Flashcards in week five Deck (91)
Clinical judgement/patient problem about responses to health problems or life processes that nurses are licensed to treat
The probable cause of the problem joined with r/t. can not be medical diagnosis.
Things a person tells you about that you cannot observe through your senses; symptoms
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
meeting between examiner and patient with the goal of gathering a complete health history
Physical Health Assessment (Examination)
an evaluation made for the purpose of diagnosis by identifying physical evidence of disease, such as signs and symptoms
Collecting data, organizing data, validating data, documenting data
Analyzing data, identifying health problems, risks, and strengths, formulate diagnostic statements
Prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting nursing interventions
Reassess client, determine nurse's need for assistance, implement the nursing interventions, supervise delegated care, document nursing activities
Collect data related to outcomes, compare data with outcomes, relate nursing actions to client goals/outcomes, draw conclusions about problem status
Describe the relationship between critical thinking and the nursing process
Critical thinking is the purposeful, reflective, mental activity using skills in reasoning, analysis and decision making relevant to the discipline of nursing. The nursing process is a systematic approach to the delivery of nursing services.
Describe the step in assessment: Collect Data
gather information about a patient's health status using information that comes from the patient (primary source, or family, health records, other health professionals (secondary source).
Describe the step in assessment: Organize Data
Written or electronic format organize the collected patient data systematically
Describe the step in assessment: Validate Data
Double-checking of gathered data to confirm it is accurate and factual. Not all data requires validation.
Describe the step in assessment: Document Data
Data are recorded in a factual manner without interpretation by the nurse. Subjective data should be documented in the patient's own words and in quotes.
Data Collection Methods: Interview
planned communication. Directive: structured for specific information - nurse controls. Non Directive: build rapport, patient controls. The three stages of an interview are the opening, body, and closing.
Sets the tone, establishes rapport and states the purpose for the interview
Communication phase, data collection
Nurse or patient end the conversation, important for building trust and continuing rapport
Data Collection Methods: Physical Assessment
Inspection, palpation, percussion, auscultation
visual examination, purposeful and systematic, must have sufficient lighting
Sense of touch, determine texture, temperature, position, size, distention, mobility of organs, pulsation, presence of pain
Striking or tapping the body surface so that sounds can be heard or vibrations felt
Listening to sounds produced within the body. Can be direct (with ear alone) or indirect (with a stethoscope)
Actual Nursing Diagnosis
The problem is present at the time of assessment
Risk For Nursing Diagnosis
The problem does not currently exist, BUT based on the RN's clinical judgement there are risk factors that indicate that a problem is likely to develop without RN intervention
Wellness Nursing Diagnosis
Focuses on the patient's desire to maintain or increase current level of health/wellness. "Readiness For"