive) and use good coordination and precision to administer the injection correctly (motor).
What are some examples of direct care?
Activities of daily living (ADLs)
Instrumental activities of daily living (writing checks, food shopping, occupational therapy) helping patient do these things
Physical care techniques: Inserting IV or catheter, feeding tube ( safe administration of nursing procedures)
Lifesaving measures: AED machine on patient
Counseling: helping patient in therapy manage stress
Teaching: identifying knowledge needs at discharge, trach teaching for family (need to see them doing it)
Controlling for adverse reactions: unintentional or harmful (no side effects) see it identify it
Preventative interventions: Immunizations, flu shots, covid vaccine (trying to prevent something form occurring)
What are examples of indirect care?
Still doing for the patient but away from them
-Hand off report
-Delegating Tasks
-Nursing rounds to talk about patient
Indirect care is?
Interventions performed away from patients but on behalf of patients 
Reflect on action
Reflecting on what you did in the past
Reflect in action
Reflecting on watch you are doing currently (CPR)
What are the elements of evaluation?
standards
environment
experience,
Knowledge
attitudes for evaluation
environment
Seek and evaluate!
What is revision?
when is not met, we have to reassess to meet the ultimate goal or revise the plan
Steps of the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment
the deliberate and systematic collection of information about a patient to determine the patients current and past health and functional status and his or her present and past coping patterns. Includes two steps:
Collection of information and Analysis of data
Primary data collection
information collected from the patient through interviews, observations, and physical examinations
Secondary data collection
information collected from family members or significant others reports and response to interviews, other members of the health care team, medical records, scientific and medical literature
Cue
information that you obtain through use of the senses
Inference
your judgement or interpretation of these cues
Different types of assessments
Patient centered interview
Physical examination
periodic assessment
Comprehensive patient history
A Full Assessment
1) Use structured database format on the basis of an accepted theoretical framework or practice standard
2) Problem Focused
Watson and Foster’s model of “The Attending Caring Nurse” supports
a comprehensive assessment of caring needs and concerns from a patients frame of reference.
It uses caring theory as a guide of identifying caring needs and assessing the meaning of both subjective and objective concerns
Nola Pender’s Health Promotion Model
several key factors that provide primary motivation for individuals to adopt behaviors that maintain and improve their health
- the goal is for the individual to move toward a balanced state of positive health and well-being
Gordeons Model of 11 Functional health patterns
Offers a holistic framework for assessment of any health problem provides for a comprehensive review of a patients health care problems
Subjective Data
your patient’s verbal descriptions of their health problems
Objective Data
observations or measurements of a patient’s health status
Sources of data include
Patient
Family and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse’s experience
Patient data is
usually your best source of information. Patients who are conscious, alert and able to answer questions without cognitive impairment provide the most accurate information.
Family and Significant Others data are used
in cases of severe illness or emergency situations, families are often the only source of information for health care providers
Medical Records data
is a valuable tool for checking the consistency and similarities of data with your personal observations
Patient Center Interview
is an organized conversation focused on learning about the well and the sick as they seek care.
This becomes the basis for forming trust and an effective long term therapeutic relationships with patients.
Effective communication skills include
Courtesy
Comfort
Connection
Confirmation
Courtesy involves
greeting patients by preferred names
Introducing yourself and explaining your role
meeting and acknowledging any visitors in a patients room and learning their names
Comfort involves
In a hospital setting performing any necessary comfort measures before beginning the interview
Connection involves
establishing eye contact and sitting at eye level if possible during an interview
not dominating a discussion or assuming that you know the nature of a patients problems.
Start with open ended questions
listen and be attentive
use your observation skills
respect silence and be flexible ‘let the patients needs, concerns, or questions guide your follow up questions
Confirmation involves
Asking the patient to summarize the discussion so there are no uncertainties
Being open to further clarification or discussion
Phases of an Interview are
-orientation and setting an agenda
-working phase
-terminating an Interview
Orientation and setting an agenda phase of an interview involves
Set the scene! Your aim is to set an agenda for how you will gather information about a patient
current chief concerns or problems
-explaining your purpose
-asking patient for his or her list of concerns/problems
-nothing that all information will be confidential
In the working phase of an interview you
start an assessment or a nursing health history with open ended questions that allow patients to describe more clearly their concerns or problem
When Terminating an interview you
Summarize your discussion with a patient and check for accuracy of the information collected
Give your patient a clue that the interview is coming to an end
Interview techniques include
Observation
Open-ended questions
Leading questions
Back channeling
Direct closed-ended questions
Observation is
The gathering of information through nonverbal behavior, appearance, and interaction with the environment, you determine whether the data you obtained are consistent with what the patient states verbally
This will help you lead to pursue further objective information to form accurate conclusions
open-ended questions will
-elicit a patient’s unique story.
-gives a patient the ability to decide how much information to disclose
-for example, “So, tell me more about…” or “What are your concerns about this?”
This approach does not lead to a specific answer.
Leading Questions
These are the most risky questions because of possibly limiting the information provided to what a patient thinks you want to know
Two examples of leading questions are (1) “It seems to me this is bothering you quite a bit. Is that true?”
and (2) “That wasn’t very hard to do, do you agree?”
Back Channeling is an
Active listening technique that Reinforces your interest in what a patient has to say by using good eye contact and listening.
includes active listening prompts such as “all right,” “go on,” or
“uh-huh.”
