Unit 7 Def

Front 1

- first step of the nursing process.
-Includes; data collection, data validation, data sorting, and data documentation.
- The purpose is to gather information for health problem identification.

Back 1

Assessment

Front 2

Active listening techniques that indicate that the nurse has heard what the client says

Back 2

Back channeling

Front 3

Question that limits the client’s answers to one or two words, used to clarify previous information or provide additional information.

Back 3

Closed-ended question

Front 4

Information about a client’s level of health practices, past illnesses, present illnesses, and physical examination combined to serve as the basis for the plan of care.

Back 4

Database

Front 5

Taking one proposition as a given and guessing that another proposition follows.

Back 5

Inference

Front 6

Type of communication with a client that is initiated for a specific purpose and focused on a specific content are.

Back 6

Interview

Front 7

Measure of a phenomenon generally accepted as the ideal standard performance against which other measures of the phenomenon may be measured.

Back 7

Norm

Front 8

Association between the nurse and the client; involves a mutual concern for the well-being of the client

Back 8

Nurse-client relationship

Front 9

Data collected about a client's present level of wellness, changes in the client's life patterns, sociocultural role, and mental and emotional reactions to an illness.

Back 9

Nursing health history

Front 10

Data relating to a client's health problem that are obtained through observation, or diagnostic measurements.

Back 10

Objective data

Front 11

Inquires aimed at obtaining a full client response and discussion between the client and the nurse

Back 11

Open-ended question

Front 12

Measure or guide that serves as a basis for comparison when evaluating similar phenomena or substances

Back 12

Standard

Front 13

Data relating to a client's health problem that are given in the client's own words.

Back 13

Subject data

Front 14

Cluster of signs and symptoms that are observed in the client and that imply a specific nursing diagnosis

Back 14

Defining characteristics

Front 15

Process of determining a client's health status and evaluating the factors that influence that status

Back 15

Diagnostic process

Front 16

Identification of the cause of a problem. The cause may be a direct or a contributing factor in the development of a client problem or need.

Back 16

Etiology

Front 17

Identification of a specific disease or pathological process

Back 17

Medical diagnosis

Front 18

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. (NANDA)

Back 18

Nursing diagnosis

Front 19

Nursing association with the following purpose: "to develop, refine and promote a taxonomy of nursing diagnosis terminology of general use for professional nurses"

Back 19

North American Nursing Diagnosis Association (NANDA)

Front 20

- Response of a nurse to a client's health care needs and nursing diagnoses.
- This intervention is an independent action based on scientific rationale that is executed to benefit the client.

Back 20

Nurse-initiated interventions

Front 21

Interventions based on the physician's response to a medical diagnosis; the nurse responds to the physician's written orders

Back 21

Physician-initiated interventions

Front 22

- Minimum level of care accepted to ensure high quality of care to clients.
- Define the types of therapies typically administered to clients with defined problems or needs

Back 22

Standard of care

Front 23

- A system used to identify, diagnose, and treat human responses to health and illness.
- This process enables the nurse to organize and deliver nursing care

Back 23

Nursing process

Front 24

ANA 2003 definition of the nursing process:

Back 24

“The nursing process is used to identify, diagnose, and treat human responses to health and illness.”

Front 25

- “Data collection”
- Gather organized information about the client’s condition.
- Effective communication techniques must be used.
- Must be documented accurately and in a concise manner.

Back 25

Assessment

Front 26

- Identify the client’s problems.
- A statement that describes the client’s actual or potential response to a health problem that the nurse is licensed or competent to treat, analyze and interpret data, form clusters of data.

Back 26

Diagnosis

Front 27

- Set goals of care and desire outcomes and identify appropriate nursing actions.
- Determine how to prevent, reduce, or resolve the identified patient problems; determine patient centered goals and expected outcomes, establish priorities, select interventions.

Back 27

Planning

Front 28

- Perform the nursing actions identified in planning.
- Assist in ther performance of ADL’s, counseling and education, provide direct nursing care, supervise and evaluate the work of other staff (delegated)
- Nurse initiated = independent
- Dr initiated= dependent
- collaborative = interdependent (phys, occ, speech therapists)

Back 28

Implementation

Front 29

Determine if goals met and outcomes achieved

Back 29

Evaluation

Front 30

Two independent observers would gather the same information, (can be observations or measurements).

Back 30

Objective Data

Front 31

What you gather

Back 31

Primary Objected Data

Front 32

someone else gathers the info ex lab tests

Back 32

Secondary Objective Data

Front 33

- A patient’s perceptions about their health problems.
- What the patient or other person tells you during an interview

Back 33

Subjective Data

Front 34

before beginning, the nurse reviews the purpose for the purpose of the interview, the types of data to be obtained, and the methods most appropriate for conducting the interview

Back 34

Orientation Phase

Front 35

lay the groundwork for the nurse to understand the client’s needs, and begin the relationship that allows the client to become a partner in decisions about care

Back 35

Establishing the nurse-client relationship

Front 36

- The nurse asks questions to form the database from which the nursing care plan will be developed.
- This is where the 4 interview techniques are implemented.

