P&P Chapter 16 Nursing Thinking Flashcards
Fundamental blueprint for how to care for a patient.
Nursing Process
Collection, verification, and analysis of data
Assessment
The patient percived needs, health problems, and responses
Database
Information that was obtained through the use of the senses.
Cue
Your judgment or interpretation of cues.
Inference
Gordon’s 11 functional health patterns
- Health perception-health management
- Nutritional- metabolic
- Elimination
- Activity-exercise
- Sleep-rest
- Cognitive-perceptual
- Self perception-self concept
- Role-relationship
- Sexuality-reprroductive
- Coping-stress tolerance
- Value-belief
Describes patient’s self-report of health and well-being; how patient manages health knowledge of preventive health practices
Health perception-health management pattern
Describes patient’s daily/weekly pattern of food and fluid intake.
Nutritional-metabolic pattern
Describes patterns of excretory function.
Elimination pattern
Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living.
Activity-exercise pattern
Describes patterns of sleep, rest, and relaxation
Sleep-rest pattern
Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability.
Cognitive-perceptual pattern
Describes patient’s self-concept pattern and perceptions of self.
Self perception-self concept pattern
Describes patient’s patterns of role engagements and relationships
Role-relationship pattern
Describes patient’s patterns of satisfaction and dissatisfaction with sexuality pattern; patient’s reproductive patterns; premenopausal and postmenopausal problems
Sexuality-reproductive pattern
Describes patient’s ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance
Coping-stress tolerance pattern
Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient’s choices or decisions
Value-belief pattern
Surces where patient data can be obtained.
- Patient
- Family and significant others
- Health Care Team
- Medical records
- Literature
Interview process four steps.
- Set the stage (orientation phase)
- Gather information (chief complaint)
- Collect the assessment (RN health Hx)
- Terminate interview (summarize)
Active listning prompts
Back channeling
Factual demographic data about the patient
Bographical information
Chief concern or problem
Reasons for seeking health care
Pient understanding of why he or she is seeking health care.
Patient expectations
Essential and relevant data about the nature and onset of symptoms
Present illness/health concerns
Halth care experiences and current health habits and lifestyle patterns
Health history
To determine whether the patient is at risk for illnessesnof a genetic or a familial nature
Family history
Patient’s home and work, focusing on determining the patient safety
Environmental history
Reveals the patient’s support systems and coping mechanisms
Psychosocial history
Represents the totality of one’s being
Spiritual history
Systematic approach for collecting thepatient’s self-reported data on all body systems
Review of system
Five techniques involving physical examination
- Inspection
- Palpation
- Percussion
- Auscultation
- Smell
Comparision of data with another source to determine data accurancy
Data validation
Recognizing patterns or trends in the clustered data, comparing them with standards and then coming to a conclusion about the patient’s responses to a health problem.
Data analysis
Nursing process
1. Assessment 2 .Diagnosis 3. Planning 4. Implementation 5. Evaluation
When collecting data be aware of?
- Inaccurate data
- Incomplete data
- Inappropriate data
Differents sources of data validation:
- Labs (CBC, Chem7, UA)
- Radiology (x-rays, cat scans, MRIs)
- Pathology (biopsies, Pap smears)
- Cultures (sputum, urine, blood)
- Physical Exam
The information obtained in a review of system (ROS) is ?
Subjective