This technique shows that you have heard what a patient says, are interested in hearing the full story, and are encouraging the patient to give more details.
Probing involves
As patients tell their stories, encourage a full description without trying to control a story’s direction.
This requires you to probe with more open-ended questions, such as “Is there anything else you can tell me?” or “What else is bothering you?” Each time a patient offers more detail, probe again until the patient has nothing else to say and has told the full description.
Always be observant. If a patient becomes fatigued or uncomfortable, know that it is time to postpone the interview until later.
direct closed-ended questions
Questions that can be answered with short responses such as “yes” or “no.”
or a number of frequency of a symptom
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For example, the nurse asks, “How often does the diarrhea occur?” and “Do you have pain or cramping?” This technique requires short answers and clarifies previous information to provide a more comprehensive database. The questions do not encourage patients to volunteer more information than you request.
Nursing health history
You gather a nursing health history during either your initial or early contact with a patient.
It’s a Major part of assessment.
Includes biographical information, reason for seeking health care, patient expectations, present illness or health concerns, health history, family history, environmental history, psychosocial history, spiritual health, review of systems, and documentation of history findings.
Cultural Considerations
adapts each assessment to the unique needs of patients of background and cultures different from your own
Be respectful
understand these differences
do no impose on your own attitudes, biases, and beliefs
components of nursing health history include
biographic data
chief complaint
history of present illness
past history
family history of illness
lifestyle
social data
psychological data
patterns of health care
biographic information includes:
Factual demographic data;
age;
address;
occupation;
working status;
marital status;
source of health care;
and types of insurance
Chief concern of reason for seeking health care
is a brief statement about why a patient (in the patient’s own words) is seeking health care
Patient Expectations is
A Patient’s understanding of why he or she is seeking health care.
The assessment of patient expectations is not the same as the reason for seeking medical care, although they are often related. Failure to identify a patient’s expectations of health care providers results in poor patient satisfaction.
Present Illness or Health Concerns
Essential and relevant data about the nature and onset of symptoms.
Follow Acronym PQRST:
Provokes
Quality
Radiates
Severity
Time
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P-Provokes (precipitating and relieving factors): How did it come about? What might be the causes for the symptom? What makes it better or worse? Are there activities (e.g., exercise, sleep) that affect it?
Quality: What does the symptom feel like? (Have patients explain in their own words.) If the patient has difficulty in describing symptoms, offer probes (e.g., “Is the pain sharp? Dull?” or “Do you feel light-headed, dizzy, off-balance?”). What does the illness or symptom mean to the patient?
R-Radiate: Where is the symptom located? Is it in one place? Does it go anywhere else? Have the patient be as precise as possible.
S- Severity: Ask the patient to rate the severity of a symptom on a scale of 0 to 10 (with no symptom at 0 and the worst intensity at 10). This gives you a baseline with which to compare in follow-up assessments.
-Time: Assess the onset and duration of symptoms. When did the symptom first occur? Does it come and go? If so, how often and for how long? What time of day or on what day of the week does it occur?
Also assess whether the patient is experiencing other symptoms along with the primary symptom. For example, does nausea accompany pain? Does the patient have pain along with shortness of breath?
What is Health History?
provides a holistic view of a patient’s health care experiences and current
health habits
Medical history
surgical history
medication history
Allergies
Social History
Family History
history that includes data about immediate and blood relatives. This also reveals info about the family structure, interaction, support, and function
Psychosocial history
provides information about a patient’s support system, which often includes a spouse or partner, children, other family members, and close friends.
Also includes how the patient typically copes with stress
Spiritual History
The spiritual dimension represents the totality of one’s being and is difficult to assess quickly.
Review with patients their beliefs about life, their source for guidance in acting on beliefs, and the relationship they have with family in exercising their faith.
Also assess rituals and religious practices that patients use to express their spirituality. Patients may request availability of these practices while in a health care setting.
Review of Systems (ROS)
A systematic approach for collecting the patient’s self-reported data on all body systems.
Observation of Patient Behavior
- It is important to closely observe a patient’s verbal and nonverbal behaviors.
- Adds depth to objective database
- Observations direct you to gather additional objective information to form accurate conclusions about the patient’s condition.
- An important aspect of observation includes a patient’s level of function: the physical, developmental, psychological, and social aspects of everyday living.
diagnostic and laboratory data
These data are valuable in confirming observational findings (eg, ifa sample of urine is cloudy in appearance, a specimen of urine examined by a culture test can indicate if infection is present).
The data can also direct nurses to explore a patient’s condition more fully (e.g., if an x-ray of the chest suggests lung congestion, the nurse will auscultate lung sounds to further determine extent of congestion).
Interpreting and validating assessment data
the successful ongoing interrelation and validation of assessment data ensure that you have collected a complete database.
interpretation
this is clinical reasoning
you are determining the presence of abnormal findings, recognizing that further observations are needed to clarify information, and beginning to identify a patients health problems
Data Validation
validate the information you have collected to avoid making incorrect inferences
Validation of assessment is the comparison of data with another source to determine data accuracy
Gives you the opportunity to clarify vague or unclear data
data documentation
record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology. this information becomes the baseline to identify patient health problems, plan and implement care, and evaluate a patient’s response to interventions.
Concept Mapping
Visual representation that allows you to graphically show the connections among a patient’s many health problems
