Midterm 1 Flashcards by Craig Haas

An organized & systematic process of providing goal-oriented care.

Nursing Process

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5 Steps of the Nursing Process

1- Assessment
2- Diagnosis
3- Planning
4- Implementation
5- Evaluation

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A process whereby the nurse collects, synthesizes & analyzes information about the level of functioning of an individual in order to make a clinical judgment.

Nursing Assessment

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Types of Nursing Assessment: (4)

1- Initial Comprehensive
2- Partial/Ongoing Assessment
3- Focused
4- Emergency

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The first detailed assessment of an individual.

Initial Comprehensive

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Assessment that occurs after the initial db has been established.

Ongoing/Partial

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Assessment that focuses on a specific health concern.

Focused

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Assessment that is rapid & occurs in life threatening circumstances.

Emergency

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4 Steps of Assessment

1- Collection of Subjective Data
2- Collection of Objective Data
3- Validation of Data
4- Documentation of Data

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Data that can only be provided & verified by the client.

Subjective Data

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Data which is measurable or can be sensed.

Objective Data

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Organizational tools for the systematic collection of Data.

Assessment Frameworks

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The Framework we’re using?

Head-to-Toe

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“People are individuals that are part of other interacting wholes called systems” is an example of…

Context in Health Assessment

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7 Context Considerations?

1- Role in family
2- Place/role in peer group
3- Cultural beliefs
4- Religious beliefs
5- Cultural impact on communication/sharing health information
6- Biological/Anatomical variations
7- Socioeconomic community

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This is define as a search for meaning & purpose in life, and to understand life in relation to the sacred.

Spirituality

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T/F Sense of spirituality is related to health status.

TRUE - Spirituality can be a strong coping mechanism when confronted with threatening illness.

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Has absence of spirituality been associated to illness?

Yes - Psychological Illness

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Two types of Spirituality Assessment:

1- Formal

2- Informal

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Examples of informal questions?

What in your life gives you internal support?
What gives you hope, strength, comfort?
What keeps you going?
What sustains you in difficult times?

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Examples of formal assessments?

Questionnaires that evaluate spirituality ex
1- Brief Religious Coping Ques. (RCOPE)
2- FICA Spiritual Assessment Tool

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What does FICA stand for?

Faith and beliefs
Importance and influence
Community
Address (how can I address these?)

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Mnemonic to help assess a sign/symptom or concern?

COLDSPA

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What are the components of COLDSPA?

Character
Onset
Location
Duration
Severity
Pattern
Associated Factors/ Affects Client

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10 examples of subjective data

Beliefs, desires, feelings, ideas, judgments, personal information, perceptions, preferences, sensations, values.

Subjective data is collected by interview which has 3 phases:

1- Introductory Phase 2- Working Phase 3- Closure

2 Goals of Introductory Phase:

1- Establish Rapport | 2- Ensure Comfort

What should we do to establish rapport?

Extend a cordial greeting, address client by name (surname), introduce w/ name & title, offer a handshake, assume a position of equality.

What should we do to ensure comfort?

Use private setting, State the purpose at the beginning, explain what types of questions, assure confidence, give a sense of how long it will take.

The working phase involves the structured interview that elicits information about: (8)

``` 1- Biographical Data 2- Reasons for seeking care 3- History of present health concerns 4- Personal health history 5- Family health history 6- Review of body systems 7- Lifestyle & health practices 8- Developmental Level ```

T/F In the working phase use broad opening statements?

TRUE From Broad - Specific, leave sensitive topics for once rapport has been established

Should you use technical language in the working phase?

NO - Use language the client will understand.

We should ______________ to the client as the end of the interview is approaching, so he is prepared

Provide Clues

In the Closure phase we....(2)

1- Summarize & Validate Data | 2- Discuss any plans to resolve problems with client.

Effective Communication Actions Include:

Appropriate grooming, name tag & credentials, attending body posture, calm & composed, neutral & friendly facial expressions, no judging, open ended question, use silence, summarize points.

Ineffective Communication Actions:

Standing while client is sitting, attending to other tasks at the same time, insufficient or excessive eye contact, biased/leading question, rushing/reading the interview.

In collecting objective data we have to:

1- Use an appropriate setting 2- Prepare ourselves 3- Prepare the client 4- Gather equipment

There are 6 ways to position a client. They are:

