PRELIMS Flashcards
the promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses
ANA (american nurses association)
a series of organized steps designed for nurses to provide excellent care ; organization to a nurse’s critical thinking skills
nursing process
it is the first and most critical phase of the nursing process
assessment
the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses
health assessment
the purpose of this is to establish a database about the client’s response to health concerns or illness and ability to manage healthcare needs
assessment
known as assessment from head to toe
cephalocaudal assessment
involves collection of subjective data about the client’s perception of their health ; specified time after admission
initial or comprehensive assessment
the purpose is to establish a complete database
initial comprehensive assessment
perform whenever and wherever the nurse or another health care prof. has an encounter w the client in any setting
ongoing or partial assessment
the purpose is to determine any changes from the baseline data
ongoing or partial assessment
performed when a comprehensive database exists for a client with a specific health concern
focused or problem oriented assessment
the purpose of this is to have a thorough assessment of a PARTICULAR health problem
focused or problem oriented assessment
during a crisis of the client ; rapid assessment performed in life threatening situations or prompt treatment or intervention
emergency assessment
time where nurses relied on their natural senses (change in color, temperature, muscle strength)
late 1800s - early 1900s
inspection, palpation, auscultation ; 3 senses
1901
the american journal of public health documents routine client and home inspection by public health nurse in 1930s
1930-1949
nurses were hired to conduct pre-employment health histories and physical examination for major companies such as NY telephone
1950-1969
conducts health histories and physical and psychological assessments
1970-1989
downsizing budget cuts and restructuring were the priorities ; demand for documentation ; advanced nursing practices
1990 - present
performs a focused assessment, and then incorporates assessment findings with a multidisciplinary team to develop a comprehensive plan of care
acute care nurse
safely assess critically ill clients who are outside the structure intensive care environment
critical care outreach nurse
assess and screen clients to determine the need for physician referrals
ambulatory care nurses
make independent nursing diagnoses and referrals for collaborative problems
home health nurses
practice of promoting and protecting the health of populations using knowledge from nursing, social
public health nurses
specialized practice of public health nursing, protects and promotes student health
school nurses
specialist in the nursing field who is trained to work closely with terminally ill patients
hospice nurses
in this phase of the interview, the nurse reviews the medical record revealing past health history and reason for seeking care
pre-introductory
this phase is the introduction, explaining purpose of interview, reason, cooperation, types of questions asked, taking notes assure, comfortable, develop trust
introductory
in this phase, the nurse elicits the client’s comments ; biographical data, reason for seeking health care, history of present health concern, past health history, family history, review of body systems, and lifestyle and health
working phase
this phase is the summarization of information obtained during the working phase
summary or closing phase
what are the nonverbal communication
appearance
demeanor
facial expression
attitude
silence
listening
what are the verbal communications
open ended questions
closed ended
laundry list
rephrasing
well placed phrases
inferring
providing information
special considerations during the interview
gerontologic
cultural
emotional
is the information you gather when you initially set an agenda during a patient centered interview
reasons for seeking healthcare
often typed on the patient’s admission sheet ; medical term to describe the primary problem
chief complaint
collect of essential and relevant data about the symptoms and their effects on the patients health
history of present health
provides a holistic view of a patient’s health care experiences and current health habits ; hospitalized or surgeries
past health history
includes data about immediate and blood relatives ; determine whether a patient is at risk for illness
family health history
document the client’s description of her health status of each body system and note the client’s denial of signs and symptoms
review of system
includes information about the client that the nurse directly observes during interaction
objective data
