Mod 1 Flashcards
(25 cards)
Critical thinking process used by professional nurses to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
Nursing Process
Written guidelines for client care that organize nursing actions and resources
Nursing care plan
Ability to identify a problem, analyze it, develop a response and follow through based on experience, knowledge, and intuition
Critical thinking
What is the purpose of health assessment in nursing practice?
To establish a database concerning a client’s physical, psychosocial, and emotional health and to identify health-promoting behaviors and potential health problems.
What is an initial comprehensive assessment?
Also called an admission assessment, performed when a client enters a healthcare facility to evaluate health status and identify problematic functional health patterns.
What is a problem-focused assessment?
Collects data about a problem that has already been identified, has a narrower scope, and a shorter time frame than the initial assessment.
What is an emergency assessment?
Takes place in life-threatening situations with a focus on rapid identification and intervention for the client’s health problems.
What is a time-lapsed assessment?
Takes place after the initial assessment to evaluate changes in the client’s functional health over time.
What are the activities during assessment?
- Collecting data
- Verifying/validating data
What is subjective data?
Data from the client’s point of view, including feelings, perceptions, and concerns.
What is objective data?
Observable and measurable data obtained through physical examination and laboratory testing.
Who is the primary source of data in health assessment?
The client.
What is the purpose of diagnosing in nursing?
To identify the patient’s health care needs and prepare diagnostic statements.
What does the P in a nursing diagnosis statement stand for?
Problem.
What does the E in a nursing diagnosis statement represent?
‘Related to’ statement that indicates the cause or contributing factors.
What is the purpose of outcome identification?
To formulate and document measurable, realistic, patient-focused goals.
What does planning involve in nursing?
Determining strategies or courses of action to be taken before implementation of nursing care.
What is the purpose of implementation in nursing?
To carry out planned nursing interventions to help the patient attain goals and achieve optimal health.
What does evaluation in nursing encompass?
Determining the outcome of achievements and identifying factors affecting achievement of outcomes.
What is the purpose of an interview in health assessment?
To gather, organize, complete, and accurate data about the patient’s health state.
What factors affect communication during an interview?
- Internal factors: liking others, empathy, ability to listen
- External factors: physical setting, privacy, interruptions
What is the intimate zone in non-verbal communication?
0 to 1 ½ feet, best for assessing breath and body odors.
Fill in the blank: The gathering of data by using the five senses is known as _______.
[Data Collection Method]
What is the purpose of a contract in the interview process?
To establish time and place of the interview, explain the nurse’s role, and outline expectations.
