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HA - MODULE 1
| Question | Answer |
|---|---|
| It is a systematic, rational method of planning and providing individualized nursing care. | Nursing process |
| What are the main purposes of the nursing process? | To identify a client’s health care status and actual or potential health problems To establish plans to meet identified needs To deliver specific nursing interventions to address those needs |
| Why is the nursing process described as cyclical? | Because care may be terminated if goals are achieved, or the process may continue with reassessment or modification of the care plan. |
| What are the five phases of the nursing process (ADPIE)? | A – Assessment D – Diagnosis P – Planning I – Implementation E – Evaluation |
| This phase is about Collecting, organizing, validating, and documenting client data To establish a database about the client’s response to health concerns or illness and their ability to manage health care needs. | Assessment phase |
| • Collecting data • Organizing data • Validating data • Documenting data These are the major activities of? | Assessment phase |
| This phase is about analyzing and synthesizing data To identify client strengths and health problems that can be prevented or resolved through independent and collaborative nursing interventions. | Diagnosis phase |
| • Analyzing and interpreting data • Comparing data against standards • Clustering data • Identifying gaps and inconsistencies • Formulating nursing diagnoses • Documenting diagnoses in the care plan These are the major activities of? | Diagnosis phase |
| About determining how to prevent or resolve the identified priority client problems; how to support client strengths To develop an individualized nursing care plan that specifies client goals, desired outcomes, and appropriate nursing interventions. | Planning phase |
| • Setting priorities • Writing goals and desired outcomes • Selecting nursing interventions • Consulting other health professionals • Writing and communicating the care plan These are the major activities of? | Planning phase |
| This phase is about carrying out and documenting the planned nursing interventions To assist the client in achieving desired outcomes, promote wellness, prevent illness, restore health, and facilitate coping with altered functioning. | Implementation phase |
| • Reassessing the client • Determining need for assistance • Performing nursing interventions • Supervising delegated care • Documenting nursing actions and client responses These are the major activities of? | Implementation phase |
| Measuring the degree to which goals have been achieved and identifying factors that positively or negatively influence goal achievement To determine whether to continue, modify, or terminate the nursing care plan based on goal achievement. | Evaluation phase? |
| What activities are included in evaluation? | • Collecting outcome-related data • Comparing outcomes with goals • Judging goal achievement • Modifying or terminating the care plan • Documenting results |
| What are the nurse’s roles in health assessment? | Preparing for examination Collecting subjective and objective data Validating data Documentation Communication Making informed judgments |
| Information obtained from the client interview, including biographic data, health concerns, health history, family history, and patterns of functioning. Based on what an individual reports or feels. | Subjective data |
| Information obtained through observation and physical examination, including positioning and physical exam techniques such as IPPA. Based on evidence that anyone can verify. | Objective data |
| What is IPPA? | Inspection Palpation Percussion Auscultation |
| This technique is your sense of sight to observe the body for color, shape, movement, symmetry, lesions, or other visual cues. | Inspection technique |
| This technique is the touch (finger pads are most sensitive) to feel for texture, temperature, vibration, size, consistency, location, and tenderness of body parts like masses or organs. | Palpation technique |
| This technique is about tapping on the body surface to create vibrations and sounds, helping assess underlying organs and cavities | Percussion technique |
| This technique is used by listening to body sounds, typically with a stethoscope, for heart, lung, bowel, and blood flow sounds. | Auscultation technique |
| Why is data validation important? | To ensure accuracy and reliability of information and to avoid errors in clinical judgment. |
| What are the purposes of documentation? | • Communication among healthcare team • Legal documentation • Clinical judgment support • Evidence for future research |
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