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[1] NUR112 | HEALTH ASSESSMENT > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

A systematic, client-centered method for structuring the delivery of nursing care.

A

Nursing Process

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2
Q

Nursing Process…
• Provides structure for __________

A

nursing practice

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3
Q

Nursing Process…
• Entails gathering and analyzing __________

A

data

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4
Q

Nursing Process…
• Helps enhance __________

A

critical thinking

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5
Q

Nursing Process…
• __________ – central figure

A

Patients

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6
Q

PURPOSES of the NURSING PROCESS
1. To identify client’s (1) __________
2. To identify actual or potential (2) __________ or __________

A

(1) health status
(2) health care problems or needs

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7
Q

PURPOSES of the NURSING PROCESS
3. To establish plans to meet (1) __________
4. To deliver specific (2) __________ to meet identified needs

A

(1) identified needs
(2) nursing interventions

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8
Q

Systematic & continuous collection, organization, validation, & documentation of data

A

Health Assessment

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9
Q

Health Assessment is a __________

A

continuous process

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10
Q

The focus of Health Assessment: __________

A

client’s health status

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11
Q

Preparing for Assessment
•Organize (1) _______ and ________
•Organize your (1) __________
•Review (3) __________
•Keep an (4) __________ and avoid __________

A

(1) equipment and supplies
(2) thoughts
(3) medical record
(4) open mind / judgments

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12
Q

STEPS OF HEALTH ASSESSMENT
• Collection of (1) _______ data
• Collection of (2) _______ data
• (3) _______ of data
• (4) _______ of data

A

(1) subjective
(2) objective
(3) Validation
(4) Documentation

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13
Q

• Personal information
• Feelings

A

STEP 1: COLLECTION OF SUBJECTIVE DATA

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14
Q

• Physical symptoms related to body parts
• Past health history
• Family history
• Health and lifestyle practices

A

MAJOR AREAS OF SUBJECTIVE DATA

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15
Q

• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing

A

STEP 2: COLLECTION OF OBJECTIVE DATA

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16
Q

• Ensures that the assessment process is not ended before all relevant data is collected
• Ensures documentation of accurate data

A

STEP 3: VALIDATION OF DATA

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17
Q

• Provides data for all other members of the health care team

A

STEP 4: DOCUMENTATION OF DATA

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18
Q

Characteristics of the STEPS:

• (1) __________
• Performed (2) __________, at times

A

(1) Overlapping
(2) concurrently

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19
Q

So, thorough assessment can generate A LOT OF ________.

A

DATA

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20
Q

• Interpret assessment data
• Identify client strengths & problems

A

DIAGNOSING

21
Q

Data Analysis
Problem Identification
Formulation of Nursing Diagnostic Statement

A

DIAGNOSING

22
Q

• Actual or potential health problem that independent / interdependent nursing interventions can prevent or resolve

A

Nursing Diagnosis

23
Q

Nursing Diagnosis
• Describes a (1) __________; deviations from health, presence of risk factors and areas of enhanced personal growth

A

(1) continuum of health status

24
Q

• What do you want to happen?
• How can you make it happen?

A

Planning

25
Q

Planning
> Developing a (1) __________
> Nurse works with the client to (2) __________

A

(1) plan of care
(2) set goals / outcomes

26
Q

Planning
1. Setting (1) __________
2. Establishing (2) __________
3. Selecting (3) __________
4. Writing individualized (4) __________ on care plan

A

(1) priorities
(2) client goals
(3) nursing interventions
(4) nursing interventions

27
Q

In Planning:
1. The most important (1) _______ to the patient
2. (2) _______ of potential problems
3. (3) _______, _______ available, _______, _______ needed

A

(1) problems
(2) Effect
(3) Costs / resources / personnel / time

28
Q

• Describes a change in the patient’s health status or functioning
• Expected outcome, predicted outcome, outcome criterion, objective

A

Goal

29
Q

Situation: Frail elderly man with a pressure ulcer on his sacral area

Type of Goal: The patient’s sacral area will exhibit no evidence of a pressure ulcer.

A

Long Term Goal

30
Q

Situation: Frail elderly man with a pressure ulcer on his sacral area

Type of Goal: At the end of the first week, the patient’s pressure ulcer would have decreased in size by a quarter inch.

A

Short Term Goal

31
Q

Guidelines for Writing Goals

S - _______
M - _______
A - _______
R - _______
T - _______

A

Specific
Measurable
Attainable
Realistic
Time-Bound

32
Q

Attribute of Goal: The patient will ambulate with assistance from bed to bathroom by tomorrow.

A

MEASURABLE GOALS

33
Q

Guidelines for Writing Goals

The goal is (1) ________ with and (2) ________ of other therapies.

A

(1) congruent
(2) supportive

34
Q

Guidelines for Writing Goals

• Whenever possible, the goal is important and valued by (1) __________.
• Derive each goal from only (2) __________.
• Keep the goal (3) __________.

A

(1) the patient, the nurses, and the physician
(2) one nursing diagnosis
(3) short

35
Q

• Activities the nurse plans and implements to help a patient achieve identified goal

A

SELECTING NURSING INTERVENTIONS

36
Q

Components of Nursing Intervention

A

PDx - Diagnostics
PTx - Therapeutic
PEd - Education or Health Teaching

37
Q

(Diagnostics)
ex: weighing, VS, Hgt monitoring

A

PDx

38
Q

(Therapeutic)
ex: administering of Paracetamol 500 mg. 1
tab. q4H as ordered by the physician

A

PTx

39
Q

(Education or Health teaching)
ex: Instruct the patient on proper wound dressing.

A

PEd

40
Q

Nursing interventions on the care plan should be:
• (1) ________ when they are written
• (2) ________ regularly at intervals

A

(1) Dated
(2) Reviewed

41
Q

Implementation
D - ________
D - ________
D - ________

A

Doing
Delegating
Documenting

42
Q

Putting the nursing care plan into action to achieve
the expected outcome

A

Implementation

43
Q

Giving nursing care/carrying out the planned nursing activities

A

Implementation

44
Q

Delegating the care to another health care team member

A

Implementation

45
Q

Documenting and validating care
Continuing data collection

A

Implementation

46
Q

Determining the client’s response to nursing interventions using the goals of care as criteria whether they were
- Met
- Partially Met
- Not Met

A

Evaluation

47
Q

Goal Statement
• Will ambulate half the length of hallway w/ assistance 3x daily

Evaluative Statement
• Goal is __________. Patient refused to ambulate in the morning but walked to the bathroom once in the afternoon w/ the assistance of one nurse.

A

Goal partially met

48
Q

Goal Statement
• Body temperature will decrease from 38.50C to 36.50C - 37.50C within 2 hrs. after administering TSB.

Evaluative Statement
• Goal is ________. Body temperature went down to 37.20C within 2 hours after TSB administration.

A

Goal met

[1] NUR112 | HEALTH ASSESSMENT (11 decks)

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