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Health Assessment > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

Nursing Process

A

A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and illnesses.

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2
Q

Systemic method of providing care to our client

A

Nursing Process

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3
Q

Purposes of Nursing Process

A

To identify a client’s health status and actual or potential health care problems or needs.
To established plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.

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4
Q

Components of Nursing Process

A

Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation

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5
Q

Characteristics

A

Cyclic- repeated process
Dynamic in nature- ongoing process
Client centeredness- plan of care is organized
Focus on problem-solving and decision making- informed clients, based on facts, data, and evidences
Interpersonal and collaborative style
Universal Applicability
Use is critical thinking and clinical reasoning

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6
Q

Assessment

A

Systematic and continuous collection, organization, validation and documentation of data.

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7
Q

Types of Assessment

A
  1. Initial Nursing Assessment
  2. Problem-focused Assessment
  3. Emergency Assessment
  4. Time-lapse Assessment
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8
Q

Initial Nursing Assessment

A

Performed within specific time
Example: Admission of Client

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9
Q

Problem-focused Assessment

A

Determine the status of a specific problem identified on an earlier assessment.
Example: hourly checking of fever client

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10
Q

Emergency Assessment

A

During emergency situation to identify any life-threatening situation.
Example: Rapid assessment of an individuals airway, breathing status and circulation during cardiac arrest

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11
Q

Process of gathering information about a client’s status.

A

Data Collection

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12
Q

Convert data, clear only to the person affected and can be described only by that person.

A

Subjective Data

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13
Q

Overt data, are detachable by an observer or can be measured or tested against an accepted standard.

A

Objective Data

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14
Q

Time-lapse Assessment

A

To compare the client’s current health status with data previously obtained.

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15
Q

Sources of Data

A

Primary and Secondary

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16
Q

It is the direct source of information.
Example: The patient verbalizes, “ My stomach is excruciating”.

A

Primary Data

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17
Q

Indirect source of information.

A

Secondary Data

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18
Q

Methods of DATA COLLECTION

A

Observation, Interview , and Examination

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19
Q

Gathering by using the senses

A

Observation

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20
Q

a planned communication

A

Interview

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21
Q

Types of Interview

A

Direct interview- highly structured, directly asked
Indirect interview - client controls the interview

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22
Q

Stages of an Interview

A
  1. The opening or introduction
  2. The body or development
  3. The closing
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23
Q

A systematic data collection method to detect health problems

A

Examination

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24
Q

Nursing health nursing or history assessment form. Interpretation of data.

A

Organization of data

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25
Q

Validation of data

A

The information gathered during the assessment is double checked to confirm that it is accurate and complete.

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26
Q

To complete the assessment phase, the nurse records client data.

A

Documentation of data

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27
Q

Assessment Process

A

Collecting, organizing, validating, and documenting data

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28
Q

Diagnosis

A

Nurses use critical thinking skills to interpret assessment data to identify client problem.

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29
Q

Clinical judgement concerning a human response to health condition/processes of life, or a vulnerability for that response by an individual, family group, or community

A

North American Nursing Diagnosis Association

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30
Q

Components of NANDA

A

Problem statement, Etiology, and Defining characteristics

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31
Q

Acute Pain-
Related to abdominal surgery-
As evidences by patient discomfort and pain scale-

A

Problem statement
Etiology
Defining characteristics

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32
Q

Status of nursing diagnosis

A

Actual diagnosis, possible diagnosis, risk nursing diagnosis, the syndrome diagnosis, a d wellness diagnosis

33
Q

A client problem that is present at the time of the nursing assessment.

A

Actual diagnosis

34
Q

A problem may be present, but requires more data collection to rule out or confirm it’s existence

A

Possible diagnosis

35
Q

Clinical judgement that a problem may develop or does not exist, but the presence of risk factors indicates that a problem may develop

A

Risk nursing diagnosis

36
Q

Clusters of problems predicted to be present because of an event situation

A

The syndrome diagnosis

37
Q

Health-related problemat which a healthy person obtains nursing assistance to maintain or perform at a higher level

A

Wellness diagnosis

38
Q

Nursing Diagnosis

A

Statement of nursing judgement that made by the nurse, their education licensed to treat.

39
Q

Made by a physician

A

Medical diagnosis

40
Q

Ineffective breathing
Activity intolerance
Acute oain
Disturbed body image

A

Asthma
Cerebrovascular accident
Appendicitis
Amputation

41
Q

Planning

A

Process of prioritizing, identifying, selecting, ND documenting.
Process of formulating client’s goals and deciding the nursing interventions required to prevent, reduce, or eliminate the client’s health problems.

