Nursing Process: Assessment Flashcards

1
Q

It is a systematic client care-centered with 5 processes

A

Nursing Process

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2
Q

Nursing Process (ADPIE)

A
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
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3
Q

Gather information about the client’s condition.

What do you under this nursing process?

A

ASSESSMENT:

o Collect
o Organize
o Validates
o Document

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4
Q

Set goals of care and designed outcomes and identify appropriate nursing actions

What do you under this nursing process?

A

PLAN:

o Prioritize Problems
o Formulate Goals
o Select Interventions
o Write Interventions

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5
Q

Identify the client’s problems.

What do you under this nursing process?

A

DIAGNOSIS:

o Analyze
o Identify Problem
o Formulate Nursing Diagnosis

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6
Q

Determines if goals are met and
outcomes achieved.

What do you under this nursing process?

A

EVALUATION:

o Collect Data
o Compare
o Relate To Goals
o Conclude
o Continue/ Modify
o Terminate

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7
Q

Perform the nursing actions identified in planning.

What do you under this nursing process?

A

IMPLEMENTATION:

o Reassess
o Implement
o Supervise
o Assist
o Document

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8
Q

Process Involved in Nursing Process

A

o Critical Thinking
o Problem-solving
o Decision Making

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9
Q

Specific to the nursing profession

A

Nursing Process

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10
Q

Nursing Process is a framework for

A

Critical Thinking

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11
Q

“Diagnose and treat human responses to _____ or _____ health problems“

A

Actual or Potential

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12
Q

Purpose of Nursing Process

A

o Organized framework guide practice
o Problem solving method
o Systematic
o Goal oriented
o Dynamic-always changing, flexible
o Utilizes critical thinking processes
o Universally applicable
o Client-centered
o Interpersonal and collaborative

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13
Q

ADVANTAGES OF NURSING PROCESS

A

o Provides individualized care.
o Client is an active participant.
o Promotes continuity of care.
o Provides more effective communication among nurses and health care professionals.
o Develops clear and efficient plan of care.
o Provides personal satisfaction as you see client achieve goals.
o Professional growth as you evaluate effectiveness of your interventions.

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14
Q

Provide direction for planning interventions

A

Goals of Care

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14
Q

Actions taken by the nurse to
achieve patient goals and get
desired outcomes

A

Intervention

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15
Q

Critical thinking statements
that explain why a particular
intervention is necessary for
the patient’s care plan.

A

Rationale

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16
Q

To ensure the desired
outcome has been met

A

Evaluation

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17
Q

First Step of the Nursing Process

A

ASSESSMENT

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18
Q

TRUE OR FALSE?

ASSESSMENT - gathering information/collecting data

A

TRUE

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19
Q

Primary sources of an assessment

A

Client/Family

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19
Q

Secondary sources of an assessment

A

Physical Exam, Nursing
History, Team Members, Lab Reports, Diagnostic Tests.

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19
Q

TRUE OR FALSE?

ASSESSMENT - systematic, deliberate process

A

TRUE

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20
Q

To establish data base about the
client’s response to health concerns or illness and the ability to manage health care needs.

A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION

A

A. ASSESSMENT

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21
Q

Collecting, organizing and communicating/recording
client data.

