Chapter 16 Flashcards

(47 cards)

0
Q

Database

A

About the patients perceived needs, health problems and responses to these problems.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

Assessment

A

Is the deliberate and systematic collection of information about a patient to determine to his or her current and past health.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Cue

A

Is information that you obtain through use of the senses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Inference

A

Is your judgment or interpretation of these cues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Gordon’s model of 11 functional health patterns

A
1 - Health perception - health management pattern
2 - Nutritional - metabolic pattern 
3 - Elimination pattern 
4 - Activity - exercise pattern 
5 - Sleep-rest pattern 
6 - Cognitive-perceptual pattern 
7 - Self-Perception/Self concept pattern 
8 - Role-Relationship pattern 
9 - Sexuality-reproductive pattern 
10 - Coping-stress tolerance pattern
11 - Value-belief pattern
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Subjective data

A

Is data about your patient verbal descriptions of their health problems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Objective data

A

Are observations or measurements of a patients health status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Identify variety of sources where data can be obtained

A
1 - Medical records
2 - Family 
3 - Health Care team
4 - Scientific records 
5 - Nurses experiences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Patient centered interview

A

Is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Interview process “4” steps

A

(1) Setting the stage
(2) Gathering information about patient’s chief concerns or problems and setting an agenda
(3) Collecting the assessment or a nursing health history
(4) Terminating the interview

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Open-minded questions

A

Prompts patients to describe a situation in more than one or two words. This technique leads to a discussion in which patients actively describe their health status.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Back channeling

A

Which includes active listening prompts such as “all right,” “go on”. These indicate that you have heard what the patient says and are interested in hearing the full story.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Closed-ended questions

A

Form of questions that limits a respondent ‘s answer to one or two words

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Concomitant symptoms

A

Other symptoms that a patient experiences along with the primary symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Five techniques of a Physical Examination

A

Inspection
Palpation
Percussion
Auscultation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Data cluster

A

Is a set of signs or symptoms gathered during assessment that you group together in a logical way.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Related factor

A

Is a condition, historical factor or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Actual nursing diagnosis

A

Describes human responses to health conditions or life processes that exist in an individual, family or community

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Risk nursing diagnosis

A

Describes human responses to health conditions or life processes that may develop in a vulnerable individual, family or community.

19
Q

Health promotion nursing diagnosis

A

Is a clinical judgement of a person’s, family’s or community motivation, desire and readiness to increase well being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise.

20
Q

Diagnostic label

A

Is the name of the nursing diagnosis as approved by NANDA international .

21
Q

Etiology

A

Related factor or a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.

22
Q

PES format

A

P- Problem
E- Etiology
S- Symptoms

Makes a diagnosis even more specific problem “NANDA” etiology, symptoms

23
Q

Purpose of concept mapping

A

Concept maps promotes critical thinking because you identify, biographically linking concepts by analyzing info

24
Planning
Involves setting priorities identifying patient - centered goals and expected outcomes, and prescribing individualized nursing interventions
25
Goal
Is a broad statement that describes a desired change in a patients condition or behavior .
26
Expected outcome
Is a measurable criterion to evaluate goal achievement. Once an outcome is met, you then know that a goal has been at least partially achieved.
27
Patient centered goal
Reflects a patients highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources.
28
Short term goal
Is an response that you expect a patient to achieve in a short time, usually less than a week.
29
Long term goal
Is a response that you expect a patient to achieve over a longer period of time "several days, weeks or months"
30
Iowa intervention project
Published the nursing outcome classification
31
Independent nursing interventions
Actions that a nurse initiates, these do not require an order from another health care professional
32
Dependent nursing interventions
Actions that require an order from a physician or another health care professional. Advanced practice nurses are able to write dependent nursing interventions .
33
Collaborative interventions
Independent interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.
34
When choosing six important factors
(1) characteristics of nursing diagnosis (2) goals and expected outcomes (3) evidence base for the interventions (4) feasibility of the intervention (5) acceptability to the patient (6) your own competency
35
Domain 1 - Physiological : Basic
Care that supports physical functioning
36
Domain 2 - Physiological: Complex
Care that supports homeostatic regulation
37
Domain 3 - Behavioral
Care that supports psychosocial functions and facilitates lifestyle change
38
Domain 4 - Safety
Care that supports protection against harm
39
Domain 5 - Family
Care that supports the family
40
Domain 6 - Health system
Care that supports effective use of the health care delivery system
41
Domain 7 - Community
Care that supports the health of the community
42
Nursing care plans
Include nursing diagnosis, goals and or expected outcomes, specific nursing interventions and a section for evaluation findings so any nurse is able to quickly identify a patients clinical needs.
43
Interdisciplinary care plans
Which include contributions from all disciplines involved in patient care. The interdisciplinary plan is designed to improve the coordination of all patient therapies
44
Nursing hands off
Is a critical time when nurses collaborate and share important information that ensures continuity of care for a patient and prevents error or delay.
45
Critical pathways
A clear map that points patient progress and defines transition points in patients and draws a coordinated map.
46
Consultations
Is a process by which you seek the expertise of a specialist such as as your nursing instructor, a physician or a clinical nurse educator to identify ways to handle problems