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38 Cards in this Set
- Front
- Back
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What does the Nursing Process mean?
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A systematic, rational method of planning and providing individualized nursing care.
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What are the 5 phases of nursing process?
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Assessing, Diagnosing, Planning, Implementing, and Evaluating.
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What are some characteristics of the nursing process?
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cyclic and dynamic nature, client centeredness, focus on problem solving and decision making, interpersonal and collaborative style, universal applicability, and use of critical thinking.
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What is Assessing?
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Collect data
Organize data Validate data Document data |
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What is Diagnosing?
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Analyze data
Identify health problems, risks and strengths Formulate diagnostic statements |
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What is Planning?
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Prioritize problems/diagnoses
Formulate goals/desired outcomes Select nursing interventions Write nursing interventions |
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What is Implementing?
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Reassess the client
Determine the nurse's need for assistance implement the nursing interventions Supervise delegated care Document nursing activities |
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What is Evaluating?
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Collect data related to outcomes
Compare data with outcomes Relate nursing actions to client goals/outcomes Draw conclusions about problem status Continue, modify, or terminate the client's care plan |
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Where can you find all information about a client, such as: the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel?
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The hospital's database.
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What is subjective data?
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Symptoms, also known as covert data.
*things that can only be felt/verified by the person its affecting such as a stomach ache. **Sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation. |
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What is objective data?
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Signs, also known as overt data. Detectable by the observer or can be measured or tested against.
*The patient says the have a fever and testing it with a thermometer. |
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What are the two types of data?
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Objective and Subjective.
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What are the sources of data?
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The client, support people (family/friends/caregivers), the client's records, Health care professionals (PCP, social workers, physiotherapist), literature (professional journals, and reference texts).
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What are the 3 data collection methods?
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Observing, interviewing, and nondirective interview.
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A planned communication or a conversation with a purpose to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, provide counseling or therapy is an _______.
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Interview.
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During what form of communication are you building a rapport?
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Nondirective Interview.
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What is a Rapport?
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an understanding between two or more people.
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What is a closed question?
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Something that usually ends in a yes or no, or one word answer.
*usually start with when, where, who, what, do(did, does), or is(are, was). |
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What is a neutral question?
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A question the client can answer without direction or pressure from the nurse, is open ended and is used in nondirective interview.
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What is an open-ended question?
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A question that lets the client to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings.
*associated with non directive interview |
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What is a leading question?
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Usually closed, used in directive interview, and this directs the client's answer.
Ex. "You're stressed about surgery tomorrow, aren't you?" |
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What are some things to consider while planning the interview?
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Time, place, seating arrangement, distance, and language.
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What are the 3 major stages of an interview?
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the opening/introduction, the body/development, and the closing.
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During the opening stage of the interview what should the nurse do?
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Establish rapport and orientation.
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What is in the body of an interview?
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the client communicates what they think/feel/knows/perceives in response to questions from the nurse.
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What are some techniques to close an interview?
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Offer to answer any questions
Conclude by saying "thats all I need to know for now" or "well those are all the questions I have for now" Thank the client Express concern for the person's future or welfare "I hope all goes well for you" Plan for the next meeting Provide a summary to verify accuracy and agreement. |
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What category does examining fall under in the Nursing Process?
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Assessing.
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Cephalocaudal-
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Head-to-Toe.
Head, neck, thorax, abdomen, extremities and ends at the toes |
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What is a screening examination?
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(also called a review of systems) is a brief review of essential functioning of various body parts or systems.
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What are some ways to organize data?
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Conceptuals models/Frameworks, Wellness models, and nonnursing models.
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What are the different types of Frameworks?
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Gordon: functional health pattern (which contains a framework of 11 functional health patterns).
Orem: self-care model (delineates 8 universal self-care requisites of humans) Roy's: adaption model (outlines data to be collected according to the roy's adaption model and classifies observable behavior into 4 categories: physiological, self-concept, role function, and interdependence) |
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Why do Nurses use wellness models?
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to assist clients to identify health risks and to explore lifestyle habits and health behaviors, belies, values, and attitudes that influence levels of wellness.
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What are some examples of health wellness?
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Health history
Physical fitness evaluation Nutritional assessment Life-stress analysis Lifestyle and health habits Health beliefs Sexual health Spiritual health Relationships Health risk appraisal |
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What frameworks are in the Nonnursing models?
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Body systems model, Maslow's Hierarchy of needs, and Developmental theories.
pg. 195 |
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Why do nurses validate data?
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to make sure info is complete, factual, and accurate.
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What is a "cue"
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subjective or objective data that can be directly observed.
What the client says/does or what the nurse can see, smell, feel, hear, or measure. |
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What are "interferences"
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nurse's interpretations or conclusions made based on cue.
Ex. is a wound is hot, red and swollen and a nurse assumes it is infected would be an interference. |
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What completes the assessment phase?
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Documenting data
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