Module 1-c Flashcards
(42 cards)
Physical Assessment
Subjective/Objective findings when doing a head to toe physical assessment on a patient. Least invasie to most invasive.
Components of a physical assessment
Inspect, Auscultate, Percuss, Palpate
Basic History and a physical assessment
1.Biographical data, 2.Reason for seeking health care, 3.Hx of present health care concern, 4.Medical Hx, 5.Family Hx 6. Lifestyle
Nursing Process (systemic, dynamic,interpersonal,outcome oriented, universally acceptable)
Communication in the Nursing ProcessSystemic method for organizing and delivering nursing care. Framework for nursing practice. Patient centered, helps the nurse manage care scientifically, holistically, and creatively.
Assessing
collection of pt data, validation, and communication of pt data.
Diagnosing
analysis of pt data to ID pt strengths and health problems that independent nursing intervention can prevent or resolve.
Outcome ID and planning
Specification of !) pt outcomes to prevent, reduce, or resolve the problems ID’d in the nursing diagnoses, 2) related nursing interventions
Implementing
carrying out the plan of care.
Evaluating
Measuring the extent to which the patient has achieved the outcomes specified in the plan of care.ID factors that positively/negatively influenced outcome achievement. Revising the plan if necessary.
Characteristics of data
(good data) is Purposeful, Complete, Factual/Accurate, Relevant
Objective data (observable/ measurable)
age, weight, height vital signs. “posterior, left midcalf is warm and red” , :pt observed fidgeting with bed covers, facial features are tightly drawn
Subjective data (perceptions/feelings)
pain scale, symptoms “ my leg hurts when I walk”, I am so afraid”
Methods of data collection
Observation, Interview, and Physical Assessment
Components of Nursing HX
PT profile (demographics, reason for seeking care, health habits/patterns, current state of health, body systems, pain, PMH/PSH, Meds, allergies, vacs, Health status, Participation, personal resources, perception of health status, Developmental ,family, enviromental, physchosocial, Expectations of providers, Educational needs & willingness to learn, Potential for injury
Phases of the Interview Process
Preparatory (reading chart, taking report)
Introduction (meeting the pt, exchanging names)
Working (longest part of the process)
Termination (end of the process, summarize w/ the pt, look to the future)
Validation of data
Act of confirming or verifying. Purpose is to :free from error, bias, misinterpretation, question discrepancies, determine accuracy, address lack of objectivity.
Analysis of data
Recognize significant date ( Hypertension), recognize patterns/clusters, ID strengths and problems, ID potential complications, reach conclusion, partner w/ the pt.
Analyzing data ( standards or “norms”)
Rule, Measure, Pattern, Model, Compares same class or catrgory. (related to/ as evidenced by)
Comparing data to standards (analysis phase)
changes in normal patterns- deviation from population norm- nonproductive behavior-developmental lag or dysfunction
Analyzing data
Recognize significant data ( high temp, VS, etc…) , Recognize patterns or clusters (productive coughing/ smoking 1 pack per day for 15 yrs.)
Medical vs Nursing Diagnosis
MEDICAL DIAGNOSIS (ID’s disease, describes problems & directs TX, remains the same as long as the disease is present.) NURSING DIAGNOSIS (focus on IDing unhealthy responses to health/illness. problems treated by nurse in scope of nursing. may change day to day as the pt responds)
Types of Nursing Diagnoses
5 TYPES 1. Actual, 2.Risk, 3.Possible, 4.Wellness, 5. Syndrome.
ACTUAL (nursing diagnosis)
4 components …label, definition, defining characteristics, & related factor. (I.E. Imbalanced nutrition is greater than body requirements. (label), intake of nutrients exceeds metabolic needs (definition), weight 20% over ideal (defining characteristics), R/T excessive intake in relation to metabolic need (related factors)
RISK (nursing diagnosis)
risk for impaired skin integrity
