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HA Flashcards

1
Q

→ The term nursing process were used by

A

Hall (1955), Johnson
(1959), Orlando (1961), Wiedenbach ( 1963), ANA (1973)

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2
Q

a systematic; rational method of planning and providing
individualized nursing care.

A

NURSING PROCESS

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3
Q

NURSING PROCESS
organized, systematic, goal oriented, humanistic care BY

A

(Lydia
Hall)

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4
Q

→ provides legal framework for nursing practice

A

NURSING PROCESS

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5
Q

CHARACTERISTICS OF A NURSING PROCESS

A
  1. cyclic and dynamic in nature
  2. client-centered
  3. Focus: problem solving and decision making
  4. different but parallel to process used by physicians
  5. Interpersonal and Collaborative Style
  6. Universal applicability
  7. Use of critical thinking – logic, intuition and creativity
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6
Q

CHARACTERISTICS OF A NURSING PROCESS
1. cyclic and dynamic in nature

A

 data from each phase provide input to the next
phase
 regularly repeated event or sequence of events (a
cycle)
 continuously changing (dynamic) – not static

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7
Q

→ discipline-specific

A

CRITICAL THINKING

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8
Q

→ reflective reasoning process

A

CRITICAL THINKING

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9
Q

→ PURPOSE:
✔ Guides a nurse in generating, implementing, and
evaluating approaches for dealing with client care and
professional concerns.

A

CRITICAL THINKING

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10
Q

COMPONENTS OF CRITICAL THINKING

A

 critical analysis
 Inductive and deductive reasoning
 making valid inferences
 differentiate facts from opinions
 evaluating the credibility of information
 clarifying concepts
 recognizing assumptions

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11
Q

→ comprehensive assessment of one’s health status

A

HEALTH ASSESSMENT

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12
Q

→ PRIMARY COMPONENTS: HEALTH ASSESSMENT

A

✔ Nursing Health History
✔ Physical Assessment

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13
Q

PURPOSES OF HEALTH ASSESSMENT

A

 To obtain baseline data
 To supplement, confirm, or refute data.
 To establish nursing diagnoses and plans of care.
 To evaluate physiological outcomes of health care.
 To make clinical judgments.
 To identify areas for health promotion and disease
prevention.

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14
Q

→ systematic and continuous collection, organization,
validation, and documentation of data

A

ASSESSMENT

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15
Q

→ systematic and continuous collection, organization,
validation, and documentation of data

A

ASSESSMENT

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16
Q

→ a continuous process carried out during all phases of the
nursing process

A

ASSESSMENT

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17
Q

→ all phases of the nursing process depend on the accurate and
complete collection of data

A

ASSESSMENT

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18
Q

ASSESSMENT
→ PURPOSE:

A

✔ establish a database

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19
Q

ASSESSMENT: ACTIVITIES

A
  1. Collecting Data
  2. Organizing Data
  3. Validating Data
  4. Documenting Data
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20
Q

TYPES OF DATA:

A

A. Subjective data (symptoms)
→ itching, pain, and feelings of worry.
B. Objective data (signs)
→ BP 120/80, reddish urine.

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20
Q
  1. COLLECTION OF DATA
    → Formulation of DATABASE which contains:
A

 nursing health history
 physical assessment
 primary care provider’s history
 physical examination
 results of laboratory and diagnostic tests

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21
Q

ASSESSMENT FORMAT
Conceptual Models / Frameworks

A

A. Gordon’s Functional Health Pattern
B. Orem’s Self-Care Model
C. Roy’s Adaptation Model
D. Wellness Model
E. Non-nursing Models
Body Systems Model
Maslow’s Hierarchy of Needs
Freud’s Developmental Theories

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21
Q

SOURCES OF DATA:

A
  1. Primary
    → client
  2. Secondary
    → family, support persons, other health professionas,
    medical
  3. Records and Reports, Laboratory and Diagnostic,
    Relevant literature
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21
Q

