SEMI-FINALS Flashcards
A systematic,rational method of planning providing nursing care
NURSING PROCESS
TYPES OF ASSESSMENT
Initial assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment
Is the process of gathering information about a client’s health status
data collection
Referred to a symptoms or covert data , appeared only to the person affected ( client’s sensations, feelings,values)
subjective data
referred to as signs or overt data, are detectable by an observer or can be measured
objective data
is the client
primary source
family or anyone else that is not the client
secondary source
methods of data collection
observing
interviewing
examining
is gather data by using the sense, conscious,deliberate skill that is developed through effort and with an organized
observing
is planned communication or a converstation with purpose, for example, to get or give informartion
interviewing
two approaches of interviewing
directive interview
nondirective interview
directs interview,client responds to question and has limited chances to discuss concerns
directive interview
rapport-building where the client is in control of the purpose
nondirective interview
invites client to discover and explore,elaborate,clarity, or illustrate their thoughts and feelings
open-ended
used in directive interviewing, are question that is recquire yes or no
close-ended
a question that the client can answer without direction,’‘what do you think you had the operation?’’
neutral question
directs the clients answer,’’ your are stressed about the surgery tommorow,aren’t you?’’
leading question
systematic data-collection method that uses observation to detect health problems
examining
using a written or computerized format that organizes the assessment data
organizing data
is the act of ‘‘double checking or veriyfing data to confirm that is accurate or factual
validation
subjective or objective data can be observed by the nurse,either what the client says or what the nurse can see
cues
nurse intrepretations or conclusions based on the cues
inferences
to complete the assessment phase, the nurse records client data
documenting data
TYPES OF NURSING DIAGNOSIS
actual diagnosis
risk nursing diagnosis
wellness diagnosis
possible nursing diagnosis
syndrome diagnosis