NURSING PROCESS INTRO & ASSESSMENT Flashcards
- systematic and client centered method that provides a structure in the delivery of nursing care
- goal oriented method that provides a framework for nursing practice
nursing process
- patients as central figure
- gathering and analyzing data to identify health issues / concerns
nursing process
what are the phases or nursing process?
ADPIE assessment, diagnosis, planning, implementation, evaluation
systematic continuous collection, organization, validation and documentation of data
assessment
- establish a complete database for problem identification, reference and future comparison
- within a specified time after admission
initial / comprehensive assessment
- determine the status of a specific problem
- ongoing process
problem-focused assessment
- to identify life-threatening and overlooked problems
- during any physiologic or psychologic crisis
emergency assessment
- compare the client’s status to baseline data
- several months after initial assessment
time-lapsed assessment
4 major activities done during assessment
COVD collecting, organizing, validating, documenting
gives subjective information on how a health condition came about
nursing health history
true or false: the chief complaint must be recorded as direct quotes from the client
true
how can the family history be presented as?
genogram / family tree
infancy
trust vs mistrust
early childhood
autonomy vs shame and doubt
preschool
initiative vs guilt
school age
industry vs inferiority
adolescence
identity vs role confusion
young adulthood
intimacy vs isolation
middle adulthood
generativity vs stagnation
maturity
ego integrity bs despair
person’s description of his current health
health perception - health management
person’s nourishment
nutritional - metabolic
- person’s excretory pattern
- disease of digestive, urinary system, or skin
elimination
- person’s description of his weekly pattern of activities, leisure, exercise, and recreation
- any disease that affects his cardio-respiratory and/or musculoskeletal systems
activity - exercise
person’s description of the person’s sleep-wake cycle
sleep - rest
- person’s ability to express himself clearly and logically
- person’s education
cognitive - perceptual pattern
- if person is comfortable with his appearance
- description of the person’s feeling state
self-perception / self-concept
person’s description of his various roles in life
role - relationship
person’s satisfaction with his situation related to sexuality
sexuality - reproductive
person’s means/actions of coping with problems
coping - stress tolerance
- principals that the person learn as a child which are still important to him
- person’s identification with any cultural, ethnic, religious, regional, or other groups
value - belief
the patient’s subjective response to a series of body system-related questions
review of systems
- also referred to as symptoms or covert data
- can be described or verified only by the individual
subjective data
- also referred to as signs or overt data
- can be measured or tested against an accepted standard
objective data
best source of data
primary / client
refers to all sources other than the client
secondary source
- a conscious and deliberate skill in gathering data using
the senses - involves noticing data then selecting, organizing, and interpreting data
observing
planned communication or a purposeful conversation
interviewing
- highly structured
- nurse establishes the purpose and controls the interview
directive interview
- a rapport-building interview
- the client controls the purpose, subject matter, and pacing
nondirective interview
- used during direct interviews
- generally restrictive; requires a yes, no, or short factual responses
- often used when information is needed quickly
closed questions
- associated with non-directive interviews
- invites longer responses from the clients
- provides the client with freedom to share information
open-ended questions
- open-ended, used in non-directive interviews
- can be answered by the client without direction or pressure
neutral questions
- closed questions and are used in directive interviews
- directs the client’s answers
- gives the client less opportunity to decide if responses are true or not
leading questions
- complete health assessment
- orderly and systematic
examining
4 basic skills of examining
IPPA inspection palpation percussion auscultation
approaches of examining
cephalocaudal, body system approach
- assessment of the patient’s general appearance
- uses the sense of sight, hearing and smell
inspection
uses the sense of touch; “therapeutic touch”
palpation
- the skin is depressed for about 1-2 cm using the finger pads
- used to assess texture, tenderness, temp., moisture, elasticity
- light palpation
- can be done with 1 or 2 hands, skin is depressed for about 4-5 cm
- this is used when trying to feel for the internal organs
deep palpation
involves the striking of a body surface, usually with a tip of the finger to elicit a sound or vibration
percussion
- uses pads of 2, 3, or 4 fingers or with a pad of the middle finger
- commonly used when percussing adult sinuses
direct percussion
- the nurse strikes an object (another finger) held against a body area
- uses pleximeter (finger placed on the skin), plexor (striking finger)
indirect percussion
involves the process of listening to sounds produced within the body and could either be direct or indirect
ausculation
use of unaided ear
direct ausculation
use of stethoscope
indirect auscultation
constitutes another source of objective data, which is important in assessing many health problems and conditions
using laboratory results
enumerate the hierarchy of needs from the lowest to highest level
physiological, safety, love and belonging, esteem, self-actualization
This model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development
orem’s self care model
- the act of double-checking or verifying data to confirm that it is accurate and factual
- differentiate between cues and inference
validation
- should include all data collected about the client’s health status
- recorded in a factual manner and not interpreted by the nurse
documentation