DATA COLLECTION METHODS

A

 Observation - using senses
 Interview - planned communication or a
conversation

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22
Q

→ act of “double-checking” or verifying data to confirm
that it is accurate and factual

A
  1. VALIDATION OF DATA
23
Q

DOCUMENTING DATA: RECORDING OF DATA

A

→ must be accurate
→ Factual manner and not as interpreted by the nurse
→ Subjective data - virbatim

24
Q

TYPES OF HEALTH ASSESSMENT

A
  1. Initial Comprehensive Assessment
  2. Ongoing or Partial Assessment
  3. Focused or Problem Oriented Assessment
  4. Emergency Assessment
25
Q

CRTICAL THINKING IN HEALTH ASSESSMENT

A

→ a purposeful, goal-directed thinking process that strives
to problem solve patient care issues through the use of
clinical reasoning
→ It combines logic, intuition, and creativity

26
Q

CRTICAL THINKING IN HEALTH ASSESSMENT
→ PURPOSE:

A

✔ is to establish potential strategies to assist patients in
reaching their desired health goals

27
Q

COMPONENTS OF CRITICAL THINKING

A

1.Interpretation
2.Analysis
3.Inference
4.Explanation
5.Evaluation
6.Self-regulation

28
Q

TYPES OF INTERVIEW QUESTIONS
→ Non-directive; invite clients to discover and explore,
elaborate, clarify, or illustrate their thoughts or feelings
Examples: “What” “How”

A

Open-Ended Questions

29
Q

TYPES OF INTERVIEW QUESTIONS
1→ Directive Interview (gather short factual answers)
Examples: Yes or No Questions, “When” , “Where”
“Who”, “What”, “Do”, “Is”

A

. Closed-Ended Questions

29
Q

TYPES OF INTERVIEW QUESTIONS
→ Without direction or pressure from the nurse (openended and non-directive

A

Neutral Questions

30
Q

TYPES OF INTERVIEW QUESTIONS
→ Closed, directive interview

A

. Leading Questions

31
Q

is a
systematic data collection method that uses observation

A

→ Physical examination or Physical assessment

32
Q

PHYSICAL EXAMINATION (IPPA TECHNIQUE

A

 Inspection
 Palpation
 Percussion
 Auscultation

33
Q

→ nurse uses a written (or computerized) format that organizes
the assessment data systematically in the form of:

A
  1. ORGANIZING DATA
34
Q

→ a basic structure underlying a process, system, concept,
or text

A

FRAMEWORK

34
Q

TYPES OF FRAMEWORK\

A

TYPES OF FRAMEWORKS
1.Functional Health Framework
2.Cephalocaudal Framework
3.Body Systems Framework

35
Q

TYPES OF FRAMEWORKS
→ Evaluates the effects of mind, body and environment in
relation to a person’s ability to perform the ADLs

A
  1. FUNCTIONAL HEALTH FRAMEWORK
35
Q

TYPES OF FRAMEWORKS
→ Data collection in terms of Gordon’s 11 Functional
Health Patterns

A
  1. FUNCTIONAL HEALTH FRAMEWORK
36
Q

→ System data in an organized manner: head to toe

A
  1. CEPHALOCAUDAL FRAMEWORK
36
Q

GORDON’S 11 Functional Areas:

A
  1. Health-perception-health management
  2. Nutrition-metabolic
  3. Activity-exercise
  4. Elimination
  5. Sleep-rest
  6. Cognitive –perceptual
  7. Self-perception-self-concept
  8. Roles-relationships
  9. Sexuality-reproduction
  10. Coping-stress tolerance
  11. Values-beliefs
37
Q

→ Used to improve efficiency and expedite the actual
physical examination

A
  1. CEPHALOCAUDAL FRAMEWORK
38
Q

→ maybe used during the focused assessment of an acutely
or critically ill client

A

BODY SYSTEM FRAMEWORK

38
Q

→ a framework that medical practitioners commonly use as
it focuses more on the pathophysiology involved within
specific organ body systems

A

BODY SYSTEM FRAMEWORK

39
Q

→ a disciplined, creative and reflective approach used
together with critical thinking

A

CLINICAL REASONING

40
Q

COMPONENTS OF CRITICAL THINKING
→ decode hidden messages, clarify the meaning of the
information, categorize the information
→ (categorization, clarifying meaning)
→ Nursing Practice Application:
✔ Be systematic in data collection. Look for patterns to
categorizedata you are uncertain about.

