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27 Cards in this Set
- Front
- Back
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What are the characteristics of the Nursing process?
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It is cyclic & dynamic, client centered, open & flexible, interpersonal & collaborative, planned, goal oriented, permits creativity and emphasizes feedback and is universally applicable.
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(def)
What is Evaluating ? |
A planned, ongoing purposeful activity to determine clients progress toward goals and effectiveness of care plan.
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(def)
What is Implementing? |
A phase of nursing process in which the nursing care plan is put into action.
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(def)
What is planning? |
A delibrate, systematic phase that involves decision-making and problem solving.
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(def)
What is Assessing? |
A systematic & continuous collection, organization, validation and documentation of data.
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(def)
What is Diagnosing? |
A clinical judgement about individual, family or community responses to actual or potential health problems / life process.
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(def)
What is Interviewing? |
Planned communication.
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(def)
What is Examing? |
The use of observational skills
(inspection, auscultation, palpation, and percussion) Use the Cephalocaudel approach (head - toe) |
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What are the sources of data?
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-Client - best source
-Support people -Client records -Health Care Professionals -Literature |
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What are the 4 types of assessment?
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*Initial - baseline
*Problem Focused - ID specific or ID new problem *Emergency - ID life threatening problem Time lapsed - compare current problem to baseline after several months |
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What are goals?
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Directed-effort between the patient and nursing team to achieve desired outcomes-short and long term goals
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What do Nursing assessments focus on?
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A clients response to a health problem
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What are the 5 phases of the nursing process?
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Assessment
Diagnosis Planning Implementation Evaluation |
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What information does a database include?
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A nursing Health Hx. And nurses physical assessment along with the MD's Hx and Physical assessment of the Patient, results of all labs and Dx tests, and materials contributed by other health care personnel
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According to JCAHO an initial assessment and physical must be preformed and documented within what time frame?
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Within 24 hours of being admitted as an inpatient
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What is Subjective data?
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The information that only the client feels and can describe (Symptoms)
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What is Objective data?
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The observable and measurable facts (Signs)
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During which phase of the nursing process is the care plan revised as needed?
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In the Evaluation phase
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What does a Nursing Diagnosis do?
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It facilitates comprehensive nursing care by identifying the health problem and validating the contributing factor
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What are the signs & symptoms of anxiety?
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* restlessness or feeling keyed up or on edge
* being easily fatigued * difficulty concentrating or mind going blank * irritability * muscle tension * sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep |
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What are Maslow's hierarchy of needs?
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physiological
safety love/belonging esteem self-actualization |
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What are the 3 Data collecting methods?
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Observing
Interviewing Examination |
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Explain the data collection method: Observation?
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It is noticing stimuli, selecting, organizing and interpreting data.
**Observe in this order: - Patient distress - Patient Safety - Functioning equipment - immediate environment |
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What are the 2 forms of interviewing?
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*Directive - Elicits specific
information. Nurses ask close ended questions. * Non-directive - Rapport building. Nurses ask open ended questions. |
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What factors do you need to consider to schedule a patient interview?
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* Time
* Is pt comfortable, not tired * Is pt pain free * Does pt have visitors The location: * Well lighted * Well ventilated * Private |
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What are the 3 stages of an interview?
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Opening - establish rapport and orient pt to purpose.
Body - gather information with various types of questions Closing - maintain rapport and trust to facilitate future interactions. |
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What is validating data?
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It is double-checking data to ensure assessment is complete.
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