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50 Cards in this Set

  • Front
  • Back
Purpose of the assessment phase of the nursing process
gather info about a client's health status to identify concerns and needs that can be treated or managed by nursing care
Purpose of the assessment phase part II
-Establish database with which to plan & evaluate comprehensive care
-Identify actual potential problems to make nursing diagnoses
-focus on specific problem
-determine immediate needs to establish priorities
-determine cause of problem
-determine related/contributing factors
-identify strengths as basis for changing behavior
-identify risk for complications
-recognize complications
types of assessment
initial
focused
emergency
ongoing
initial assessment
-more comprehensive
-begins w/problem that led client to seek treatment
-obtains holistic overview of client's level of functioning
-rule out and identify problems
-focus relates directly to goals of prevention,maintenance,restoration or rehabilitation
focused assessment
-each problem
-examines evidence in detail, considers etiologies, looks for contributing factors, characteristics that will help client solve problems
-when client has a complaint or new problem
Emergency assessment
-life-threatening or time-important situation
-only key data related to problem
-A-airway
-B-breathing
-C-circulation
cue
indicator of presence or existence of problem or contition that represents a client's underlying health status
cardinal signs and symptoms
data of greatest significance in diagnosing a particular illness, disease, or health problem
Subjective data
information provided by the client and that you cannot directly observe
symptoms
subjective data supplied by client that describe characteristics of disease or dysfunction
(pain,nausea,cramps,dizziness,
ringing in ears)
you can't observe, client must tell you
objective data
characterisics about the client you can observe directly
-can be observed through your senses, replicated and replicated from one exam to the next
(size of wound, amt of drainage,number of blood cell)
-high degree of certainty
signs
objective data that indicate disease or dysfunction
sources of data
client
significant others
colleagues
client records
ANA standards of practice
broad guidelines that require clinical judgement
may be used in a court of law
List ANA standards of practice
Assessment
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Steps in active listening/processing
Observing
Listening
Translating
Reasoning
Using intuition
Validating
phases of assessment interview
preparation
orientation
working phase
termination
assessment interview:
preparation
client comfortable
assess client reliablilty in providing health info
find out pertinent data ahead of time
assessment interview:
orientation
brief exchange to establish interview purpose, exam procedures and nurse's role
establish nurse-client relationship as a legally binding contract
rapport
identify immediate concerns and address them
assessment interview:
working phase
client and nurse work together to review health history and establish actual and potential problems to be addressed
nurse gains insight about concerns/expectations
assessment interview:
termination
announce time interview will take
ask if client has any further questions
elements of health history
biographical data
expectations and goals
reason for visit
medical history
family history
PERSON:
P
Psychosocial
History
Description of pt
Assessment of family
Home & community assessment
Current status
P-need meds
P-need diagnostic tests
PERSON:
E
Elimination
History
Current Status
E-need meds
E-need diagnostic tests
PERSON:
R
Rest,Regulatory,Reproductive
History
Current Status
Meds
Diagnostic tests
includes neuro and endocrine
PERSON:
S
Safety
History
Current status
Medications not included elsewhere
Meds: antibiotics
Diagnostic tests
PERSON:
O
History
Current status
Diagnostic tests
O-need medications
PERSON:
N
Nutrition
History
Current status
Labs/diagnostic test
Meds
Purpose of diagnosis phase of nursing process
Naming client problems/needs that are amenable to treatment with nursing care
Difference between nursing diagnosis and medical diagnosis
diagnosis of response to to illness or heatlth needs vs. diagnosis of illness or medical condition
NANDA definition of nursing diagnosis
clinical judgement about individual,family, or community responses to actual or potential health problems/life processes that provides bases for definitive therapy toward achievement of outcomes for which a nurse is responsible
Components of a correctly stated nursing diagnosis
Diagnostic label
definition
defining characteristics
related factors
risk factors
Diagnostic label
(component of nursing diagnosis)
Name of nursing diagnosis
Used to develop goal of nursing care
Represents pattern of related cues that characteristics, signs, or symptoms
May include descriptor, or a judgement that modifies limits or specifies meaning of nursing diagnosis (decreased,deficient,excessive,
readiness)
Definition
(component of nursing diagnosis)
provides description of the pattern of signs and symptoms, delineates the meaning of the label, and helps to differentiate it from similar diagnoses
Defining Characteristics
(component of nursing diagnosis)
description of a client's behavior that determine whether a nursing diagnosis is present and whether a particular diagnosis is accurate.
Either directly or indirectly observable cues.
cues
indiciators of the presence or existence of a problem or condition that represents a client's underlying health status.
Subjective and objective data (signs and symptoms) of a problem provide clinical clues that a problem is present
Related Factors
(component of nursing diagnosis)
Show some type of patterned relationship to the nursing diagnosis.
Specific related factors help direct how the problem should be managed.
Risk Factors
(compononet of nursing diagnosis)
Factors in the internal or external environment that increase the vulnerablility of the person, family or community to an unhealthful state or event.
Actual Nursing Diagnoses
Describe human responses to health conditions/life processes that exist at the present time.
Describe a client's current problem.
Signs and symptoms that indicated presence of the diagnosis can be identified,
"Risk for" Diagnoses
describes human responses that MAY develop in a vulnerable person, family or community.
Supported by risk factors that contribute to increased vulnerability.
Used to help you plan nursing care aimed at preventing the problem.
Purpose of the planning phase of the nursing process
Setting goals and plan nursing
Identify expected outcomes and devise interventions to achieve expected outcomes for each problem
Relationship of the goal to the nursing diagnosis
Nursing diagnostic label establishes a goal for the problem.
Expected outcomes
specific measurable and realistic goals to achieve related to the specific problem
Components of a correctly stated outcome
Realistic
Measurable
acceptable to the client
include a time frame
Measurable (in terms of outcome)
should describe expected outcomes so that outcomes can be directly observed.
Use verbs that are measurable to describe cognitive, affective, and psychomotor actions
Direct Care Nursing Intervention
treatment performed through interaction with the client
Physiological and psychosocial actions to improve client health or modifiy environment in a way that is conducive to health or that prevents disease
Indirect Care Nursing Intervention
Treatment performed away from the client but on behalf of a client or group of clients
Include nursing action airmed at management of the client care environment and interdisciplinary collaboration
Support effectiveness of the direct care intervention
Nurse Initiated Intervention
initiated by the nurse in response to nursing diagnosis
autonomous action based on scientific rationale that is executed to benefit the client in a predicted way related to the nursing diagnosis and projected outcome
(helping the client to dress)
Physician Initiated Intervention
treatment initiated by a physician in response to a medical diagnosis, but carried out by a nurse in response to doctor's order.
Nursing intervention according to NIC
514 nursing intervention labels
Each label is provided w/ a definition and a list of nursing activities