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27 Cards in this Set

  • Front
  • Back
What are the characteristics of the Nursing process?
It is cyclic & dynamic, client centered, open & flexible, interpersonal & collaborative, planned, goal oriented, permits creativity and emphasizes feedback and is universally applicable.

What is Evaluating ?
A planned, ongoing purposeful activity to determine clients progress toward goals and effectiveness of care plan.

What is Implementing?
A phase of nursing process in which the nursing care plan is put into action.

What is planning?
A delibrate, systematic phase that involves decision-making and problem solving.

What is Assessing?
A systematic & continuous collection, organization, validation and documentation of data.

What is Diagnosing?
A clinical judgement about individual, family or community responses to actual or potential health problems / life process.

What is Interviewing?
Planned communication.

What is Examing?
The use of observational skills
(inspection, auscultation, palpation, and percussion)

Use the Cephalocaudel approach (head - toe)
What are the sources of data?
-Client - best source
-Support people
-Client records
-Health Care Professionals
What are the 4 types of assessment?
*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
What are goals?
Directed-effort between the patient and nursing team to achieve desired outcomes-short and long term goals
What do Nursing assessments focus on?
A clients response to a health problem
What are the 5 phases of the nursing process?
What information does a database include?
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
According to JCAHO an initial assessment and physical must be preformed and documented within what time frame?
Within 24 hours of being admitted as an inpatient
What is Subjective data?
The information that only the client feels and can describe (Symptoms)
What is Objective data?
The observable and measurable facts (Signs)
During which phase of the nursing process is the care plan revised as needed?
In the Evaluation phase
What does a Nursing Diagnosis do?
It facilitates comprehensive nursing care by identifying the health problem and validating the contributing factor
What are the signs & symptoms of anxiety?
* 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
What are Maslow's hierarchy of needs?
What are the 3 Data collecting methods?
Explain the data collection method: Observation?
It is noticing stimuli, selecting, organizing and interpreting data.

**Observe in this order:
- Patient distress
- Patient Safety
- Functioning equipment
- immediate environment
What are the 2 forms of interviewing?
*Directive - Elicits specific
information. Nurses ask
close ended questions.

* Non-directive - Rapport
building. Nurses ask open
ended questions.
What factors do you need to consider to schedule a patient interview?
* Time
* Is pt comfortable, not tired
* Is pt pain free
* Does pt have visitors

The location:
* Well lighted
* Well ventilated
* Private
What are the 3 stages of an interview?
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.
What is validating data?
It is double-checking data to ensure assessment is complete.