A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION

A

A. ASSESSMENT

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22
Assessment is finding all the “_________ ______ ______” to get a picture of your patient’s health status.
necessary puzzle pieces
23
Analyzes data about the patient, clients human responses, health status, strengths and concerns. A. ASSESSMENT B. DIAGNOSIS C. PLANNING D. IMPLEMENTATION E. EVALUATION
A. ASSESSMENT
24
TRUE OR FALSE? Assessment is a not continuous data collection.
FALSE Assessment is a continuous data collection.
25
TYPES OF DATA
Objective Data and Subjective Data
26
From the client
Subjective Data
27
Observable data
Objective Data
28
Other term for Objective Data
Sign
29
Other term for Subjective Data
Symptom
30
TYPE OF ASSESSMENT
Initial Assessment Problem-focused Assessment Emergency Assessment Time-lapsed Assessment
31
Type of assessment that is performed after admission A. Initial Assessment B. Problem-focused Assessment C. Emergency Assessment D. Time-lapsed Assessment
A. Initial Assessment
32
Type of assessment that is an ongoing process integrated with nursing care period of confinement. A. Initial Assessment B. Problem-focused Assessment C. Emergency Assessment D. Time-lapsed Assessment
B. Problem-focused Assessment
33
During any physiological or psychological crisis of the client. A. Initial Assessment B. Problem-focused Assessment C. Emergency Assessment D. Time-lapsed Assessment
C. Emergency Assessment
34
Several months after initial assessment. A. Initial Assessment B. Problem-focused Assessment C. Emergency Assessment D. Time-lapsed Assessment
D. Time-lapsed Assessment
35
Type of assessment that its purpose is to compare the client’s current status to baseline data previously obtained.
Time-lapsed Assessment
36
Type of assessment that its purpose is to identify life-threatening problems to identify new or overloaded problems
Emergency Assessment
37
Type of assessment that its purpose is to determine status of a specific problem identified in an earlier assessment
Problem-focused Assessment
38
Type of assessment that its purpose is to establish complete data base
Initial Assessment
39
Rapid assessment of individual’s airway, breathing and circulation during a cardiac arrest assessment of suicidal tendencies
Emergency Assessment
40
Reassessment of a client’s functional health patterns in a home care or outpatient settings
Time-lapsed Assessment
41
Nursing admission assessment
Initial Assessment
42
Hourly assessment of client’s intake and output, or vital signs
Problem-focused Assessment
43
CHARACTERISTICS OF AN ASSESSMENT THAT PROMOTES CRITICAL THINKING
Purposeful Focused & Relevant Systematic
44
Must be focused to gain relevant information, depending on purpose and context.
Focused & Relevant
45
Helps pay attention to what’s important, learn how to prioritize, be comprehensive and avoid omission errors.
Systematic
46
2 MAIN TYPES OF DATABASE
Data Base Assessment Focus Assessment
47
“Start of care” Assessment.
Data Base Assessment
48
___________ - is a comprehensive information gathered on ______ contact with the person to assess all aspects of health status.
Data Base Assessment; initial
49
Data gathered to determine the status of a specific condition.
Focus Assessment
50
ASSESSMENT ACTIVITY
1.Collecting Data 2.Identifying Cues and Making Inferences 3.Validating/Verifying Data 4.Organizing/Clustering Data 5.Identifying Patterns/Testing First Impression. 6.Reporting and Recording Data
51
“The most up-to-date information comes from your ______ __________ __ ___ _______. “
direct assessment of the patient
52
ASSESSMENT – COLLECTING DATA
1. Nursing Interview (history) 2. Health Assessment – Review of systems 3. Physical Examination 4. Make sure information is complete and accurate 5. Validate prn 6. Interpret and analyze data 7. Compare to “standard norms “ 8. Organize and cluster data
53
Noting pieces of information or cues through the use of senses (sight, touch, hearing, smell and taste).
Observation
54
KEY POINTS FOR AN INTERVIEW
o Ability to establish rapport. o Ability to asks questions. o Ability to listen is essential to successful interviews. o Ability to observe.
55
PHYSICAL EXAMINATION INCLUDES
o Inspection o Palpation o Percussion o Auscultation
56
TYPES OF INTERVIEW
Direct Interview Indirect Interview
57
The nurse allows the client to control the purpose, subject matter and pacing.
Indirect Interview
58
Highly structured and elicit specific information by asking closed ended questions
Direct Interview
59
TYPES OF QUESTIONS
Close ended questions Open-ended questions
60
Lead or invite clients to explore their thoughts or feelings.
Open-ended questions
61
Restrictive and generally require only short answers giving specific information; other begin with when, where, who, what, do, does, did.
Close ended questions
62
THINGS TO CONSIDER WHEN PLANNING AN INTERVIEW AND SETTING
Time Place Seating Arrangement
63
Need to be scheduled when the client is comfortable and free of pain
Time
64
Must have adequate privacy to promote communication
Place
65
Most people feel comfortable _ to _ ft. apart during an interview
3 to 4
66
Most people feel comfortable 3 to 4 ft. apart during an interview
Seating arrangement — Distance
67
STAGES OF AN INTERVIEW
o Opening o Body o Closing
68
Important in facilitating future interactions.
Closing
69
Client communicates what he or she thinks, feels, knows and perceives in response to questions from the nurse.
Body
70
Sets the tone of the remainder of the interview.
Opening
71
Two parts of an Opening Interview
ESTABLISH RAPPORT ORIENTATION
72
Process of creating good will and trust.
ESTABLISH RAPPORT
73
Explaining the purpose and nature of the interview.
ORIENTATION
74
Your aim is to gain all information needed to ensure that your patients have “Individualized Care”
Purposeful