A

. INTERPRETATION

40
Q

COMPONENTS OF CRITICAL THINKING

→ speculates, derives, or reasons a specific premise based
on information and assumptions obtained from the patient;
can be challenging skill for the novice nurse because a
certain level of knowledge and experience must be
possessed in order to draw conclusions and provide
alternatives in any given scenario (examining evidence,
speculating or conjecturing alternatives, making
conclusions)
→ Nursing Practice Application:
✔ Look at the meaning and significance of findings. Are
there relationships between findings? Does the data
about the client help you determine that a problem
exists?

A

INFERENCE

41
Q

COMPONENTS OF CRITICAL THINKING

→ ideas and data presented, identifies any discrepancies,
and reflects on the reason for the discrepancies
→ Nursing Practice Application:
✔ Be open-minded as you look at information about a
client. Do not make careless assumptions. Do the data
reveal what you believe is true, or are there other
options? Look for patterns to categorize data you are
uncertain about.

A

ANALYSIS

41
Q

COMPONENTS OF CRITICAL THINKING

→ requires that the conclusions drawn from the inferences
are cored and can be justified.
→ The use of scientific and nursing literature constitutes the
basis for clinical justification
→ (stating results, justifying procedures)
→ Nursing Practice Application:
✔ Support your findings and conclusions. Use
knowledge to select strategies you use in the care of
clients

A

EXPLANATION

42
Q

COMPONENTS OF CRITICAL THINKING

→ examines the validity of the information and hypothesis;
this leads to a final conclusion that can be implemented.
→ (assessing results, assessing arguments)
→ Nursing Practice Application:
✔ Look at all situations objectively. Use criteria (e.g.
expected outcomes, pain characteristics, learning
objectives) to determine results of nursing actions.
Reflect on your own behavior.

A
  1. EVALUATION
42
Q

“Changes in color,
temperature, muscle strength, use of limbs, body output,
and degrees of nutrition, and hydration.”

A

(Nightingale,
1992)

43
Q

HEALTH ASSESSMENT ACROSS TIME
1901

A
  • Journal Records : examples of independent nursing
    practice: inspection, palpation, and auscultation have been
    recorded
44
Q

HEALTH ASSESSMENT ACROSS TIME
1901- 1938

A
  • American Journal of Nursing: RNs
    doing gastrointestinal palpation, testing cranial nerve
    function and examination of children in school systems
45
Q

HEALTH ASSESSMENT ACROSS TIME
1930s

A

American Journal of Public Health: routine client
and home inspection by PHN

46
Q

HEALTH ASSESSMENT ACROSS TIME
1970s

A

provision of primary health services and expansion
in conduct of health histories and physical/psychological
assessments

47
Q

HEALTH ASSESSMENT ACROSS TIME
1980s

A

Acute care nurses employed the “primary care”
method of delivery of care

48
Q

HEALTH ASSESSMENT ACROSS TIME
1990-Present
Priorities

A

downsizing, budget cuts, and
restructuring
= 1990s: Critical pathways or care maps
= Demand for documentation emerged
= APNs
= Reimbursement Issues
= Diagnosis-Related Groups (DRGs)
= Health care coverage plans (HMOs)
= Preferred provider organizations (PPOs).

49
Q

HEALTH ASSESSMENT ACROSS TIME
21st Century
Emerging Roles and Its’ Impact on Health
Assessment

A
  1. Forensic
  2. Acute Care
  3. Ambulance Care
  4. Critical Care Outreach
  5. Ambulatory Care
  6. Home Health
  7. Public Health
  8. School
  9. Hospice

biochem (45 decks)

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