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50 Cards in this Set
- Front
- Back
Purpose of the assessment phase of the nursing process
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gather info about a client's health status to identify concerns and needs that can be treated or managed by nursing care
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Purpose of the assessment phase part II
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-Establish database with which to plan & evaluate comprehensive care
-Identify actual potential problems to make nursing diagnoses -focus on specific problem -determine immediate needs to establish priorities -determine cause of problem -determine related/contributing factors -identify strengths as basis for changing behavior -identify risk for complications -recognize complications |
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types of assessment
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initial
focused emergency ongoing |
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initial assessment
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-more comprehensive
-begins w/problem that led client to seek treatment -obtains holistic overview of client's level of functioning -rule out and identify problems -focus relates directly to goals of prevention,maintenance,restoration or rehabilitation |
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focused assessment
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-each problem
-examines evidence in detail, considers etiologies, looks for contributing factors, characteristics that will help client solve problems -when client has a complaint or new problem |
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Emergency assessment
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-life-threatening or time-important situation
-only key data related to problem -A-airway -B-breathing -C-circulation |
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cue
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indicator of presence or existence of problem or contition that represents a client's underlying health status
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cardinal signs and symptoms
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data of greatest significance in diagnosing a particular illness, disease, or health problem
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Subjective data
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information provided by the client and that you cannot directly observe
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symptoms
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subjective data supplied by client that describe characteristics of disease or dysfunction
(pain,nausea,cramps,dizziness, ringing in ears) you can't observe, client must tell you |
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objective data
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characterisics about the client you can observe directly
-can be observed through your senses, replicated and replicated from one exam to the next (size of wound, amt of drainage,number of blood cell) -high degree of certainty |
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signs
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objective data that indicate disease or dysfunction
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sources of data
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client
significant others colleagues client records |
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ANA standards of practice
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broad guidelines that require clinical judgement
may be used in a court of law |
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List ANA standards of practice
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Assessment
Diagnosis Outcomes Identification Planning Implementation Evaluation |
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Steps in active listening/processing
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Observing
Listening Translating Reasoning Using intuition Validating |
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phases of assessment interview
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preparation
orientation working phase termination |
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assessment interview:
preparation |
client comfortable
assess client reliablilty in providing health info find out pertinent data ahead of time |
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assessment interview:
orientation |
brief exchange to establish interview purpose, exam procedures and nurse's role
establish nurse-client relationship as a legally binding contract rapport identify immediate concerns and address them |
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assessment interview:
working phase |
client and nurse work together to review health history and establish actual and potential problems to be addressed
nurse gains insight about concerns/expectations |
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assessment interview:
termination |
announce time interview will take
ask if client has any further questions |
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elements of health history
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biographical data
expectations and goals reason for visit medical history family history |
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PERSON:
P |
Psychosocial
History Description of pt Assessment of family Home & community assessment Current status P-need meds P-need diagnostic tests |
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PERSON:
E |
Elimination
History Current Status E-need meds E-need diagnostic tests |
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PERSON:
R |
Rest,Regulatory,Reproductive
History Current Status Meds Diagnostic tests includes neuro and endocrine |
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PERSON:
S |
Safety
History Current status Medications not included elsewhere Meds: antibiotics Diagnostic tests |
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PERSON:
O |
History
Current status Diagnostic tests O-need medications |
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PERSON:
N |
Nutrition
History Current status Labs/diagnostic test Meds |
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Purpose of diagnosis phase of nursing process
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Naming client problems/needs that are amenable to treatment with nursing care
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Difference between nursing diagnosis and medical diagnosis
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diagnosis of response to to illness or heatlth needs vs. diagnosis of illness or medical condition
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NANDA definition of nursing diagnosis
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clinical judgement about individual,family, or community responses to actual or potential health problems/life processes that provides bases for definitive therapy toward achievement of outcomes for which a nurse is responsible
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Components of a correctly stated nursing diagnosis
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Diagnostic label
definition defining characteristics related factors risk factors |
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Diagnostic label
(component of nursing diagnosis) |
Name of nursing diagnosis
Used to develop goal of nursing care Represents pattern of related cues that characteristics, signs, or symptoms May include descriptor, or a judgement that modifies limits or specifies meaning of nursing diagnosis (decreased,deficient,excessive, readiness) |
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Definition
(component of nursing diagnosis) |
provides description of the pattern of signs and symptoms, delineates the meaning of the label, and helps to differentiate it from similar diagnoses
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Defining Characteristics
(component of nursing diagnosis) |
description of a client's behavior that determine whether a nursing diagnosis is present and whether a particular diagnosis is accurate.
Either directly or indirectly observable cues. |
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cues
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indiciators of the presence or existence of a problem or condition that represents a client's underlying health status.
Subjective and objective data (signs and symptoms) of a problem provide clinical clues that a problem is present |
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Related Factors
(component of nursing diagnosis) |
Show some type of patterned relationship to the nursing diagnosis.
Specific related factors help direct how the problem should be managed. |
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Risk Factors
(compononet of nursing diagnosis) |
Factors in the internal or external environment that increase the vulnerablility of the person, family or community to an unhealthful state or event.
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Actual Nursing Diagnoses
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Describe human responses to health conditions/life processes that exist at the present time.
Describe a client's current problem. Signs and symptoms that indicated presence of the diagnosis can be identified, |
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"Risk for" Diagnoses
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describes human responses that MAY develop in a vulnerable person, family or community.
Supported by risk factors that contribute to increased vulnerability. Used to help you plan nursing care aimed at preventing the problem. |
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Purpose of the planning phase of the nursing process
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Setting goals and plan nursing
Identify expected outcomes and devise interventions to achieve expected outcomes for each problem |
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Relationship of the goal to the nursing diagnosis
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Nursing diagnostic label establishes a goal for the problem.
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Expected outcomes
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specific measurable and realistic goals to achieve related to the specific problem
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Components of a correctly stated outcome
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Realistic
Measurable acceptable to the client include a time frame |
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Measurable (in terms of outcome)
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should describe expected outcomes so that outcomes can be directly observed.
Use verbs that are measurable to describe cognitive, affective, and psychomotor actions |
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Direct Care Nursing Intervention
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treatment performed through interaction with the client
Physiological and psychosocial actions to improve client health or modifiy environment in a way that is conducive to health or that prevents disease |
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Indirect Care Nursing Intervention
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Treatment performed away from the client but on behalf of a client or group of clients
Include nursing action airmed at management of the client care environment and interdisciplinary collaboration Support effectiveness of the direct care intervention |
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Nurse Initiated Intervention
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initiated by the nurse in response to nursing diagnosis
autonomous action based on scientific rationale that is executed to benefit the client in a predicted way related to the nursing diagnosis and projected outcome (helping the client to dress) |
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Physician Initiated Intervention
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treatment initiated by a physician in response to a medical diagnosis, but carried out by a nurse in response to doctor's order.
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Nursing intervention according to NIC
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514 nursing intervention labels
Each label is provided w/ a definition and a list of nursing activities |