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34 Cards in this Set

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open ended or closed question?

"what brought you to the hospital"
open ended
best position when talking with patient?
two chairs placed at right angles / patient in bed chair placed at 45 degree angle
group chair setting?
horseshoe or circular chair arrangement
acceptable personal space
18" in US / 24" in Britian / 36" in Japan
Validation
the act of dbl checking or verifying data to confirm that it is accurate and factual
what are Cues?
sub or obj data that can be directly observed by the nurse ; hear, feel smell or measure, or seen
Inferences?
R.N. interpretation or conclusion made based on cues (nurse observes the cues that incision is red, hot and swollen)
nursing assessment must be complete and
accurate because nursing diagnoses and interventions are based on this information
data must recorded in factual manner w/o ?
interpretation or inferences
Diagnosing
analyze data, identify health problems, risks and strengths, formulate diagnostic statements
taxonomy?
system or set of categories arranged on the basis of a single principle or set of priciples
diagnosing refers to ?
the reasoning process
diagnosis?
a statement or conclusion regarding the nature of phenomenom
what are the five types of nursing diagnosis?
accutal, wellness, risk, possible and syndrome.
risk diagnosis?
problem does not exist, but risk factors are present
wellness diagnosis?
human response to levels of wellness in person, family or community that have readiness for enhancement
possible nursing diagnosis
evidence about a health problem is incomplete or unclear
syndrome diagnosis
diagnosis associated with acluster of diagnoses
what three components of NANDA nursing diag?
1. problem and definition
2. etiology
3. defining characteristics
what are qualifiers?
words added to NANDA labels to give additional meaning
independent functions?
areas of healthcare unique to nursing and seperate from medical management
dependent functions
nurse is obligated to carry out therapies and tx written by MD
three steps of diagnosing process
analyzing data
identifying health problems, risks and strengths
formulating diagnostic statements
two parts of nursing diagnosis are joined by?
related to / why? due to implies that one part causes or is responsible for the other
basic format of nursing diagnosis
problem related to etiology
planning
prioritze problems/diagnosis/
formulate goals/desired outcomes/select nursing interventions/write nursing orders.
nursing intervention
any treatment based on clinical judgement and knowledge a nurse performs to enhance client outcomes
when does effective discharge planning begin?
at first client contact / involves comprehensive and ongoing assessment to obtain information
formal nursing care plan
written or computerized guide that organizes information about the client's care
standardized care plan
formal plan that specifies nursing care for groups of clients with common needs (ie...MI)
individulized care plan
tailed to meet unique needs of a specific client
rationale
scientific principle given as the reason for selecting a particular nursing intervention
multidisciplinary care plan
standardized plan outlining care required for common predictable medical conditions
indicator
is concrete observable patient state, behavior, or self reported perception or evaluation