Module 1-c

Question 1

Physical Assessment

Answer 1

Subjective/Objective findings when doing a head to toe physical assessment on a patient. Least invasie to most invasive.

Question 2

Components of a physical assessment

Answer 2

Inspect, Auscultate, Percuss, Palpate

Question 3

Basic History and a physical assessment

Answer 3

1.Biographical data, 2.Reason for seeking health care, 3.Hx of present health care concern, 4.Medical Hx, 5.Family Hx 6. Lifestyle

Question 4

Nursing Process (systemic, dynamic,interpersonal,outcome oriented, universally acceptable)

Answer 4

Communication in the Nursing ProcessSystemic method for organizing and delivering nursing care. Framework for nursing practice. Patient centered, helps the nurse manage care scientifically, holistically, and creatively.

Question 5

Assessing

Answer 5

collection of pt data, validation, and communication of pt data.

Question 6

Diagnosing

Answer 6

analysis of pt data to ID pt strengths and health problems that independent nursing intervention can prevent or resolve.

Question 7

Outcome ID and planning

Answer 7

Specification of !) pt outcomes to prevent, reduce, or resolve the problems ID’d in the nursing diagnoses, 2) related nursing interventions

Question 8

Implementing

Answer 8

carrying out the plan of care.

Question 9

Evaluating

Answer 9

Measuring the extent to which the patient has achieved the outcomes specified in the plan of care.ID factors that positively/negatively influenced outcome achievement. Revising the plan if necessary.

Question 10

Characteristics of data

Answer 10

(good data) is Purposeful, Complete, Factual/Accurate, Relevant

Question 11

Objective data (observable/ measurable)

Answer 11

age, weight, height vital signs. “posterior, left midcalf is warm and red” , :pt observed fidgeting with bed covers, facial features are tightly drawn

Question 12

Subjective data (perceptions/feelings)

Answer 12

pain scale, symptoms “ my leg hurts when I walk”, I am so afraid”

Question 13

Methods of data collection

Answer 13

Observation, Interview, and Physical Assessment

Question 14

Components of Nursing HX

Answer 14

PT profile (demographics, reason for seeking care, health habits/patterns, current state of health, body systems, pain, PMH/PSH, Meds, allergies, vacs, Health status, Participation, personal resources, perception of health status, Developmental ,family, enviromental, physchosocial, Expectations of providers, Educational needs & willingness to learn, Potential for injury

Question 15

Phases of the Interview Process

Answer 15

Preparatory (reading chart, taking report)
Introduction (meeting the pt, exchanging names)
Working (longest part of the process)
Termination (end of the process, summarize w/ the pt, look to the future)

Question 16

Validation of data

Answer 16

Act of confirming or verifying. Purpose is to :free from error, bias, misinterpretation, question discrepancies, determine accuracy, address lack of objectivity.

Question 17

Analysis of data

Answer 17

Recognize significant date ( Hypertension), recognize patterns/clusters, ID strengths and problems, ID potential complications, reach conclusion, partner w/ the pt.

Question 18

Analyzing data ( standards or “norms”)

Answer 18

Rule, Measure, Pattern, Model, Compares same class or catrgory. (related to/ as evidenced by)

Question 19

Comparing data to standards (analysis phase)

Answer 19

changes in normal patterns- deviation from population norm- nonproductive behavior-developmental lag or dysfunction

Question 20

Analyzing data

Answer 20

Recognize significant data ( high temp, VS, etc…) , Recognize patterns or clusters (productive coughing/ smoking 1 pack per day for 15 yrs.)

Question 21

Medical vs Nursing Diagnosis

Answer 21

MEDICAL DIAGNOSIS (ID’s disease, describes problems & directs TX, remains the same as long as the disease is present.) NURSING DIAGNOSIS (focus on IDing unhealthy responses to health/illness. problems treated by nurse in scope of nursing. may change day to day as the pt responds)

Question 22

Types of Nursing Diagnoses

Answer 22

5 TYPES 1. Actual, 2.Risk, 3.Possible, 4.Wellness, 5. Syndrome.

Question 23

ACTUAL (nursing diagnosis)

Answer 23

4 components …label, definition, defining characteristics, & related factor. (I.E. Imbalanced nutrition is greater than body requirements. (label), intake of nutrients exceeds metabolic needs (definition), weight 20% over ideal (defining characteristics), R/T excessive intake in relation to metabolic need (related factors)

Question 24

RISK (nursing diagnosis)

Answer 24

risk for impaired skin integrity

Question 25

POSSIBLE ( nursing diagnosis)

Answer 25

possible low self esteem

Question 26

WELLNESS (nursing diagnosis)

Answer 26

readiness for enhanced health maintenance

Question 27

SYNDROME (nursing diagnosis)

Answer 27

post-trauma syndrome

Question 28

Components of a nursing diagnosis

Answer 28

Directs your nursing diagnosis/interventions. 3 components 1. Problem (ID’s what is unhealthy, suggests pt outcomes, independent nursing intervention. 2. Etiology (ID’s factors, based on collected data, directs interventions. 3. Defining Characteristics (subjective/objective data, real or potential and tangible)

Question 29

Examples of nursing DX statements

Answer 29

Problem- frequent liquid stools, Etiology-R/T increased intake of high fiber foods. Defining characteristic- as manifested by liquid stools 5 x/day for 2 weeks.

Question 30

Outcome, Identification, and Planning

Answer 30

Pt goals (aim or end, expected conclusion, developed by RN/PT, derived from problem statement) Outcomes prevent, reduce, or eliminate the problem & must support overall goals

Question 31

Short term goals

Answer 31

Short, 8 hr shift, complete quick

Question 32

Long term goals

Answer 32

longer, greater than a week, may be discharge gaols

Question 33

Etiology of a Problem & Nursing Measures

Answer 33

Problem statement, etiology of a problem, standards of care, interventions (TX based on clinical judgment)

Question 34

Nursing Intervention Classification (NIC)

Answer 34

list of nursing interventions (comprehensive, validated, and facilitate ID of appropriate interventions)

Question 35

Dependent Nursing Interventions (Actions)

Answer 35

Physician initiated (Dr orders)

Question 36

Independent Nursing Interventions (Actions)

Answer 36

Nurse initiated ( RN prescribes interventions)

Question 37

Interdependent Nursing Intervention (Actions)

Answer 37

Collaborative interventions (performed jointly by RN and other members of the healthcare team)

Question 38

Types of outcomes

Answer 38

Cognitive (increased pt knowledge), Psychomotor (pt achieves a new skill), Affective (change in pt values/beliefs), Physiologic ( physical changes)

Question 39

Expected Outcomes and evaluation process

Answer 39

Measurable, ID factors (success/failure), document findings, modify nursing plans as needed.

Question 40

Plan of care evaluation

Answer 40

Terminate, Modify, Continue

Question 41

Nursing guidelines for legal documentation

Answer 41

Complete, reflects nursing process, observations of behavior, avoid generalizations, note problems, medical visits, responses, factual info

Question 42

Documentation (timing)

Answer 42

agency policy and frequency, type of entry/information, time of execution, military time, never document before doing. Approved abbreviations only.