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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
- Distinguishing relevant from irrelevant data
- Distinguishing important from unimportant data
- Validating data
- Organizing data
- Recognizing assumptions
- Identifying gaps in the data
4 Types of Assessments
-
Initial Assessment
- Problem-Focused Assessment
- Emergency Assessment
- Time-Lapsed Reassessment
Initial (baseline) Assessment
- Performed within specific time frame after admission to a health agency (refer to agency policy and procedure)
- Purpose is to establish a complete baseline for problem identification, reference, and future comparison.
- An example would be a nursing admission
assessment
Problem-Focused (System Specific) Assessment
- Ongoing process integrated with nursing care
- Purpose is to determine the status of a specific problem identified in an earlier assessment.
- Hourly assessments of client's fluid intake and urinary output in an intensive care unit (ICU). Assessment of a client's ability to perform self-care while assisting a client to bathe.
Emergency Assessment
- During any physiologic or psychologic crisis.
- To identify life-threatening problems.
- To identify new or overlooked problems.
- Rapid assessment of a person's airway, breathing status, and circulation during a cardiac arrest. Assessment of suicidal tendencies or potential for violence.
Ongoing Reassessment
-
Several months after initial assessment.
- To compare the client's current status to baseline data previously obtained.
- Reassessment of a client's functional health patterns in a home care or outpatient setting or, in a hospital, at shift change.
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?"
"Are you having any pain now? Show me where it is."
"When did you fall?"
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:
- dangle for 5 minutes 12h post op.
- stand at bedside 24h post op; observe for pallor, dizziness, and weakness.
- check pulse before and after ambulating. Do
not progress if pulse is > 110.
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:
- the clients progress toward achievement of goals/outcomes.
- the effectiveness of the nursing care plan.
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.
example: Goal met - oral intake 300mL more than output; skin turgor resilient; mucous membranes moist.
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
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