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39 Cards in this Set
- Front
- Back
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what are the phases of the nursing process? (5) |
1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation |
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Define Assessment |
collecting subjective and objective data |
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Analyzing subjective and objective data to make a professional nursing judgment |
Diagnosis |
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Determining the outcome criteria and developing a plan |
Planning |
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Define Evaluation |
Assessing whether outcome criteria have been met and revising the plan as necessary |
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Define Nursing Assessment: |
Collective subjective and objective data to determine a clients overall level of functioning in order to make a professional clinical judgement |
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Focuses primarily on the client's physiologic development status: |
Medical Assessment |
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key notes on Communication: (Verbal) |
*Verbal communication: -open & closed ended questions -laundry list (providing patient list of words to choose from when describing issue) -rephrasing -providing info -inferring -well placed phrases |
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Non-verbal Communication: |
-posture -gestures -facial expression -eye contact (not too much, not too little) -voice -touch |
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An ideal interview environment with the patient |
-physical environment -empathy -be an active listener -ensure privacy (confidentiality) -reduce interruptions -note taking |
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What are the phases of Therapeutic Communication? (4) |
1. Preintroductory phase 2. introductory phase 3. working phase 4. Termination/summary/closing phase |
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What are barriers to communication? |
-need for interpreters (language) -cross cultural conversations -perspectives on professional interactions -etiquette -space & distance -cultural considerations on gender & sexual orientation. |
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Never be within ______ space of someone! |
Never INTIMATE ( 1.5 ft) |
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Interviewing people w special needs |
-hearing-impaired people -acutely ill people -under the influence of drugs or alcohol -personal questions asked of the clinician - sexually aggressive people -people who are crying/angry people -people who threaten violence -people who are anxious |
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what is the purpose of collection of a health history? (HH) |
-data collection -establish rapport-close/harmonious relationship to understand each others feelings/ideas -adapt to client needs |
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Collection of a Health History (HH) Considerations: |
Developmental Cultural |
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Types of Health Assessments? (4) |
1. Initial comprehensive 2. Ongoing or partial 3. Focused or problem oriented 4. Emergency |
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What to look at when looking/asking for Health History? |
-Biographical data (birthday, residence, marital status, contact info etc.) -reason for seeking care -current health or history of current illness -past health/personal health history -family history -review of systems (overall health state) -lifestyle and health practices profile |
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Biographical data include: |
name address, number, email birthday, age, birth place sex marital status race occupation-usual and present source of info |
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When asking for Reason why they seek care: |
-"Chief complaint" -presenting symptom(s) subjective sensations -Sign(s) objective abnormality detectable on physical exam or in lab reports |
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Current Health or History of Current Illness |
Characteristics of symptoms: COLDSPA |
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Past Heath/Personal Health History |
-childhood illnesses -accidents or injuries -serious or chronic illnesses -hospitalizations -surgeries -obstetric history (pregnancy, childbirth,postpartum period) -immunizations -last exam date -allergies & current meds |
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Family History |
-age & health or cause of death of blood relatives -health of close family members -Family history of various conditions (heart disease, diabetes, cancer, etc.) -Family Tree ( genogram) |
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Review of systems |
-General overall health state -skin, hair, nails -head & neck -eyes -ears -mouth, throat, nose, sinuses -Thorax & lungs |
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Review of Systems Cont. |
-breasts & regional lymphatics -heart and neck vessels -peripheral vascular -abdomen -genitalia -anus, rectum, prostate -musculoskeletal -Neurologic |
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What must you do during review of systems? |
*Must document every section & all of the info in that section! -Do NOT document a system as "Denies abdominal problems" *Write: Patient denies indigestion, difficulty swallowing, nausea, vomiting, jaundice, and hernias. |
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when asking about patients Lifestyle & Health practices: |
-description of typical day -nutrition and weight management -activity level & exercise -sleep & rest -medication & substance use self-concept and self-care responsibilities |
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Lifestyle & health practices CONT |
-social activities -relationships -values & belief system -education & work -stress levels and coping styles -environment |
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The Physical Assessment (General Survey) |
-Physical development & body build -Gender & sexual development -apparent age as compared to reported age -skin condition & color -dress & hygiene |
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Physical Assessment General Survey cont |
-posture and gait (mannor of walking) -level of consciousness -behaviors, body movement etc -facial expression -speech -vital signs |
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Physical Assessment Inspection: |
-Involves smell, touch, & vision -when you first see the patient -compare patients left to right side |
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Physical Assessment Palpation: |
-to feel -light palpation -deep palpation |
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What are the Characteristics assessed by Palpation? |
-texture -temp -moisture -swelling -crepitus (grating sound from friction of bone & cartilage or fractured parts of a bone) -presence of lumps or masses - vibration or pulsation |
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Physical Assessment Percussion: |
-to create sound -indirect -direct -blunt |
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Physical Assessment Auscultation: |
-to listen -listen by the ear -listen through a stethoscope |
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Stethoscope use: |
-Bell
-Diaphragm -Earpiece placement -cleaning -positioning |
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Physical Assessment SETTING: |
-warm room temp. -quiet -private (confidentiality) -safe environment -necessary equipment -Reassure the client |
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A SAFER environment: |
-clean the equipment -clean vs. used area for handling equipment -*prevent nosocomial infections -handwashing or alcohol-based hand run -WEAR GLOVES -Trasmission-based precautions |
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Documentation: |
-overall summary of findings -document objective findings -avoid value judgments -use standard abbreviations -follow policy regarding formal -avoid WNL (within normal limits) |