42
Q

Types of planning

A
  1. Initial planning
  2. ongoing planning
  3. Discharged planning
43
Q

Done after the initial assessment

A

Initial planning

44
Q

Continuous planning. Done by individual nurses

A

Ongoing planning

45
Q

Needs after the discharge. Process or anticipating client after discharge, medication of clients.

A

Discharged planning

46
Q
  1. Setting Priorities
    Prioritization
  2. Establishing client goals/ desired outcomes
    Goal
    Outcome
A

Planning Process

47
Q

Planning by deciding which nursing diagnosis requires attention first, second and so on.

A

Setting Priorities

48
Q
  1. High Priority- first priority, life threatening condition
  2. Medium Priority- health threatening condition
  3. Low Priority- Physiological needs, long term period
A

Maslow’s Pyramid

49
Q

Nurses set goals for each nursing diagnosis

A

Establishing client goals/ desired outcomes

50
Q

Expected or desired outcomes, management of diagnosis if it is appropriate

A

Goal

51
Q

Kinds of goals

A

Short term goals and long term goals

52
Q

Outcomes achievable in a few days to 1 week or a few hours

A

Short term goals

53
Q

Characteristics of short term goals

A

Specific, Measurable, Accompanied by a target date, Realistic, Time-bound, Client-centered

54
Q

Takes weeks or months

A

Long term goal

55
Q

Clients needs consistency and continuity of care to achieve goals.

A

Communicating the Plan of z
CARE

56
Q

-Carrying out the plan
-Consists of doing and documenting the activities

A

Implementation

57
Q

The process of implementation

A

-Implementing the nursing interventions
Selecting Nursing Intervention

58
Q

Any treatment that the nurse performs to improve patient health

A

Nursing Intervention

59
Q

Types of Nursing Interventions

A
  1. Independent Interventions
  2. Dependent Interventions
  3. Collaborative Interventions
60
Q

Independent Interventions

A

Activities that nurses are licensed to initiate on the basis of their knowledge and skills

61
Q

Activities carried out under the orders or supervision of a licensed physician

A

Dependent Interventions

62
Q

Actions that nurses carries out in collaboration with other health team members.

A

Collaborative Interventions

63
Q

Nursing Care Plan

A

A written or computerized information about the client’s care.

64
Q

A planned, ongoing, purposeful activity in which the murse determines

A

Evaluation

65
Q

The client’s progress towards achievement, goals/outcomes and the effectiveness of the nursing care plan.

A

Evaluation outcome

66
Q

Nursing Health Assessment

A

Gathering of information about the physiological, sociological, and Spiritual by a client.
Holistic/overall aspect of an individual.

67
Q

-In conducting a comprehensive health assessment nurses encompasses the physical, psychological, social, and spiritual health.
-A comprehensive health assessment can be performed as client makes contact within the health care system.
-A comprehensive health assessment can be performed as client makes contact within the health care system.

A

Theoretical Basis of Health Assessment

68
Q

Basic functions: eating, walking, breathing.
Factors: lifestyle, diet, physical activity, behavior

A

Physical health

69
Q

Involves the intellect but how your client response to your questions. Emotions and behavior of client.

A

Psychological health

70
Q

Relation to your family, friends, and colleagues. Relationships and interactions with other.

A

Social dimension of health

71
Q

A comprehensive that focuses on the belief of the higher being, personal interventions, meaning of life, and moral decisions of life.

A

Spiritual Health

72
Q

Components of focus health assessment

A

General survey, taking vital signs , and assessing specific areas that relate to the problem.

73
Q

Goal of Health Assessment

A

To establish a data base for the client’s normal ability, risk factors, and current alteration.

74
Q

A complete assessment can provide?

A

An adequate database

75
Q

Framework of Health Assessment

A
  1. Functional health framework
  2. Head to toe Framework
  3. Body System Framework
76
Q

-Evaluates the effects of the mind, body, and environment in relation to person’s ability to perform the ADL.
-Marjorie Gordon’s 11 functional health patterns

A

Functional Health Framework

77
Q

A system for collecting data in an organized manner, starting from the head and proceeding systemically downward to their toes

A

Head to toe Framework

78
Q

Medical practitioners commonly used it as it focuses on the pathophysiology involved within specific organ body systems.

A

Body System Framework

Health Assessment (5 decks)

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