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Nursing Process1
Nursing Process
| Question | Answer |
|---|---|
| Purpose of the nursing process | to collect subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment |
| The 5 parts of the nursing process | Assessment, Diagnosis, Planning, Implementing, Evaluation (ADPIE) |
| Assessment frameworks offer | a systematic approach to identifying patterns of functioning and they are organized tools developed to enable the systematic collection of data. |
| Types of Assessments (4) | Initial comprehensive, Ongoing or partial assessment, focused or problem-oriented and emergency assessment |
| Subjective data is.. | what the client states, how the client sees themselves in relation to their health, how it affects them, their family and community. This includes past and present family history. |
| COLDSPA stands for.. | C-Character (Describe symptoms) O-Onset (When did it start?) L-Location (Where?) D-Duration (How long does it last?) S-Severity (How bad is it?) Pain scale P-Pattern (What makes it worse or better?) Does it radiate? A-Associated symptoms |
| Nonverbal communication involves | appearance, posture, facial expressions, attitude |
| Subjective data includes | Biographic data, reasons for seeking health care, history of present health concern, past health history, family health history, review of body systems for current problems, lifestyle practices, developmental level. |
| Health History includes | Immunizations and vaccinations, genogram, demographics, allergies, OTC meds,and COLDSPA |
| The 5th vital sign is | Pain |
| Types of pain | Acute (sudden), Chronic (long lasting, over 6 mo's) Cancer pain, Radiating pain |
| A visual analog pain scale could be used for patients who | had a stroke and cannot talk |
| Types of pain scales | Wong Baker Pain scale (faces), Visual Analog scale, Verbal Descriptor scale (mild, moderate, severe), Numeric (0-10) |
| Inspection of pain | Posture, facial expression, Vital sign changes |
| Normal Heart rate for an adult is | 60-100 bpm |
| Normal respirations for an adult is | 12-20 breaths/min |
| Normal blood pressure for an adult is | 120/80 |
| Objective data is | what you observe, physical, body functions, appearance, behavior, measurements, results of tests, reviewing previous documentation of health history |
| Physical exam techniques for all body parts except for the abdomen in order are | Inspection, Palpation, Percussion Auscultation. |
| Physical exam technique for the abdomen in order is | Inspection, Auscultation, Palpation, percussion |
| Example of validating data is | You ask the client questions related to skin questions and the same time you are inspecting the skin. |
| From collected subjective and objective data you formulate a care plan, implement and evaluate your actions. The areas of the care plan include (4) | Strengths, weakness, risks, and areas of promotion |
| If you don't document then... | you didn't do it |
| Analysis of data formulate a | Nursing Diagnosis |
| In some Middle Eastern African cultures, self infliction of pain is a sign of | mourning or grief |
| This assessment involves collection of subjective data about the client's perception of her health of all body parts or systems, past health hx, family hx, and lifestyle and health practices as well as objective data gathered during a physical exam | Initial comprehensive assessment |
| This assessment consists of data colletion that occurs after the comprehensive database is established. It consists of a mini-overview of the client's body systems, any problems are reassessed to determine any major changes from the baseline | Ongoing or partial assessment |
| This assessment is very rapid and performed in life threatening situations | Emergency assessment |
| What are the major steps in the assessment phase (4) | collection of subjective data, collection of objective data, validation of data, and documentation of data. |
| Before actually meeting the client you should | Review the medical record, know the biographical data, educate yourself about the client's diagnosis, reflect on your own feelings regarding your initial encounter with the client to avoid biases, and gather equipment necessary |
| This assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem | Focused or problem-oriented assessment |
| The four types of nursing diagnoses | Wellness, Risk, Actual, Collaborative problems and referrals |
| For a wellness nursing diagnosis, it is best to use the following format | Readiness to enhanced + diagnostic label+ related to (r/t) + etiology + as manifested by (AMB) + symptoms |
| For a risk nursing diagnosis, it is best to use the following format | Risk for + Diagnostic label + related to + etiology Ex: Risk for + Infection + related to + presence of dirty knife wound, leukopenia, and lack of client knowledge of how adequately to care for the wound. |
| For a actual nursing diagnosis, it is best to use the following format | NANDA label (for problem) + r/t + etiology + AMB + defining characteristics. Ex: Fatigue r/t an increase in job demands and personal stress AMB client's statements of feeling exhausted all of the time and inability to perform usual work & home responsib |
Created by:
Jmariez
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