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Flashcards in week five Deck (91)
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1

Nursing Diagnosis

Clinical judgement/patient problem about responses to health problems or life processes that nurses are licensed to treat

2

Etiology

The probable cause of the problem joined with r/t. can not be medical diagnosis.

3

dx

diagnosis

4

Subjective Data

Things a person tells you about that you cannot observe through your senses; symptoms

5

Objective Data

what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination

6

Interview

meeting between examiner and patient with the goal of gathering a complete health history

7

Physical Health Assessment (Examination)

an evaluation made for the purpose of diagnosis by identifying physical evidence of disease, such as signs and symptoms

8

Assessment

Collecting data, organizing data, validating data, documenting data

9

Diagnosis

Analyzing data, identifying health problems, risks, and strengths, formulate diagnostic statements

10

Planning

Prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting nursing interventions

11

Implementing

Reassess client, determine nurse's need for assistance, implement the nursing interventions, supervise delegated care, document nursing activities

12

Evaluating

Collect data related to outcomes, compare data with outcomes, relate nursing actions to client goals/outcomes, draw conclusions about problem status

13

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.

14

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).

15

Describe the step in assessment: Organize Data

Written or electronic format organize the collected patient data systematically

16

Describe the step in assessment: Validate Data

Double-checking of gathered data to confirm it is accurate and factual. Not all data requires validation.

17

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.

18

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.

19

Interview Opening

Sets the tone, establishes rapport and states the purpose for the interview

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Interview Body

Communication phase, data collection

21

Interview Closing

Nurse or patient end the conversation, important for building trust and continuing rapport

22

Data Collection Methods: Physical Assessment

Inspection, palpation, percussion, auscultation

23

Inspection

visual examination, purposeful and systematic, must have sufficient lighting

24

Palpation

Sense of touch, determine texture, temperature, position, size, distention, mobility of organs, pulsation, presence of pain

25

Percussion

Striking or tapping the body surface so that sounds can be heard or vibrations felt

26

Auscultation

Listening to sounds produced within the body. Can be direct (with ear alone) or indirect (with a stethoscope)

27

Actual Nursing Diagnosis

The problem is present at the time of assessment

28

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

29

Wellness Nursing Diagnosis

Focuses on the patient's desire to maintain or increase current level of health/wellness. "Readiness For"

30

dx

Diagnosis