Flashcards in Nursing Process Part 2 Deck (14)
What are the 5 types of nursing assessments?
patient centered assessment method
What are some skills that help with critical thinking?
reflective practice: journaling and debriefing
Explain the 5 core values of assessment:
-systematic and comprehensive to identify medical concerns
-determine credibility of info sources
-find normal from abnormal and risk for abnormal
-judgments of significance of data
-check accuracy, reliability, and missing info
What are the 2 types of data used?
subjective: info perceived only by the patient
objective: observable and measurable
What are some sources of data?
medical history, physical
What are some problems related to data collection?
failure to chart
recording interpretation rather than observed data
What are the 5 steps of assessment?
identify cues and make inferences
clustering related data
reporting and recording data
this leads to:
-clinical reasoning (analyzing, synthesizing, reflecting, drawing conclusions)
What are the 5 steps of Diagnosis?
-creating a list of suspected problems
-ruling out similar problems
-naming actual/potential problems
-determining risk factors
-identifying resources, strengths, and areas for health promotion
What is the prupose, vision, and mission of NANDA?
purpose: implementation of ND
vision: ensure patient safety through standardized terminology
mission: standardized nursing diagnostic
What is the difference between a ND and a medical diagnosis?
ND: nurse treats independently
Medical: physician directs the treatment
Collaborative: physician and nurse prescribed
What does a ND provide?
-a definition of problems and common language for patient needs
-focus on scope of practice
-foster nursing knowledge
What are the 3 types of ND's?
-actual: human response to health conditions or life processes
-risk: same as actual but they may develop
-health promotion: clinical judgment of motivation, desire, and readiness to enhance well-being and does not require a current level of wellness
What are the 3 parts of the nursing diagnosis?
-Problem: diagnostic labe
-Etiology: related to "r/t" (don't use medical diagnosis)
(risk and health promotion diagnosis will not have this section)
-Defining characteristics: as evidenced by AEB, (use subjective and objective data)