Back 36

Working Phase

Front 37

- The clients should be given a clue the interview is about to end.
- The interview ends in a friendly manner and the nurse specifically indicates when there will be additional contact.

Back 37

Termination Phase

Front 38

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes, (North America Nursing Diagnosis Association, [NANDA] 2003).

Back 38

Nurisng diagnosis

Front 39

Standards of the diagnostic process:

Back 39

ANA scope of nursing practice, Intellectual standards of measurement, Client-centered care.

Front 40

Attitudes of the diagnostic process:

Back 40

Perseverance, Responsibility, Fairness, Integrity, Confidence

Front 41

Experience of the diagnostic process:

Back 41

Previous client care experience, Validation of assessment findings, Observation of assessment techniques.

Front 42

Knowledge of the diagnostic process:

Back 42

Underlying disease process, Normal growth and development, Normal psychology, Normal assessment findings, Health promotion.

Front 43

the identification of a specific disease or condition

Back 43

Medical diagnosis

Front 44

outlines the patient’s actual or potential response to their condition.

Back 44

nursing diagnosis

Front 45

Diagnostic process

Back 45

(label problem w/ an approved NANDA diagnosis)- gathering the assessment database, identifies actual or potential client problems

Front 46

Analyzing and interpreting data

Back 46

look for clusters in the assessment data

Front 47

Identifying client needs

Back 47

analyze the client’s general health care problems, move from general to specific, could be an actual or at risk problem

Front 48

Formulating the nursing diagnosis

Back 48

once data and clusters are sorted and the client needs are identified, the nurse is ready to form the diagnosis.

Front 49

a measurable change of the client's status in response to nursing care

Back 49

outcome

Front 50

outcome statement:
- Client-centered factors

Back 50

reflect expected client behavior and responses to intervention, focuses on the client and specific diagnosis

Front 51

outcome statement:
- Singular factors

Back 51

each goal and expected outcome addresses only one behavioral response

Front 52

outcome statement:
- Observable factors

Back 52

expected outcomes should be observable. Can be physiological finding, knowledge, or behavior

Front 53

outcome statement:
- Measurable factors

Back 53

allows the nurse to objectively quantify changes in the client’s status

Front 54

outcome statement:
- Time-limited factors

Back 54

indicates when the expected outcome should occur, determines whether progress is being made at a reasonable rate

Front 55

outcome statement:
- Mutual factors

Back 55

mutual (client and nurse agree) setting of goals and outcomes can increase the client’s motivation and cooperation

Front 56

outcome statement:
- Realistic factors

Back 56

short-term realistic goals and expected outcomes quickly provide the nurse and client with a sense of accomplishment

Front 57

The nursing implementation process is...

Back 57

step in which nurses provide care to their patients & carry out interventions outlined in the planning stage.

Front 58

the identification of a specific disease or condition

Back 58

Medical diagnosis

Front 59

outlines the patient’s actual or potential response to their condition.

Back 59

nursing diagnosis

Front 60

Diagnostic process

Back 60

(label problem w/ an approved NANDA diagnosis)- gathering the assessment database, identifies actual or potential client problems

Front 61

Analyzing and interpreting data

Back 61

look for clusters in the assessment data

Front 62

Identifying client needs

Back 62

analyze the client’s general health care problems, move from general to specific, could be an actual or at risk problem

Front 63

Formulating the nursing diagnosis

Back 63

once data and clusters are sorted and the client needs are identified, the nurse is ready to form the diagnosis.

Front 64

a measurable change of the client's status in response to nursing care

Back 64

outcome

Front 65

outcome statement:
- Client-centered factors

Back 65

reflect expected client behavior and responses to intervention, focuses on the client and specific diagnosis

Front 66

outcome statement:
- Singular factors

Back 66

each goal and expected outcome addresses only one behavioral response

Front 67

outcome statement:
- Observable factors

Back 67

expected outcomes should be observable. Can be physiological finding, knowledge, or behavior

Front 68

outcome statement:
- Measurable factors

Back 68

allows the nurse to objectively quantify changes in the client’s status

Front 69

outcome statement:
- Time-limited factors

Back 69

indicates when the expected outcome should occur, determines whether progress is being made at a reasonable rate

Front 70

outcome statement:
- Mutual factors

Back 70

mutual (client and nurse agree) setting of goals and outcomes can increase the client’s motivation and cooperation

Front 71

outcome statement:
- Realistic factors

Back 71

short-term realistic goals and expected outcomes quickly provide the nurse and client with a sense of accomplishment

Front 72

The nursing implementation process is...

Back 72

step in which nurses provide care to their patients & carry out interventions outlined in the planning stage.