Flashcards in CH. 11-15 Deck (70)
What is the nursing process?
An orderly and systematic problem-solving approach to patient-centered care.
Why do we perform nursing assessments?
-determine pt. normal function
-determine pt. risk of dysfunction
-determine presence or absence of dysfunction
-determine pt. strengths
-provide data for diagnosis phase
What are the four types of assessments?
Explain an admission assessment:
Determine reference baseline.
Explain a focus assessment:
Determining status of a specific problem.
Explain a time-lapse assessment:
Determining change from previous findings.
Explain an emergency assessment:
Determining presence of life-threatening conditions.
Use of all senses to collect data.
Collects subjective data for nursing history.
What are the phases of interviewing?
What are physical examination techniques?
Visual inspection performed in a methodical and deliberate manner.
Specialized use of touch that augments the inspection process.
Striking the body surface with one or both hands to produce a percussive note.
Listening to body sounds with a stethoscope.
What are the types of data?
Explain subjective data:
Patients feelings and statements about their health problems.
Explain objective data:
Observable, perceptible, and measurable data
What are sources of data?
-Primary: The patient
-Secondary: All other sources of data, including diagnostic test
Data validation increases the likelihood that cues and inference are what?
-Free from bias
What are the frameworks for assessment data organization?
-Functional health approach
-Body systems model
What is the second phase of the nursing process?
Nursing diagnosis (clinical judgement)
What are components of the nursing diagnosis?
Explain diagnostic label:
Name of nursing diagnosis.
Words that describe changes in condition, state, or some qualification of the nursing diagnosis.
Describes the characteristics of the human response under considerations.
Explain defining characteristics:
The observable cues or inferences that cluster as manifestations of an actual illness or wellness health state, or nursing diagnosis.
Explain related to factors:
Describe the conditions, circumstances, or etiologies that contribute to the problem.
Explain risk factors:
Environmental factors, physiological, psychological, genetic, or chemical elements that increase vulnerability of an unhealthful event.