UNIT 1 Flashcards
Effective nursing care begins with an ____ and _____ health assessment.”
accurate and holistic
is the first and most critical step of the nursing process and accuracy of assessment data affects all other phases of the nursing process.
Assessment
What is the Nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
It is collecting subjective and objective data
Assessment
It is the analysis of the subjective and objective data to make a professional judgment
Diagnosis
Determining outcome criteria & developing a plan
Planning
Carrying out the plan
implementation
Assessing whether outcome criteria have been met & revising the plan as necessary
Evaluation
Nursing process is not ____ but _____
linear but a cycle
IN ADOPIE, what is O?
Outcome Identification
Assessment is the gathering of information about a patient’s ______, ________
physiological
psychological
sociocultural
developmental
spiritual status
What is the purpose of assessment?
it is to collect subjective and objective data to determine a client’s overall level of functioning in order to make a PROFESSIONAL CLINICAL JUDGMENT
What are the four types of Assessment?
Initial Comprehensive Assessment
Ongoing or Partial Assessment
Focused or Problem-Oriented Assessment
Emergency Assessment
collection of subjective data about the client’s perception of ALL body parts or systems, past health hx, family hx & lifestyle & health practices plus gathering of objective data during a step-by-step physical examination
Initial Comprehensive Assessment
Initial Comprehensive Assessment is the collection of _____ about the client’s perception of ALL 1. _____, 2. ______, 3. ______, 4. _____
subjective data
1. body parts or systems
2. past health history
3. family history
4. lifestyle and health practices
data collection after comprehensive assessment
Ongoing or Partial Assessment
It is also called as baseline data
Initial comprehensive assessment
thorough assessment of a PARTICULAR client problem &DOES NOT cover areas not
related to the problem
Focused or Problem-Oriented Assessment
very-rapid assessment performed in life- threatening situations
Emergency Assessment
What is an example of an emergency assessment?
Assessment of ABCs (Airway, Breathing, Circulation)
What are the 4 Major Steps of Health Assessment?
Collection of subjective data
collection of objective data
validation of data
documentation of dafa
In preparing for the assessment, what should you do?
Gathering information before actually meeting the client
keep an OPEN MIND
Avoid Premature judgment
Educate yourself about client’s medical diagnosis
Obtain and organize materials needed for assessment
What are the data included in the subjective data?
sensations or symptoms
feelings
perceptions
desires
preferences
beliefs
ideas
values
personal information
Subjective data can only be ____ and ____ by the client
elicited and verified
What is the method used to ibtain data?
client interview
Major areas of subjective data?
biographical information
physical symptoms related to each body part or system
past health history
family history
health and lifestyle practices
In the collection of objective data it includes what data?
directly obtained by the nurse/examiner through observation and physical examination
observed by the family or significant others about the client
client’s health record
What are the MAJOR AREAS of Objective data?
physical characteristics
body functions
appearance
behavior
measurements
laboratory results
the process of confirming or verifying that the subjective data & objective data you have gathered are __________ and _____ as well as ____
reliable and accurate as well as complete
What are the METHODS of validation?
- recheck your own data
- clarify data with the client
- verify with another health care professional
- compare objective from subjective findings
What are the primary reasons why nurses need to document the data collected?
- provide the health care team with a database that becomes the foundation of care
- helps identify health problems, formulate nursing diagnoses and plan
In the evolution of nurse’s role in HA, in the past assessment integral
part of nursing ever since the days of?
and the nurses relied on their?
- Nightingale
- natural senses
In the present, ____ and ___ of nursing assessment has expanded due to advances in _______ and _____
- depth
- scope
- medical knowledge
- technology
In the future, there will be an increase _____ and ____ of assessment skills
specialization and diversity
a purposeful mental activity
critical thinking
critical thinking involves?
problem solving and decision making
critical thinking is ____, _____, _____, and _____
self-directed
self-disciplined
self-monitored
self-corrective thinking
is a major component of critical thinking.
creative thinking
goal directed thinking that leads to better solutions by using new ideas or methods
creative thinking
are standards which must be applied to thinking whenever one is interested in checking the quality of reasoning about a problem, issue or situation
universal intellectual standards for critical thinking
In the universal intellectual standards for critical thinking, what are the 8 components?
clarity
accuracy
precision
relevance
depth
breath
logic
fairness
Could you elaborate further on that point?” - “Could you express that point in another
way?”
- “Could you give me an example?”
clarity
“Is that really true? “
- “How could we find out if that is true?”
accuracy
Could you give more details? “
- “Could you be more specific?”
precision
How is that connected to the question? “
relevance
“How does your answer address the complexities in the question? “
- “Is that dealing with the most significant factors?”
depth
Do we need to consider another point of view? “
- “Is there another way to look at this question?
breadth
“Does this really make sense? “
- “Does that follow what you said?”
logic
Do I have a vested interest in this
issue?
- Am I sympathetically representing the
viewpoints of others?
fairness
Health assessment involves assessment of the individual as a
whole
The individual is part of a _____context, a _____ context, a _____ context and a _____ context, all of which affect the client’s health status.
cultural
family
spiritual
community
the totality of socially transmissible behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making.
culture
composed of people who have a distinct identity and yet are related to a larger cultural group
subculture
the classification of people according to shared biologic characteristics, genetic markers or features
race
the process where people adapt to or borrow traits from another culture
acculturation
occurs in response to transition from one cultural setting to another
culture shock
assuming all members of a culture or ethnic group are alike
stereotyping
the tendency to view your own way of culture as the most desirable, acceptable, or best, and to act in a superior manner toward other cultures
ethnocentrism
the tendency to impose your beliefs, values, and patterns of behavior on individuals from another culture
cultural imposition
What are the characteristics of culture?
