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NUR 507

Nursing Health Assessment Ch 1

NURSING The diagnosis and treatment of human responses to actual or potential health problems.
THE NURSING PROCESS A systematic problem-solving method that have 5 steps: Assessment, Nursing Diagnosis, Planning, Implementation, and Evaluation
ASSESSMENT The process of collecting, validating, and clustering data. The first, and most important, step in the Nursing Process.
NURSING DIAGNOSIS Identifying actual or potential health problems or responses. The second step in the Nursing Process.
ACTUAL NURSING DIAGNOSIS Identifies an occurring health problem for your pt.
POTENTIAL NURSING DIAGNOSIS Identifies a high-risk health problem that most likely will occur unless preventive measures are taken.
POSSIBLE NURSING DIAGNOSIS Needs further data to support it.
COLLABORATIVE PROBLEM a potential medical complication that warrants both medial and nursing interventions.
IMPLEMENTATION (also called INTERVENTION) Involves carrying out your plan to achieve goals and outcomes.
EVALUATION Involves determining the effectiveness of your plan.
COMMUNICATION A process of sharing information and meaning, of sending and receiving messages.
NONVERBAL BEHAVIOR Includes vocal cues or paralinguistics, action cues or kinetics, object cues, personal space and touch.
VOCAL CUES Describe the quality of your voice and its inflections, tone, intensity, and speed when speaking.
ACTION CUES or KINETICS Body movements that convey messages.
PERSONAL SPACE The territory surrounding a person that she or he perceives as private or the physical distance that needs to be maintained for the person to feel comfortable.
Touch A means of communication that is often culturally prescribed and easily misconstrued.
Assessment (ANA definition) The systematic, continuous collection of data about the health status of patients.
Skills needed for assessment Cognitive, problem-solving, psychomotor, affective/interpersonal and ethical.
COGNITIVE SKILLS Needed for critical thinking, creative thinking and clinical decision making.
CRITICAL THINKING A complex thinking process, reflective, reasonable thinking; involves inquiry, interpretation , analysis and synthesis.
REFLECTIVE THINKING Automatic, without conscious deliberation and comes with experience.
Created by: nolanc