Health Assessment: Nursing Process

Front 1

Collects and analyzes data:

Back 1

assessment.

Front 2

Clinical judgment:

Back 2

diagnosis.`

Front 3

Determines progress toward reaching expected or desired outcomes:

Back 3

evaluation.

Front 4

Intervening, delegating, and coordinating:

Back 4

implementation.

Front 5

Legal basis for nursing action:

Back 5

Nurse Practice Act.

Front 6

Diagnosis and treatment of human responses to actual or potential health problems:

Back 6

nursing.

Front 7

A clinical framework used for any patient in any setting:

Back 7

nursing process.

Front 8

Comprehensive outline of care:

Back 8

Plan of Care.

Front 9

Nursing process standard:

Back 9

Standards of Care.

Front 10

Criteria related to quality of care and ethical behavior, among others:

Back 10

Standards of Professional Performance.

Front 11

Your next-door neighbor calls for your help.
She has just been stung by a bee.
She says she is having trouble breathing.

What type of nursing assessment do you perform?

Back 11

An emergency nursing assessment.

Front 12

Explain the rationale for performing an emergency nursing assessment if your neighbor has just been stung by a bee and is having difficulty breathing.

Back 12

You know that the neighbor:
1. is having difficulty breathing.
2. cause: bee sting.
3. you have enough data to make a diagnosis: at risk of anaphylaxis related to a bee sting.
4. you know the intervention is "call 911".
5. you know the neighbor must go to the E.R. asap.

Front 13

A 78-year-old patient enters an extended care facility for rehabilitation purposes following a total hip replacement.

What type of nursing assessment do you perform?

Back 13

An initial nursing assessment.

Front 14

What is the rationale for performing an initial nursing assessment on a 78-year-old patient who has entered an extended care facility for rehabilitation purposes following a total hip replacement.

Back 14

A 78-year-old patient being admitted to a skilled nursing facility requires an initial nursing assessment.

In this situation, the nurse needs a thorough history, review of systems, and physical exam in order to develop a list of prioritized nursing diagnoses and an appropriate care plan.

Front 15

You are assessing a patient's response to furosemide therapy given for acute congestive heart failure (CHF).

What type of nursing assessment do you perform?

Back 15

A focused nursing assessment.

Front 16

What is the rationale for performing a focused nursing assessment on a patient prescribed furosemide therapy for acute congestive heart failure (CHF)?

Back 16

The nurse needs to perform a focused assessment to determine the therapeutic effectiveness of furosemide.

If the patient is in congestive heart failure and if furosemide was effective,
a head-to-toe focused exam will reveal a generally less anxious adult in less respiratory distress,
and color (circumorally, especially) should be improved.

Jugular venous distention should be decreasing,
along with respiratory rate/minute.

Rales in the bases of both lungs should be clearing.

It is probably too soon to see any decrease in liver size.

Peripheral edema may not be visibly decreasing,
but weight by scale should be less.

Urinary output should be increasing.

So, even though I followed a head-to-toe format in this exam, I was only focusing on signs indicative of furosemide effectiveness,
i.e. signs indicate that CHF is resolving.

This type of focus is what makes this exam a focused exam.

Front 17

You are performing a 9-month developmental exam on an infant.

You have performed developmental exams on the same infant at 2 months, 4 months, and 6 months.

What type of nursing assessment do you perform?

Back 17

A time-lapsed nursing assessment.

Front 18

What is the rationale for performing a time-lapsed nursing assessment a 9-month developmental exam on an infant in which you have performed developmental exams on the same infant at 2 months, 4 months, and 6 months.

Back 18

A repeated developmental exam in an infant is a time-lapsed assessment.

The nurse is comparing the growth and development status of the infant at one time period with that at another time period.

Front 19

List Maslow's hierarchy of needs,
then categorize and prioritized the following nursing diagnosis.

Back 19

Physical: Ineffective Airway Clearance, Ineffective Breathing Pattern, Decreased Cardiac Output.

Safety: Acute Confusion, Risk for Trauma, Risk for Aspiration.

Love: Potential for Growth in Family Coping, Social Isolation, Sexual Dysfunction.

Esteem: Self-esteem Disturbance, Situational Low Self-Esteem, Chronic Low Self-Esteem.

Self-Actualization: Spiritual Distress, Potential for Enhanced Spiritual Well-being, Health-seeking Behaviors.

Front 20

List Maslow's hierarchy of needs.

Back 20

Physical, Safety, Love, Esteem, Self-Actualization.

Front 21

Give an example of an independent nursing intervention.

Back 21

Independent nursing intervention = one that is initiated by the nurse to address a nursing diagnosis.

i.e. Patient with a gastric or nasogastric feeding tube is at risk for aspiration.
That risk is increased if the patient lies flat in bed.
Therefore, the nurse independently orders that HOB remain elevated at 30 to 45 degrees at all times.

Front 22

Give an example of an dependent nursing intervention.

Back 22

dependent nursing intervention = one that is ordered by a physician for a medical diagnoses and carried out by a nurse.

i.e. Administering physician-prescribed tube feedings for a patient with a G/Tube.

Front 23

Give an example of an collaborative nursing intervention.

Back 23

collaborative nursing intervention = one that is developed in conjunction with other health professionals such as physicians, social workers, therapists, or other nurses.

i.e. A patient who is at risk of aspiration also has impaired mobility.
A team conference is called.

Front 24

Define expected outcomes.

Back 24

A reported, observed, or quantifiable result that is "expected" to occur as a result of a nursing intervention.

During evaluation, the nurse determines whether an expected outcome has been obtained or not attained and adjusts the plan accordingly.

Front 25

Define obtained outcomes.

Back 25

The current patient behavior or finding is the attained (or obtained) outcome of a nursing intervention.

Front 26

What are alternative names for nursing interventions?

Back 26

Nursing treatments, strategies, measures, and actions.

Front 27

What does the acronym AD-PIE stand for?

Back 27

Assessment
Diagnosis
Plan of Care
Implementation
Evaluation

Front 28

* clinical judgment about client's response to actual or potential health conditions or needs.
* provides basis for determination of a Plan of Care (POC) to achieve expected outcomes.

Back 28

Diagnosis.

Front 29

* comprehensive outline of care to be delivered to attain expected outcomes.

Back 29

Plan of Care (POC).

Front 30

* may include any or all of these activities: intervening, delegating, coordinating.
* client, significant others, or healthcare providers may be designated to implement interventions with POC.

Back 30

Implementation.

Front 31

* process of determining both the client's progress toward expected outcomes and effectiveness of nursing care.

Back 31

Evaluation.

Front 32

The nursing process is:

Back 32

* systematic.
* cyclical.
* dynamic.
* patient-centered.

Front 33

* clinical framework.
* means by which majority of Nurse Practice Acts in USA define the practice of nursing.
* ADPIE

Back 33

Nursing Process.