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NUR 101 Assessment #2 > Nursing Process: Assessment, Diagnosis, and Planning Outcomes > Flashcards

Nursing Process: Assessment, Diagnosis, and Planning Outcomes Flashcards

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1
Q

Assessment

A

Collect, validate, organize and record data

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2
Q

Types and Sources of Data

A

Subjective Data

Objective Data

Primary Data

Secondary Data

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3
Q

?

What the patient says

Information communicated to the nurse by the client, family, or community

A

Subjective data

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4
Q

?

What professionals observe

  • Gathered by physical assessment and from laboratory/diagnostic tests
  • Can be measured or observed by the nurse or other healthcare providers
A

Objective data

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5
Q

?

Are obtained “secondhand”, for example, from the medical record or from another caregiver

A

Secondary data

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6
Q

?

Are the subjective and objective information obtained directly from the client in what the client says or what you observe

A

Primary data

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7
Q

Nursing Assessment Skills

A
  • Observation
  • Physical Assessment
  • The Nursing Interview
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8
Q

?

Is purposeful, structured communication in which you question the patient to gather subjective data for the nursing database

A

The Nursing Interview

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9
Q

?

Refers to the deliberate use of all of your senses to gather and interpret patient and environmental data

* “HELP”
H - Help
E - Environment/equipment
L - Look
P - People

A

Observation

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10
Q

Types of Assessment

A

Initial and Ongoing

Comprehensive

Focused

Special Needs

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11
Q

?

Is very detailed, builds your patient database

A

Comprehensive

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12
Q

?

Is very detailed, builds your patient database

aka global assessment, patient database, nursing database

  • Holistic information about client’s overall health status
  • Enables you to identify problems and strengths
  • Enhances your sensitivity to a patient’s culture, values, beliefs, and economic situation
  • Uses skills of observation, physical assessment, and interviewing
A

Comprehensive

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13
Q

A ___ assessment is performed to obtain data about an actual, potential, or possible problem that has been identified, or is suspected

A

focused

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14
Q

An ___ focused assessment is used to evaluate the status of existing problems and goals

A

ongoing

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15
Q

An ___ focused assessment is used to follow up on client-reported symptoms or unusual findings during the first exam

A

initial

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16
Q

A ___ assessment is a type of focused assessment; provides in-depth information about a particular area of client functioning and often involves using a specially designed form

* Types include nutritional, pain, cultural, spiritual health, psychosocial, wellness, family, community, and functional ability

A

special needs

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17
Q

Nursing Interview: Obtaining a Client’s Health History

  • Biographical data
  • Chief complaint (CC)
  • History of presenting illness (HPI)
  • Client perception of health
  • Client expectations of care
  • Past health history (PMH)
A

Nursing Interview: Obtaining a Client’s Health History cont’d

  • Family health history
  • Social history
  • Medication history and device use
  • Complimentary and alternative modalities (CAM)
  • Review of body systems
  • Functional abilities
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18
Q

Organize Your Data

  • NANDA-International Nursing Diagnosis Taxonomy II
  • Maslow’s Hierarchy of Needs
A
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19
Q

Documenting Your Assessment

  • Document as soon as possible after performing the assessment
  • Only use agency-approved abbreviations
  • Record the patients’ own words when possible - but only the most important ones
  • Use concrete, specific information
  • Record cues, not inferences
A

Diagnosis

  • Analyze and interpret data
  • Draw conclusions
  • Verify conclusions
  • Write the diagnostic statement
  • Prioritize the problems
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20
Q

A ___ is any condition that requires intervention to promote wellness or to prevent or treat disease or illness

A

health problem

21
Q

Understanding Health Problems

A
  • Nursing
  • Medical
  • Collaborative
22
Q

?

Describes a disease, illness, or injury, with a purpose of identifying pathology

A

Medical

23
Q

?

Is a statement of client health status that nurses can identify, prevent, or treat independently

A

Nursing

24
Q

?

Physiologic complications of disease, medical treatments, or diagnostic studies that nurses monitor to detect onset or change in status

A

Collaborative

25
Q

?

Is the thinking process that enables you to make sense of data gathered during a comprehensive patient assessment; aka analysis or ___ process

A

Diagnostic reasoning

26
Q

Types of Nursing Diagnoses

A

Actual

Risk/Potential

Possible

Wellness

27
Q

?

Problem is present

A problem response that exists at the time of the assessment

Signs and symptoms (cues) that are present

A

Actual

28
Q

?

