Nursing Process Flashcards
Is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by healthcare professionals
Assessment
Focus upon the client’s response to health problems, perceived health needs, and health practices and values
Nursing assessments
Is the collection and analysis of data that are used in formulating nursing diagnoses, identifying outcomes, and planning care and developing nursing interventions
The goal of assessment
First phase in the nursing process
Assessment
Systematic gathering of relevant and important patient data; nurse use data to;
Identify health problems
Plan nursing care
Evaluate patient outcomes
5 Elements of the assessment process
Data collection
Data verification
Data organization
Data interpretation
Data documentation
Is the process of gathering information about client, family or community health status
Data collection
Three classifications of collecting data
Interview
Observation
Physical examination
Use printed form (admission database)
Initial assessment
Use nursing model to organize; record on care plan or nursing progress notes
Ongoing assessment
Perform as needed
Special purpose assessment
Is the establish a database about a client’s physical and emotional well-being, and intellectual functioning, social relationships, and spiritual condition.
Purpose of assessment
Supports the use of the nursing process as a standard of practice for registered nurse and outlines the essential components of assessment within the nursing process
The American Nurses Association (ANA)
Client data include information that the client communicates concerning perception of his or her own health status as well as specific observations made by the nurse
Collecting data
Data from the client’s point of view and include feelings, perceptions, and concerns
Subjective data
This data (also referred to as symptoms)
Subjective data
They rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another
Subjective data
Sometimes called covert data or symptoms
Subjective data
Not measurable or observable
Subjective data
Can be obtained only from what the client’s verbalized
Subjective data
Data from significant others
Subjective data
Include client: thoughts, beliefs, feelings, sensation, perception, of self and health
Subjective data
Observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing
Objective data
This data (also called signs) can be seen heard or felt by someone other than the person experiencing them
Objective data
Can be detected by someone other than the client
Objective data
Can be obtained by observing and examining the client
Objective data
Includes pulse rate, skin color, urine output and result of diagnostic test or x-rays
Objective data
Sources of data
Primary
Secondary
Primary source of data
Client
7 Secondary sources of data
•Family or significant others
•Other healthcare professionals
•Medical records
•Interdisciplinary conference, rounds, and consultations
•Result of diagnostic tests
•Relevant literature
•Nurses knowledge and experience
Is the conscious, deliberate use of physical senses together data from the patient and the environment; it occurs whenever the nurse is in contact with the client or support person
Observation
Must be systematic so that no significant data are missed
Nursing intervention
Is purposeful, structured communication in which the nurse questions a patient to obtain subjective data
Interview
Associated with the non-directive interview, it invites patient to discover and explore their thoughts and feelings
Open ended questions
May specify the topic discussion, but it is broad and requires elaboration from the patient
Open ended question
Used in the directive interview generally requires only “yes” or “no” or short factual answer giving specific information
Close ended questions
Are specially effective in emerging situation or when a patient is highly stressed, anxious or has difficulty communicating
Close ended questions
Systematic assessment of all body systems
Physical examination
It is concerned with identifying strengths and deficits in the client’s functional abilities, rather than identifying pathology
Physical examination
Provides objective data that can be used to validate the subjective data obtained in the interview or to clarify the effect of the patient’s disease on her ability to function
Physical examination
What are the 3 data collection methods
Observation
Interview
Physical examination
Systematic process of observation that is not limited to vision but also includes the senses of hearing and smell
Inspection
Is the touching or pressing of the external surface of the body with the fingers
Palpation
Is the act of double checking or verifying data
Validating data
Five purpose of validating
•Making assumptions
•Missing key informations
•Misunderstanding situations
•Jumping to conclusion or focusing in the wrong direction
•Making errors in problem identification
Describes human response to health condition life processes that exists in an individual, family, or community
Actual
Describes human responses to health conditions life processes that may develop in a vulnerable individual, family, or community
Risk
It is supported by defining characteristics that cluster in patterns of related cues on inferences
Actual
It is supported by ______ factors that contribute to increased vulnerability
Risk
Describes human responses to level of _______ in an individual, family, or community that have a potential for enhancement to a higher state
Wellness
Three types of diagnostic concepts
Actual
Risk
Wellness
Three-Part patient diagnostic assessment
Problem
Etiology
Signs and symptoms
Two-Part diagnostic statement
Problem
Etiology
Related data together is a critical thinking principle that enhances your ability to get a clear picture of health status
Organizing data: (Clustering data)
According to Functional Health Patterns (Gordon) helps you identify nursing diagnosis and problems
Clustering data
According to human needs (Maslows) helps you set priorities
Clustering data
Perception of general health status and well-being. Adherence to preventive health practices
Health-Perception-Health Management
Patterns of food and fluid intake, fluid and electrolyte balance, general ability to heal
Nutritional-Metabolic
Patterns of excretory function and client’s perception
Elimination
Patterns of exercise activity, leisure, recreation, and activities of daily living; factors that interfere with desired or expected individual pattern
Activity-Exercise
Adequacy of sensory modes such as vision hearing, taste, touch, smell, pain perception, cognitive functional abilities
Cognitive-Perceptual
Patterns of sleep and rest relaxation periods during 24 hours a day as well as quality and quantity
Sleep-Rest
Attitudes about self, perception of abilities, body image, identity, general sense of worth, and emotional patterns
Self-Perception-Self Concept
Perception of major roles and responsibilities in current life situation
Role-Relationship
Perceived satisfaction or dissatisfaction with sexuality. Reproductive stage and pattern
Sexuality-Reproductive
General coping pattern stress tolerance, support systems, and perceived ability to control and manage situations
Coping-Stress-Tolerance
Values, goals, or beliefs that guide choices or decisions
Value-Belief
Also known as: Problem need identifications
Nursing diagnosis
It involves the analysis of collected data to identify the clients needs or problems
Nursing diagnosis
Purpose of this step is to draw conclusions regarding the client specific needs or human responses of concern so that effective care can be planned and delivered
Nursing diagnosis
Is a form of clinical judgment in which conclusion are reached about the meaning of the collected data to determine whether or not nursing intervention is needed
Diagnostic reasoning
