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Terms in this set (76)Assessment is the systematic and continuous collection of data about a client for the purpose of determining the client's current and ongoing health status, predicting the client's risks to health and identifying appropriate health-promotion activities. Collect, Organize, Validate, and Document Data. Assessment - Critical Thinking Activities - Making reliable observations 4 Types of Assessments -
Initial Assessment Initial (baseline) Assessment - Performed within specific time frame after admission to a health agency (refer to agency policy and procedure) Problem-Focused (System Specific) Assessment - Ongoing process integrated with nursing care Emergency Assessment - During any physiologic or psychologic crisis. Ongoing Reassessment -
Several months after initial assessment. Assessment Situation 1 Situation: Client complains of abdominal pain Physical Assessment: Inspect, auscultate, and palpate abdomen; assess vital signs. Assessment Situation 2 Situation: Client is admitted with a head injury. Physical Assessment: assess level of consciousness using the Glasgow Coma Scale; assess pupils for reaction to light and accommodation; assess vital signs. Assessment Situation 3 Situation: the nurse prepares to administer a cardiotonic drug to a client Physical Assessment: Assess apical pule and compare with baseline data. Assessment Situation 4 Situation: The client has just had a cast applied to the lower leg. Physical Assessment: Assess peripheral perfusion of toes, capillary refill, pedal pulse if accessible, and vital signs. Assessment Situation 5 Situation: The client's fluid intake is minimal Physical Assessment: Assess skin turgor, fluid intake and output, and vital signs. Actual Diagnosis is a client problem that is present at the time of the nursing assessment. Example is ineffective breathing pattern and anxiety. Is based on the presence of associated signs and symptoms. Assignment a downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another Closed Question used in the directive interview, are restrictive and generally require only "yes" or "no" or short factual answers giving specific information. Example: "What medication did you take?" Cognitive Skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity. They are crucial to safe, intelligent nursing care. Collaborative Care Plans Along with Critical Pathways, sequence the care that must be given on each day during the projected length of stay for the specific type of condition. Collaborative Interventions are actions the nurse carries out in collaboration with other health care team members, such as physical therapists, social workers, dietitians, and physicians. Concept Map is a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows. Critical Pathways Along with Collaborative Care Plans, sequence the care that must be given on each day during the projected length of stay for the specific type of condition. Critical Thinking is a cognitive process during which a person reviews data and considers potential explanations before forming an opinion or making a decision. Cues are subjective or objective data that can be directly observed by the nurse, that is, what the client says or what the nurse can see, hear, feel , smell, or measure. Example: Client says "My chest feels tight." (sub.) and on auscultation the nurse hears wheezing. (obj.) Database is all the information about a client; it includes the nursing health history, physical assessment, primary care providers history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Defining Characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. example: verbal report of fatigue, abnormal heart rate or blood pressure response to activity, electrocardiographic changes reflecting arrhythmias or ischemia, or exertional discomfort or dyspnea. Dependent Functions nurses are obligated to carry out physician-prescribed therapies and treatments because the nurse cannot provide these independent of medical instructions form a physician or other licensed health care provider. Dependent Interventions are activities carried out under the physician's orders or supervision, or according to specified routines. example: a medical order of "Progressive ambulation as tolerated"; a nurse may write the following: Diagnosis is a statement or conclusion regarding the nature of a phenomenon. The second phase of the nursing process. Critical thinking regarding assessment findings is crucial. Diagnostic Label the standard NANDA names for diagnoses; Directive Interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview and the client responds to questions buy may have limited opportunity to ask questions or discuss concerns. Used when time is lmited (in an EMERGENCY situation). Discharge Planning the process of anticipating and planning for needs after discharge is a crucial part of comprehensive health care and should be addressed in each clients care plan. Begins at first client contact or when first admitted. Etiology causal relationship between a problem and its related or risk factors. Evaluation is a planned, ongoing, purposeful activity in which clients and
health care professionals determine: Evaluation Statement consists of two part: a conclusion and supporting data. conclusion: is a statement that the goal/desired outcome was met, partially met, or not met. supporting data: are the list of client responses that support the conclusion.
