Test 1 Flashcards
What is nursing history?
it identifies the patients health status, strengths, health problems, health risks and need for nursing care
What is the first step in the nursing process?
assessment
What is an initial assessment?
performed shortly after the patient is admitted;its goal is to establish complete database for problem identification and care planning; collects data, establish priorities based on this data
What is a focused assessment?
the nurse gathers data about a specific problem that has already been identified
What is an emergency assessment?
when a psychological or physiological crises occurs; identify life threatening problems
What is a time lapsed assessment?
scheduled to compare a patients current status to data obtained earlier;reassessment
What are assessment priorities influenced by?
health orientation, development stage, culture and need for nursing
What is subjective data?
information perceived only by the affected person
ex: feeling chilly, nervous or nauseous
What is objective data?
observable and measurable data that can be seen, heard or felt by someone other than the person experiencing
ex: reddened skin
What are some sources of data?
Patient(primary), family and significant others, patient record, medical history, consultations, reports and lab work, report of therapies, other healthcare professionals,nursing and healthcare professionals
What are some methods of data collection?
observation and nursing history
What are the components of a nursing history?
profile (age,sex,race,etc.),reason for seeking healthcare, normal health habits and patterns, cultural considerations, current state of body systems,current medication and allergies to medication, coping status, patients and families expectations of care, patients personal resources, patients potential for injury
What are the four phases of a patient interview?
preparatory, introductory, working and termination
What is a physical assessment?
examination of the patient for objective data that may better define the patients condition
What is Review of Systems (ROS)?
examination of all body systems in a systematic manner commonly in the head to toe format
What is data validation?
act of confirming or verifying testing the data
What is a cue?
indicates that something may be wrong
ex: cannot hear
What is an inference?
judgment you reach because of a cue
ex: hearing impaired
What is the second step in the nursing process?
Diagnosis
What is a health problem/etiology?
condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness
What is a nursing diagnosis?
actual or potential health problems that can be prevented or resolved by independent nursing intervention; can change day to day
What is a medical diagnosis?
A medical diagnosis a often a disease or serious problem: a medical diagnosis stays as long as the disease is present
What is a collaborative problem?
certain physiologic complications that nurses monitor to detect onset or changes in status
What does PC stand for?
Potential complications
What is a data cluster?
grouping of patient data or cues that points to the existence of a patient health problem
How does one interpret data?
recognizing significant data, patterns or clusters, and identifying strengths and problems
What is NANDA?
the nursing terminology abbreviations book
What is an actual nursing diagnosis?
problem that has been validated by the presence of major defining characteristics