CH. 11-15 Flashcards Preview

Foundations Exam 2 > CH. 11-15 > Flashcards

Flashcards in CH. 11-15 Deck (70)
Loading flashcards...
1

What is the nursing process?

An orderly and systematic problem-solving approach to patient-centered care.

2

Why do we perform nursing assessments?

-Establish baseline
-determine pt. normal function
-determine pt. risk of dysfunction
-determine presence or absence of dysfunction
-determine pt. strengths
-provide data for diagnosis phase

3

What are the four types of assessments?

-Admission
-Focus
-Time-lapse
-Emergency

4

Explain an admission assessment:

Determine reference baseline.

5

Explain a focus assessment:

Determining status of a specific problem.

6

Explain a time-lapse assessment:

Determining change from previous findings.

7

Explain an emergency assessment:

Determining presence of life-threatening conditions.

8

Explain observation:

Use of all senses to collect data.

9

Explain interviewing:

Collects subjective data for nursing history.

10

What are the phases of interviewing?

-Preparatory
-Introductory
-Maintenance
-Concluding

11

What are physical examination techniques?

-Inspection
-Palpation
-Percuss
-Auscultation

12

Explain inspection:

Visual inspection performed in a methodical and deliberate manner.

13

Explain palpation:

Specialized use of touch that augments the inspection process.

14

Explain percuss:

Striking the body surface with one or both hands to produce a percussive note.

15

Explain auscultation:

Listening to body sounds with a stethoscope.

16

What are the types of data?

-Subjective
-Objective

17

Explain subjective data:

Patients feelings and statements about their health problems.

18

Explain objective data:

Observable, perceptible, and measurable data

19

What are sources of data?

-Primary: The patient
-Secondary: All other sources of data, including diagnostic test

20

Data validation increases the likelihood that cues and inference are what?

-Accurate
-Free from bias
-Interpreted correctly

21

What are the frameworks for assessment data organization?

-Functional health approach
-Head-to-Toe model
-Body systems model

22

What is the second phase of the nursing process?

Nursing diagnosis (clinical judgement)

23

What are components of the nursing diagnosis?

-Diagnostic label
-Descriptors
-Definition
-Defining characteristics
-Related factors
-Risk factors

24

Explain diagnostic label:

Name of nursing diagnosis.

25

Explain descriptors:

Words that describe changes in condition, state, or some qualification of the nursing diagnosis.

26

Explain definition:

Describes the characteristics of the human response under considerations.

27

Explain defining characteristics:

The observable cues or inferences that cluster as manifestations of an actual illness or wellness health state, or nursing diagnosis.

28

Explain related to factors:

Describe the conditions, circumstances, or etiologies that contribute to the problem.

29

Explain risk factors:

Environmental factors, physiological, psychological, genetic, or chemical elements that increase vulnerability of an unhealthful event.

30

Explain cue clustering:

Analyzing individual cues and fitting them to describe a specific patient problem.