Formal Nursing Care Plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for community care. Goals describe, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions. example: Improved Nutritional Status Health Promotion Diagnosis is a clinical judgment of a persons, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed by a readiness to enhance specific health behaviors. Implementation consists of doing and documenting the specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing activities for the interventions that were developed in the planning step and then concludes the implementing step by recording nursing activities and client responses. Independent Functions the areas of health care that are unique to nursing and separate the distinct from medical management. Independent Interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals. Indicator is a more concrete individual, family, or community state, behavior, or perception that serves as a cue for measuring an outcome and is similar to desired outcomes in traditional language. Individualized Care Plan is tailored to meet the unique needs of a specific client - needs that are not addressed by the standardized plain. Inferences are the nurse's interpretation or conclusions made based on the cues (ex: nurse observes that incision is red, hot, and swollen; the nurse makes the INFERENCE that the incision is infected). Informal Nursing Care Plan is a strategy for actrion that exists in the nurse's mind. (ex: the nurse thinks "Mr. Jones is very tired, I will reinforce her teaching after she is rested." interview a planned communication or a conversation with a purpose leading question a question that influences the client to give a particular answer multidisciplinary care plan a standardized plan that outlines the care required for clients with common, predictable usually medical conditions. Such plans also referred to as collaborative care plans and critical pathways, sequence the care that must be given on each day during the projected length of stay for the specific type of condition neutral question an open-ended question that does not direct the client to answer in a certain way such as "how do you feel?" nondirective interview an interview using open-ended questons and empathetic responses to build rapport and learn client concerns norm a generally accepted measure, rule, mode, or pattern; also referred to as a standard nursing diagnosis a statement or conclusion made by the nurse about the client's health problem. The statement consists of the diagnostic label and, frequently, the etiology of the health problem. nursing intervention any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. nursing interventions classifications (NIC) A taxonomy of nursing actions each of which includes a label, a definition, and a list of activities. nursing outcomes classifications (NOC) a taxonomy for describing client outcomes that respond to nursing interventions objective data Also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and are obtained by observation or physical examination. Examples of objective data include a discoloration of the skin and a blood pressure reading. open-ended question Questions that invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. An open-ended question specifies only the broad topic to be discussed, and invites answers longer than one or two words. PES format the three essential components of nursing diagnostic statements including the terms describing the problem, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms Policies rules developed to govern the handling of frequently occurring situations priority setting The process of establishing a preferential sequence for addressing nursing diagnoses and interventions. procedures the steps used to carry out a given policy protocols predetermined and preprinted plans specifying the procedure to be followed in a particular situation qualifiers words that have been added to some NANDA labels to give additional meaning to the diagnostic statement rapport a relationship of mutual trust and understanding between two people rationale the scientific principle given as the reason for selecting a particular nursing intervention risk factors a practice, behavior, or environmental factor that has potentially negative affects on individual health or causes a pt to be vulnerable to developing a health problem risk nursing diagnosis a clinical judgment that a problem does not exist but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. signs Also referred to as objective data or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. Examples of objective data include a discoloration of the skin and blood pressure reading. standard a generally accepted measure, rule, model, or pattern; also called a norm standardized care plan A formal plan that specifies the nursing care for groups of clients with common needs (all clients with myocardial infarction) standards of care The skills and learning commonly possessed by members of a profession. The term also may be used to refer to policies or standards that describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care. standing order a written document about policies, rules, regulations, or orders regarding client care subjective data Information that is apparent only to the person affected; can be described or verified only by that person. (itching, pain, feelings, and values) May be referred to as symptoms or covert data. symptoms information that is apparent only to the person affected; can be describe or verified only by that person. (itching, pain, feelings, and values) may be referred to as subjective data or covet data syndrome diagnosis a diagnosis that is associated with a cluster of other diagnoses technical skills Purposeful "hands-on" skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. validation The act of "double-checking" or verifying data to confirm that it is accurate and factual. wellness diagnosis A term that describes human responses to levels of wellness in an individual, family, or community, that have a readiness for enhancement. For example, readiness for enhanced coping Sets with similar termsUnit 5: Nursing Process - Overview74 terms AnnRuesch The Nursing Process and Care Planning38 terms JBuchananNS The Nursing Process and Care Planning38 terms graciegurl07 Fundamentals test 250 terms BKCookie_91 Sets found in the same folderNursing unit 1113 terms acyounger Chapter 35 Medications49 terms arinvelligan Unit 13 Terms N123 Mental Heath Terms41 terms Chris_Flores44 Chapter 8: Communication and the Nurse-Patient Rel…66 terms BreeemarieeePLUS Other sets by this creatorBKAT Study157 terms Rozy_Okocha ICU BKAT65 terms Rozy_Okocha ATI children336 terms Rozy_Okocha ATI OB240 terms Rozy_Okocha Other Quizlet setsSAEM Practice547 terms akua_sandy Poe Test Study Guide35 terms braden12324 AP Gov -- Chapter 9 Test53 terms hcps-haysnk Related questionsQUESTION What are the Principles of Pain Management? 15 answers QUESTION A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client? 3 answers QUESTION What ages are more susceptible to disease? 7 answers QUESTION what is the name for excrutiating spastic-type pain? 9 answers What are the types of nursing intervention?There are typically three different categories for nursing interventions: independent, dependent and interdependent.
What are 3 interventions that the nurse can help with and initiate?While some nursing interventions are doctors' orders, nurse practitioners can also develop orders using principles of evidence-based practice.. Bedside care and assistance.. Administration of medication.. Postpartum support.. Feeding assistance.. Monitoring of vitals and recovery progress.. What is a dependent intervention?Dependent nursing interventions require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider.
What is a direct nursing intervention?A direct nursing intervention is any treatment that is performed through interaction with the client/patient. An indirect nursing intervention is an action performed away from the client/patient but on behalf of the client/patient, for example a case conference.
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What type of nursing intervention refers to activities that nurses are licensed to initiate based on knowledge and skills?
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