``` 1- Standing 2- Sitting 3- Supine 4- Dorsal Recumbent 5- Lithotomy 6- Sim's ```

Flat on back, with legs straight:

Supine

Flat on back with knees raised, legs separated and feet flat on table:

Dorsal Recumbent

On back, hips on edge of table, legs raised, knees bent in stirrups:

Lithotomy

Lying on left or right side, with lower arm placed behind body, upper leg flexed and pulled forward

Sim's

Four physical examination techniques:

1- Inspection 2- Palpation 3- Percussion 4- Auscultation

Palpation may be:

1- Light Palpation .5-1" 2- Deep Palpation 1.5-2" 3- Bilateral Palpation (Both hands)

When percussing we listen for three qualities:

1- Intensity (Loudness) 2- Pitch (Frequency) 3- Quality (Hollow, booming, dull, drumlike)

There are 5 Types of Percussion Sounds. They are:

``` 1- Tympany 2- Resonance 3- Hyperresonance 4- Flatness 5- Dullness ```

Drumlike sound over air filled body parts:

Tympany (Air in stomach or bowels)

A hollow sound, loud & low pitched:

Resonance (Normal Lung)

Very loud, low & booming:

Hyperresonance (Lungs w/ trapped air)

Soft sound, high pitched & flat quality:

Flatness (Muscle or Bone)

Lower pitched than flat, moderately loud, thud like:

Dullness (Liver)

The skill of listening to the body sounds is usually the last observation technique in the assessment:

Auscultation

What tool do we need to auscultate?

Stethoscope

For low pitched sounds we use the:

Bell

For High pitched sound we use the:

Diaphragm

In auscultation, we describe the sounds in terms of: (4)

1- Pitch (High, low) 2- Intensity (Loud, soft) 3- Duration (Length) 4- Quality/Character

This is the process of verifying the subjective & objective data for accuracy.

Validation of Data

When validating we look for 3 things:

1- Changes in what client reports 2- Abnormal objective findings 3- Inconsistencies between sub & obj data

What 4 things can we do to validate?

1- Repeat the assessment element 2- Ask the client additional questions 3- Have a second opinion 4- Check perceptions w/ client

Once we've validated we...

Document!

Findings are documented for:

1- Establishment of data base 2- Communication w/ other HCW's 3- Provision of legal record of care given 4- Chronological record of events in client care.

Principles of Proper Documenting include...(5)

1- Permanent Ink! 2- Never overwrite, white-out or erase 3- If error made, draw line through and write error 4- Correct grammar, spelling & only accepted abbreviations 5- Don't use slang/jargon unless direct quote.

2 Types of Documentation Forms

1- Initial Assessment Forms | 2- Ongoing assessment Forms

Initial assessment forms tend to be...(3)

1- Long & Detailed 2- Done on admission 3- Provide Baseline data

Ongoing Assessment forms tend to be...

Flow charts or Progress charts, used to compare ongoing data.

This is the process of analyzing the data & drawing conclusions.

Diagnostic Reasoning.

Diagnostic Reasoning consists of 6 components:

``` 1- Grouping/organizing data 2- Comparing to norms 3- Clustering data 4- Generating possible conclusions 5- Formulating professional judgment 6- Validating judgment with client ```

The 7 Steps to a Nursing Diagnosis (ICDPCCD)

``` Identify Abnormal Data Cluster Data Draw Inferences Propose Nursing Diagnosis Check for Defining Features Confirm or Rule Out Document Conclusions ```

These are statements of actual or potential human problems that can be prevented, resolved or reduced through independent nursing actions.

Nursing Diagnosis Statements

There are 3 Common Types of Nursing Diagnosis Statements. They are?

Wellness Diagnosis Risk Diagnosis Actual Diagnosis

TYPE - Client does not have a problem, but can achieve a higher level of functioning.

WELLNESS

TYPE - Problem is likely to occur without intervention.

RISK

TYPE- Problem is identified. Health problem exists.

ACTUAL

What are the three elements of a Nursing Diagnosis?

Problem Etiology (RELATED TO) Signs/Symptoms (AS EVIDENCED BY)

3 Categories of Nursing Diagnosis

``` Nursing Concern (On Own) Collaborative Concern (Need someone else) Referral Concern (Send to someone else) ```

Midterm 1 Flashcards

(75 cards)