NURSING PROCESS INTRO & ASSESSMENT Flashcards
(62 cards)
1
Q
- systematic and client centered method that provides a structure in the delivery of nursing care
- goal oriented method that provides a framework for nursing practice
A
nursing process
2
Q
- patients as central figure
- gathering and analyzing data to identify health issues / concerns
A
nursing process
3
Q
what are the phases or nursing process?
A
ADPIE assessment, diagnosis, planning, implementation, evaluation
4
Q
systematic continuous collection, organization, validation and documentation of data
A
assessment
5
Q
- establish a complete database for problem identification, reference and future comparison
- within a specified time after admission
A
initial / comprehensive assessment
6
Q
- determine the status of a specific problem
- ongoing process
A
problem-focused assessment
7
Q
- to identify life-threatening and overlooked problems
- during any physiologic or psychologic crisis
A
emergency assessment
8
Q
- compare the client’s status to baseline data
- several months after initial assessment
A
time-lapsed assessment
9
Q
4 major activities done during assessment
A
COVD collecting, organizing, validating, documenting
10
Q
gives subjective information on how a health condition came about
A
nursing health history
11
Q
true or false: the chief complaint must be recorded as direct quotes from the client
A
true
12
Q
how can the family history be presented as?
A
genogram / family tree
13
Q
infancy
A
trust vs mistrust
14
Q
early childhood
A
autonomy vs shame and doubt
15
Q
preschool
A
initiative vs guilt
16
Q
school age
A
industry vs inferiority
17
Q
adolescence
A
identity vs role confusion
18
Q
young adulthood
A
intimacy vs isolation
19
Q
middle adulthood
A
generativity vs stagnation
20
Q
maturity
A
ego integrity bs despair
21
Q
person’s description of his current health
A
health perception - health management
22
Q
person’s nourishment
A
nutritional - metabolic
23
Q
- person’s excretory pattern
- disease of digestive, urinary system, or skin
A
elimination
24
Q
- person’s description of his weekly pattern of activities, leisure, exercise, and recreation
- any disease that affects his cardio-respiratory and/or musculoskeletal systems
A
activity - exercise
25
person’s description of the person’s sleep-wake cycle
sleep - rest
26
- person’s ability to express himself clearly and logically
- person's education
cognitive - perceptual pattern
27
- if person is comfortable with his appearance
- description of the person’s feeling state
self-perception / self-concept
28
person’s description of his various roles in life
role - relationship
29
person’s satisfaction with his situation related to sexuality
sexuality - reproductive
30
person’s means/actions of coping with problems
coping - stress tolerance
31
- principals that the person learn as a child which are still important to him
- person’s identification with any cultural, ethnic, religious, regional, or other groups
value - belief
32
the patient’s subjective response to a series of body system-related questions
review of systems
33
- also referred to as symptoms or covert data
- can be described or verified only by the individual
subjective data
34
- also referred to as signs or overt data
- can be measured or tested against an accepted standard
objective data
35
best source of data
primary / client
36
refers to all sources other than the client
secondary source
37
- a conscious and deliberate skill in gathering data using
the senses
- involves noticing data then selecting, organizing, and interpreting data
observing
38
planned communication or a purposeful conversation
interviewing
39
- highly structured
- nurse establishes the purpose and controls the interview
directive interview
40
- a rapport-building interview
- the client controls the purpose, subject matter, and pacing
nondirective interview
41
- used during direct interviews
- generally restrictive; requires a yes, no, or short factual responses
- often used when information is needed quickly
closed questions
42
- associated with non-directive interviews
- invites longer responses from the clients
- provides the client with freedom to share information
open-ended questions
43
- open-ended, used in non-directive interviews
- can be answered by the client without direction or pressure
neutral questions
44
- closed questions and are used in directive interviews
- directs the client’s answers
- gives the client less opportunity to decide if responses are true or not
leading questions
45
- complete health assessment
- orderly and systematic
examining
46
4 basic skills of examining
IPPA inspection palpation percussion auscultation
47
approaches of examining
cephalocaudal, body system approach
48
- assessment of the patient’s general appearance
- uses the sense of sight, hearing and smell
inspection
49
uses the sense of touch; “therapeutic touch”
palpation
50
- the skin is depressed for about 1-2 cm using the finger pads
- used to assess texture, tenderness, temp., moisture, elasticity
- light palpation
51
- can be done with 1 or 2 hands, skin is depressed for about 4-5 cm
- this is used when trying to feel for the internal organs
deep palpation
52
involves the striking of a body surface, usually with a tip of the finger to elicit a sound or vibration
percussion
53
- uses pads of 2, 3, or 4 fingers or with a pad of the middle finger
- commonly used when percussing adult sinuses
direct percussion
54
- the nurse strikes an object (another finger) held against a body area
- uses pleximeter (finger placed on the skin), plexor (striking finger)
indirect percussion
55
involves the process of listening to sounds produced within the body and could either be direct or indirect
ausculation
56
use of unaided ear
direct ausculation
57
use of stethoscope
indirect auscultation
58
constitutes another source of objective data, which is important in assessing many health problems and conditions
using laboratory results
59
enumerate the hierarchy of needs from the lowest to highest level
physiological, safety, love and belonging, esteem, self-actualization
60
This model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development
orem's self care model
61
- the act of double-checking or verifying data to confirm that it is accurate and factual
- differentiate between cues and inference
validation
62
- should include all data collected about the client’s health status
- recorded in a factual manner and not interpreted by the nurse
documentation