Learned
shared
adapted
universal
transmitted from generation to generation; learned through life experiences within one’s culture group
learned
culture is ____ by all members of the group
shared
as environmental
circumstances change, the group
changes to improve its ability to survive
adapted
all humans have culture
universal
are culturally-defined conditions which may have no equivalent from a biomedical/scientific perspective.
culture-bound syndromes
example of culture bound syndrome among Cebuanos and Hispanic Americans?
Panuhot-cebuano
empacho-hispanic Americans
In chinese culture, _____ may be considered disrespectful?
eye contact
_______ are hesitant to ask questions; _____ may not mean agreement
Chinese
nodding
Chinese has respect for _____ and ____
elders and authority figures
In chinese culture, ____ in care is preferred
family involvement
illness is an imbalance of ___ and ____ (CHINESE)
yin and yang
yin foods are
yang foods are
- cold
- hot
What are the other health practices of chinese?
- acupuncture
- medicinal herbs
- ventosa
- acupressure or massage
In ______ touching someone’s head is disrespectful
Korean
What is the culture-bound syndrome of Korean?
hwa-byung
a mental illness common in married, middle- aged women; triggered by life crises
hwa-byung
men & women do not shake hands, touch each other or go together in public, unless they are married or belong to same immediate family
Middle Eastern
_____ is considered healthy in Middle eastern
physically robust
the culture of middle eastern is
male-dominated
In middle eastern, health care provide must be ?
same sex
culture of the middle eastern is influenced by ______
islamic religion
What is the culture-bound syndrome of Middle eastern?
Zar
apathy & withdrawal believed to be caused by spirit possession)
zar
tend to be verbally expressive, yet values confidentiality
Hispanic American
believes illness to be caused either by the supernatural, as a punishment from God or as an imbalance between the _____ and ____
caliente and frio
What are the health practices of Hispanic Americans?
when ill, first seeks
advice from older women
in family
goes to jerbero (specializes in the use of herbs or **curandero or curandera (holistic healer) **
What are the culture bound syndromes of hispanic Americans?
mal ojo (evil eye)
empacho (ball of food)
susto (soul loss)
caida dela mollera (depressed fontanelle
menstruation is believed to rid the body of dirty and excess blood.
African American
African American have rich tradition of ____
herbal remedies
What are the culture bound syndromes of African American?
voodoo illness (result of withcraft)
falling out (normal reaction, fainting)
Filipino need to engage in ____ before discussing more serious matters
small talk
In filipino culture, ____ and ____ are too personal to discuss
sex and socioeconomic status
expressing _____ and ___is a sign of weakness
pain and crying
What are the cultural beliefs of Filipino?
Illness is caused by evil spirits, folk or faith healers
What are the health practices of Filipino?
Flushing (perspiration)
protection (use of amulets, religious medals, pictures, statues)
What are the culture bound syndrome of Filipino?
panuhot
pasmo
nabuyagan
kabuhi
barang
refers to an ability to interact effectively with people of different cultures
cultural competence
a search for meaning & purpose in life, w/c seeks to understand life’s questions in relation to the sacred
Spirituality
will help the nurse address client’s spiritual needs to maintain well-being
Spiritual Assessment
Spirituality is ?
informal, non-organized, self-reflection and experienced
refers to rituals, practices & experiences involving a search for the sacred (God, Allah) that are shared within a group
religion
Religion is ?
formal, organized, ritualistic, and group-oriented
prayer & meditation are used for cleansing & healing
Buddhism
death is associated with rebirth into another form
Reincarnation
Buddhism
Many buddhist are strict ____
vegetarians
Believes that illness is a result of past & current life actions or karma
Hinduism
In Hinduism, ___ hand is seen as holy
right hand
No beef diet
Hinduism
In Islam, prayer occurs?
5 times per day: sunrise, noon, afternoon, sunset, and evening
In Islam, prayers are done facing ____ on a rug, preceded by washing hands and feet
EAST
ladies are not to view men other than their husbands, naked
ISLAM
all outcomes in life are seen as predetermined by Allah
Islam
it is important for dying clients to face EAST & die facing EAST
Islam
consumption of pork & alcohol is prohibited
Islam
month of fasting; refraining from eating, drinking, having sex & indulging in anything in excess or ill- natured from dawn until sunset
Ramadan
Jesus Christ is the savior & miracles can happen through prayers
Christianity
In Christianity, there is an ____ for the dying and _____ for the dying or dead newborns
extreme unction
emergency baptism
Restrictions related to work on holy days are removed to save a life
Judaism
Psalms & last prayer of confession (vidui) are held at bedside
Judaism
what is the last prayer of confession in Judaism?
vidui
At death, arms are NOT crossed & any clothing or bandages should be buried with the person
Judaism
What is the diet of Jews?
No mixing of meat and dairy because of Kosher laws
special slaughter of animals
unleavened bread only during passover week
What is a religious person of the Jews called?
Rabbi
PROHIBITS consumption, storage & transfusion of blood
Jehovah’s Witnesses
PROHIBITS alcohol, coffee, tea and tobacco/smoking
Church of Jesus Christ in Latter Day Saints(Mormon)
Seventh Day Adventist
consists of individuals YOU consider to be your significant others
family
It is important in the family
family assessment
geopolitical communities determined by natural boundaries
community
What is the role of community in illness?
communities affect the emotional and physical health of individuals and families.
nursing which recognizes the biopsychosocial & spiritual dimensions of persons; recognizing that individuals are unitary wholes whose lives are intertwined with family, culture & environmental
holistic nursing