Problem may occur

A problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it

No signs/symptoms of the problem, but the ___ factors are present that increase the patient’s vulnerability

A

Risk/Potential

29
Q

?

Problem may be present

Use when your intuition and experience direct you to suspect that a diagnosis is present, but you do not have enough data to support the diagnosis

Main reason for including this type on a care plan is to alert other nurses to continue to collect data to confirm or rule out the problems

A

Possible

30
Q

?

Describes health status but does not describe a problem; can apply to an individual, family, group, or community

2 conditions must be present:

  1. Client’s present level of ___ is effective
  2. Client wants to move to a higher level of ___
A

Wellness

31
Q
A

Writing Diagnostic Statements

One-Part Statement

Two-Part Statement

Three-Part Statement

32
Q

One-Part Statement

Used with ___ diagnoses, as it is not describing a problem, so there is no cause

Example: Readiness for Enhanced Nutrition

A

wellness

33
Q

Two-Part Statement

Use for ___ and ___ diagnoses, as there may not be associated symptoms

Example: Risk for Deficient Fluid Volume related to excessive vomiting

A

risk, possible

34
Q

Three-Part Statements

___ Format: ___, ___, ___

Example: Constipation related to low fiber intake as evidenced by difficulty defecating, hard stools, and bowel movements every 3 to 4 days

A

PES

Problem, Etiology, Symptoms

35
Q

Planning Outcomes

A

Select standardized care plans

Create individualized care plans

Identify outcomes and goals

36
Q

Types of Planning

A

Initial Planning

Ongoing Planning

Discharge Planning

37
Q

? Planning

Begins with the first patient contact

A

Initial

38
Q

? Planning

Refers to changes made in the plan as you:

  1. Evaluate the patient’s responses to care
  2. Obtain new data and make new nursing diagnoses
A

Ongoing

39
Q

? Planning

Is the process of planning for self-care and continuity of care after the patient leaves a healthcare settting. Purpose is to:

  1. Promote the patient’s progress toward health or disease management outside of the facility
  2. Reduce early readmissions to hospital care
A

Discharge

40
Q

Nursing Care Plans

The ___ (a type of patient care plan) is the central source of information needed to guide holistic, goal-oriented care to address each patient’s unique needs

A

comprehensive patient care plan

41
Q

Why Is a Written Patient Care Plan Important?

A
  • Ensures that care is complete
  • Provides continuity of care
  • Promotes efficient use of nursing efforts
  • Provides a guide for assessments and charting
  • Meets requirements of accrediting agencies
42
Q

Standardized (model) nursing care plans detail the nursing care that’s usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition

A
43
Q

?

Are a form of a standardized plan that’s created to produce specific patient outcomes in a specific situation

For instance, a facility may adopt this for a post-op patient; on post-op day 0, do these things, on post-op day 1, do these things, all leading to outcome of having a successful postop recovery

A

Critical pathways

44
Q

?

Are NOT a care plan

Are in place to describe the minimum level of care that should be received and guide when things must be provided by; i.e. a facility states you need to conduct a comprehensive assessment on client once per shift, should be documented within 2 hours of the start of your shift

More of a checklist than care plan

A

Unit standards of care

45
Q

How Do I Write an Outcome Statement?

A

Subject (i.e. the patient)

Action Verb (i.e. apply, explain, choose, demonstrate, eat)

Performance Criteria (i.e. how, what, when, where, amount, quality, distance, speed)

Target Time (i.e. realistic date by which performance or behavior should be achieved)

Special Conditions (i.e. additional assistance or resources needed)

46
Q

SMART Goals

S - Specific

M - Measurable

A - Achievable

R - Realistic

T - Timely

A
  • What do you want to do?
  • How will you know when you’ve reached it?
  • Is it in your power to accomplish it?
  • Can you realistically achieve it?
  • When exactly do you want to accomplish it?
47
Q

Delegation

A
48
Q

Nurses Cannot Delegate What They E.A.T.

A

E - Evaluation

A - Assessment

T - Teaching

Nurses also cannot delegate nursing diagnoses, clinical judgment, the formulation of patient care plans, as well as any interventions that would require professional nursing knowledge or skills

49
Q

Only 1 phase of the nursing process can be delegated, which is?

A

Implementation

Only carrying out interventions that fall within that person’s scope of practice

NUR 101 Assessment #2 (7 decks)

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