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HEALTH ASSESSMENT > NURSING PROCESS > Flashcards

NURSING PROCESS Flashcards

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1
Q

a systematic, client-centered method for structuring the delivery of nursing care

A

Nursing Process

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2
Q

it provides structure for nursing practice,
entails gathering and analyzing data, and help enhance critical thinking

A

Nursing Process

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3
Q

central figure

A

patients

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4
Q

what are the 5 purpose of the nursing process?

A
  1. to identify client’s health status
  2. to identify actual or potential health care problems or needs
  3. to establish plans to meet identify needs
  4. to deliver specific nursing interventions to meet identified needs
  5. to evaluate and monitor the patient’s condition
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5
Q

what are the five phases of the nursing process?

A
  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation
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6
Q

systematically
gathering data, sorting and organizing the collected data, and documenting
the data in a retrievable format

A

Assessment

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7
Q

analyzing collected data to
identify the client’s needs or problems

A

Diagnosis

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8
Q

setting priorities,
establishing goals, identifying desired client outcomes, and determining
specific nursing interventions

A

Planning

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9
Q

putting the plan of care
into action and performing the planned interventions

A

Implementation

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10
Q

determining the client’s progress toward attaining the identified outcomes
and monitoring the client’s response to and effectiveness of the selected
nursing interventions.

A

Evaluation

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11
Q
  • a systematic, rational method of planning and providing nursing care
  • to identify clients health status and actual or potential problem
    -to establish plans to meet the identified needs
A

Nursing Process

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12
Q

what are the two types of data?

A
  1. subjective data
  2. objective data
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13
Q

it has measurable standards such as signs and vital signs
- (observation)

A

objective data

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14
Q

it varies from person to person
- symptoms

A

subjective data

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15
Q

what is the example of constant? (no changes)

A

Blood type ( A+ , O , O+)

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16
Q

identify the type of phases of the nursing process:

2 days fever
T: 39.5 °C
- flushing of face/redness
- chills
- wound at left foot

A

Assessment

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17
Q

identify the type of phases of the nursing process:

  • thermoregulation as evidence by temperature of 35.5 °C
A

Diagnosis

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18
Q

identify the type of phases of the nursing process:

after 4 hours of assessment intervention, the temperature will go down to 36.5°C

A

Planning

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19
Q

identify the type of phases of the nursing process:

INDEPENDENT
- tepid sponge bath
- monitor in 4 hours

DEPENDENT
- Administer paracetamol as ordered by doctor

A

Implementation

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20
Q

after 4 hours of assessment intervention, the patient’s temperature went down to 38.0°C

A

Evaluation

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21
Q

it should answer the question who, when, where, what, and why

A

Specific

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22
Q

it has criteria

A

Measurable

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23
Q

it has resources

A

attainable

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24
Q

it is relevant to the patient’s needs and it can be rationale

A

realistic

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25
specific time frame or timeline (ex. after the shift, the patient's temperature will go back to normal)
time bound
26
it is the state of complete physical, mental, in social well-being and not merely the absence of disease.
Health
27
- systematic and continuous collection, organization, validation, and documentation - to establish baseline data
Health Assessment in Nursing
28
- a continuous process - specific needs of a person - how does needs will be addressed - includes health status
HEALTH ASSESSMENT IN NURSING
29
What are the components of health assessment in nursing?
health history and physical exam
30
what is the purpose of a health assessment?
- to collect data about physical, mental, and social well-being of client - to identify problem in early stages - to determine the cause and extent of disease - to evaluate or monitor the changes in client's health status - to collect data systematically - to alleviate the complication - to determine the nature of treatment required for the client
31
determine the terminologies: determination of the nature and extent of disease
diagnosis
32
determine the terminologies: chance of recovery from disease ( good or bad)
prognosis
33
determine the terminologies: it is the science of the cause of disease - ______ - kapag hindi alam ang cause or pinagmulan
ETIOLOGY - idiopathic
34
objective evidence of the disease (observation)
signs
35
subjective evidence of disease (patient's feeling)
symptoms
36
type of data: - it is the information that is spontaneously shared with you by the client or is in response to questions that you ask the client
subjective data
37
type of data: - your senses - health care professional gathers during a physical examination and consist of information that can be seen, felt, smelled, or heard by that healthcare professional
objective data
38
"masakit ang tagiliran ko, parang tinutusok" as verbalized by the client. What type of data is being described?
subjective data
39
this data should supported by the subjective data
objective data
40
what are the 5 different types of assessment?
1. initial comprehensive assessment 2. ongoing or partial assessment 3. focus or problem oriented assessment 4. emergency assessment 5. time lapse assessment
41
this assessment establish complete database for problem identification reference and future comparison
initial comprehensive assessment
42
when does initial comprehensive assessment should be performed?
within a specified time after admission to a health care agency
43
what is the example of an initial comprehensive assessment?
nursing admission assessment
44
it is the reassessment of baseline data and brief assessment of clients normal body system or holistic health patterns to detect new problem
ongoing or partial assessment
45
this assessment determines the status of a specific problem in an earlier assessment
focus or problem oriented assessment
46
this assessment identify the **threatening** problems
emergency assessment
47
this assessment compares the client's current status to baseline data
time lapsed assessment
48
ongoing or partial assessment time performed:
whenever the nurse encounter with the client
49
Focus or problem oriented assessment Time performed:
ongoing process integrated with nursing care
50
emergency assessment time performed:
during any physiological or psychological crisis
51
time lapse assessment time performed:
several months
52
what are the three steps in health assessment?
1. collection of subjective data 2. collection of objective data 3. validation of data 4. documentation of data
53
.
role of nurses in health assessment
54
nurses relied on their natural senses: the clients face and body
role of nurses in the past
55
it has technical advancement
role of nurses in the present
56
READ
PREPARING FOR ASSESSMENT - review medical record - keep an open mind and avoid judgment - educate self about client, medical diagnosis and interventions - reflect on your own feelings - organize materials and equipment
57
it is the increased specialization and diversity of assessment skills for nurses
role of nurses in the future
58
HEALTH HISTORY GUIDELINES: - the professional interpersonal and interviewing skills are necessary to obtain a valid nursing health history
Interview
59
what are the phases of the interview?
1. Introductory Phase 2. Working Phase 3. Summary or closure Phase
60
phase of interview: first time meeting with the clients
introductory phase
61
Phase of interview: information summarized
summary or closure phase
62
READ
Non-verbal communication - appearance - demeanor - facial expression - attitude - silence - listening
63
READ! TECHNIQUES
- using open ended questions - using close ended questions - using laundry list approach to obtain specific answers - explore all data that deviate from normal deadline - making observations - restating or rephrase to reflect or clarify information - encourage verbalizing and focusing
64
READ! COMMUNICATION STYLES TO AVOID:
- excessive or insufficient eye contact -doing other things while taking the history - biased or leading questions - relying on memory to recall all the informations or recording all the details, instead of taking down notes - rushing the client - reading question from the history form, - distracting attention from the client

HEALTH ASSESSMENT (6 decks)

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