Potter 16 (Nursing Assessment) Flashcards
The ___________ is a systematic method of critical thinking used by nurses to develop individualized plans of care and provide care for patients.
nursing process
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The nursing process is
a systematic method of critical thinking used by nurses to develop individualized plans of care and provide care for patients.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The nursing process consists of ____ steps:
5
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The five steps of the nursing process are:
- Assessment
- Analysis
- Planning
- Implementation
- Evaluation
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The following are what _____ consists of
- Assessment
- Analysis
- Planning
- Implementation
- Evaluation
Nursing process
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The steps of the nursing process are________; each step requires information from the others for adequate development of an effective plan of care.
interdependent
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
At each step of the nursing process, _____ may occur.
revisions
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Assessment is the first step in the nursing process, and it involves
gathering patient cues/data.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
_________ is the first step in the nursing process, and it involves gathering patient cues/data.
Assessment
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
_____ are gathered from the primary source (patient) and secondary sources (anyone other than the patient, as well as medical records).
Data
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Data are gathered from the
primary source (patient) and secondary sources (anyone other than the patient, as well as medical records).
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
primary source is/are:
patient
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
secondary source is/are:
anyone other than the patient, as well as medical records
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
______ data are gathered from the health history and symptoms described by the patient; data can also be reported by others, such as family members. Not objectively measurable.
Subjective
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
______ data are gathered from the medical record, physical examination, laboratory results, and diagnostic test results. Objective data are measurable.
Objective
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Objective data are gathered from
the medical record, physical examination, laboratory results, and diagnostic test results. Objective data are measurable.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The______ step of the nursing process is analysis, during which the nurse utilizes the clinical-thinking process to identify actual or potential patient problems.
second
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The second step of the nursing process is______, during which the nurse utilizes the clinical-thinking process to identify actual or potential patient problems.
analysis
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The second step of the nursing process is analysis, during which the nurse utilizes
the clinical-thinking process to identify actual or potential patient problems.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The nurse states the identified problem, or response to a problem, as a _________
specific nursing diagnosis.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The nurse states the ______, or response to a problem, as a specific nursing diagnosis.
identified problem
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The _________ provides standardized nursing language for nursing diagnostic labels.
ICNP Classification Catalogue
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The ______ step of the nursing process is planning.
third
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The third step of the nursing process is _____.
planning
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
During the _____
step, the nurse prioritizes the nursing diagnoses, establishes short- and long-term goals, chooses outcomes, and identifies interventions to address patient goals.
planning
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
During the planning step, the nurse
prioritizes the nursing diagnoses, establishes short- and long-term goals, chooses outcomes, and identifies interventions to address patient goals.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Nurses should include ____, ____, and ______ to develop patient-centered plans of care.
patients, family members, and other members of the health care team
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Nurses should include patients, family members, and other members of the health care team to develop ______-centered plans of care.
patient-
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
________ is the fourth step of the nursing process and includes initiating specific nursing interventions designed to achieve goals created in the planning step.
Implementation
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Implementation is the _____ step of the nursing process and includes initiating specific nursing interventions designed to achieve goals created in the planning step.
fourth
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Implementation is the fourth step of the nursing process and includes
initiating specific nursing interventions designed to achieve goals created in the planning step.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Nurses exercise _________ and _______ before implementing interventions to ensure that actions are appropriate for the patient’s current status.
critical thinking and decision making
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
_______ is the fifth and final step of the nursing process.
Evaluation
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
Evaluation is the ______ step of the nursing process.
fifth and final
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
During the ________ step, the nurse determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised.
evaluation
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
During the evaluation step, the nurse
determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
During _____, nurses must ask questions to determine how best to proceed with individualized care.
evaluation
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
During evaluation, nurses must ask questions to
determine how best to proceed with individualized care.
(Potter 16 Nursing Assessment Introduction to Nursing Process Sherpath Key Points)
The ________ is a systematic method of critical thinking used by nurses to develop individualized plans of care and provide care for patients.
nursing process
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
The nursing process is a:
systematic method of critical thinking used by nurses to develop individualized plans of care and provide care for patients.
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
There are ___ sources of data. What are they?
2
primary (directly from the patient)
and
secondary (any source other than the patient).
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
There are three common models for organizing the assessment of patient cues. They are:
Body systems, head-to-toe, Gordon’s Functional Health Patterns
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
Gordon’s Functional Health Patterns – by area of _____
function
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
Patient cues should be recorded ____, ____, and ____.
promptly, accurately, and thoroughly.
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
_____ strategies nurses use to gather patient cues are:
Three; observation, patient interview, and physical examination.
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
The nurse implements ____ types of physical assessments:
Three; focused, comprehensive, and emergency.
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
The physical examination consists of four components that the nurse completes in order:
inspection, palpation, percussion, and auscultation.
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
When examining the abdomen, the nurse performs _______ before _____ and ____
auscultation before
palpation and percussion.
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
______ involves the use of sight, hearing, and smell to examine the entire body.
Inspection
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
______ encompasses the use of light and deep touch to assess internal organs and skin characteristics.
Palpation
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
______ includes the use of a brisk tapping motion on the surface of the skin to generate sound waves based on the underlying tissues. It can identify organ borders, abnormal pockets of air or fluid, and abnormal masses.
Percussion
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
_____ comprises the use of a stethoscope to listen to the sounds produced by the internal organs, most commonly the heart, lungs, and abdominal cavity.
Auscultation
(Potter 16 Nursing Assessment Collecting Assessment Data Sherpath Key Points)
________ is a key nursing skill that promotes safe, competent nursing care.
Clinical judgment
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points)
The _____ model consists of layers:
- Layer 0: Observation
- Layers 1–3: Cognitive operations
- Layer 4: Individual and environmental contextual factors
CJMM
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
- The CJMM model consists of layers:
- Layer 0: Observation
- Layers 1–3: Cognitive operations
- Layer 4: Individual and environmental contextual factors
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
Putting the CJMM into action in nursing practice involves a ______ to maximize patient outcomes.
repetitive cognitive process
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer ___ (observation) includes two components: patient needs and clinical decisions.
0
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer 0 (observation) includes two components:
patient needs and clinical decisions.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer 0 (________) includes two components: patient needs and clinical decisions.
observation
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer __ (clinical judgment) is a cognitive layer.
1
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer 1 (_________) is a cognitive layer.
clinical judgment
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer 1 (clinical judgment) is a _______ layer.
cognitive
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
__________ is a complex process in which the nurse must be able to recognize changes, interpret meanings, and react correctly and timely to promote patient safety and minimize adverse events.
Clinical judgment
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
Clinical judgment is a complex process in which the nurse must be able to:
recognize changes, interpret meanings, and react correctly and timely to promote patient safety and minimize adverse events.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer __ represents a repetitive process composed of three cognitive operations: form hypotheses, refine hypotheses, and evaluate outcomes.
2
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
CJMM layer 2 represents a repetitive process composed of _____ cognitive operations:
3, form hypotheses, refine hypotheses, and evaluate outcomes.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The nurse refines hypotheses through
prioritization of hypotheses, identification of patient outcomes, and development of interventions to address the patient’s condition.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The nurse evaluates outcomes by reassessing the _______ and ______ to determine if outcomes were achieved or if the plan of care must be revised.
patient’s situation and the effectiveness of interventions
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The nurse evaluates outcomes by reassessing the patient’s situation and the effectiveness of interventions to determine if:
outcomes were achieved or if the plan of care must be revised.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
Layer __ of the CJMM outlines six steps: Recognize and analyze cues, prioritize hypotheses and generate solutions, and take action and evaluate outcomes. These six steps define a repetitive process promoting completion of the three functions identified in layer 2 (form hypotheses, refine hypotheses, and evaluate outcomes).
3
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
Layer 3 of the CJMM outlines six steps:
Recognize and analyze cues, prioritize hypotheses and generate solutions, and take action and evaluate outcomes.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The first 2 of steps of Layer 3 are:
the ability to recognize and analyze cues
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The second pair of steps in Layer 3 consists of:
prioritizing hypotheses and generating solutions
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
There are ____ types of interventions: Nurse-initiated, health care provider–initiated, and collaborative.
Three; Nurse-initiated, health care provider–initiated, and collaborative.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The final set of steps in layer 3 are
taking action and evaluating outcomes, promotes completion of the overall evaluation process and revision of the plan of care if needed.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
Contextual factors are identified in layer ____ of the CJMM.
4
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
Contextual factors can be:
environmental or individual.
(Potter 16 Nursing Assessment Intro to CJMM Sherpath Key Points
The Clinical Judgment Measurement Model identifies the _________ as one of the first steps that will ultimately influence the patient’s unique plan of care.
recognition of patient cues
(Potter 16 Nursing Assessment Recognize Cues from Assessment Data Sherpath Key Points
Recognizing patient cues begins as soon as
the nurse initiates the patient encounter.
(Potter 16 Nursing Assessment Recognize Cues from Assessment Data Sherpath Key Points
The nurse should _____ and _____ to ensure a better understanding of the patient situation.
apply therapeutic communication techniques and watch for nonverbal cues
(Potter 16 Nursing Assessment Recognize Cues from Assessment Data Sherpath Key Points
A variety of factors can affect patient communication of cues, such as
cultural influences, developmental level, and emotional state.
(Potter 16 Nursing Assessment Recognize Cues from Assessment Data Sherpath Key Points
A _________ allows the nurse to collect a wide range of information that can be categorized according to relevance, importance, and concern.
detailed patient assessment
(Potter 16 Nursing Assessment Recognize Cues from Assessment Data Sherpath Key Points
Several factors can influence the nurse’s ability to recognize and categorize patient cues. Examples are prior experience with similar types of patients, understanding of a disease process, and personal beliefs and values.
prior experience with similar types of patients, understanding of a disease process, and personal beliefs and values.
(Potter 16 Nursing Assessment Recognize Cues from Assessment Data Sherpath Key Points
