H. Assess Ch 1

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H. Assess Ch 1
2015-09-07 21:05:24

Health Assess. Ch 1
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  1. nursing
    the diagnosis and treatment of human responses to actual or potential health problems
  2. nursing process
    • systematic problem-solving method, 5 steps:
    • Assessment
    • Nursing diagnoses
    • Planning 
    • Implementation
    • Evaluation
  3. What does nursing process do
    • Used to identify, prevent and treat actual or potential health problems
    • promote wellness
    • provides framework to practice nursing
  4. assessment
    • process of collecting, validating and clustering data
    • first and most important step in nursing process
    • Id's pt's strengths & limits
    • used throughout process
  5. nursing diagnosis
    Id's and prioritizes actual or potential health problems or responses
  6. actual nursing diagnosis
    Id's occuring health problems in your pt
  7. potential nursing diagnosis
    identifies high-risk health problem that most likely will occur unless preventive measures are taken
  8. possible nursing diagnosis
    one that needs more data to support it
  9. collaborative problem
    a potential med complication that warrants both medical and nursing interventions
  10. kinetics
    • also called action cues
    • body movements that convey messages
  11. touch
    • a means of communication
    • can mean an array of feelings, including anger, caring, etc.
  12. cognitive skills
    skills needed for critical thinking, creative thinking and decision making
  13. critical thinking
    • a complex thinking process
    • reflective, reasonable thinking
    • asking why?
  14. reflexive thinking
    • automatic, w/o conscious deliberation
    • comes with experience
  15. intuition
    • a problem-solving method that develops through experience, in which theory and practice are intertwined
    • how the "expert" nurse solves problems
  16. interpersonal skills
    involves both verbal and nonverbal communication skills
  17. nursing assessment vs medical assessment
    • although they may be the same, the outcomes differ
    • goal of medical is to diagnose and treat disease

    goal of nursing is to diagnose and treat human responses to actual or potential health problems 
  18. what are levels of preventive healthcare
    primary, secondary, and tertiary
  19. primary preventive care
    • focuses on health promotion and guards against health problems
    • focus not only on wellness but minimize risk of health probs
  20. secondary preventive care
    • focuses on early detection, prompt intervention and health maintenance for pt w probs
    • addresses acute probs seen w inpatient hospitalization
  21. tertiary preventive care
    • deals w rehabilitative or extended care
    • pts usually have chronic illness
    • Ex: skilled nursing facility, rehabilitative hospital, long-term care unit
  22. 2 types of assessment
    comprehensive and focused
  23. subjective findings
    • referred to as symptoms
    • things the pt tells you
    • is not measurable
    • reflects on what pt is experiencing including thoughts, beliefs, feelings, sensations, and perceptions
  24. Primary data source vs secondary data source
    • primary: the pt
    • secondary: sources that are anyone or anything aside from pt, including family, physician, old medical records, etc.
    • Both can be subjective or objective
  25. therapeutic use of self
    • when you use your interpersonal skills in a healing way to help your pt
    • showing empathy, demonstrating acceptance, and giving therapeutic use of self
  26. types of interviews
    directive and nondirective interviews
  27. directive interviews
    • structured w specific questions and controlled by the nurse
    • require less time and are very effective for obtaining factual data
  28. nondirective interviews
    • controlled by pt, although the nurse often needs to summarize and clarify the data
    • require more time but very effective at eliciting the pt perceptions and feelings
    • help to identify what is important to pt
  29. closed questions
    those that often elicit a "yes" or "no" response
  30. open question
    • elicit the pt perceptions
    • more time is needed
    • frequently used in nondirective interviews
  31. observation
    • entails deliberate use of your sense of sight, smell and hearing to collect data
    • look at both the pt and their environment to detect anything out of the ordinary
  32. framework
    • provides a way of looking at your pt and the data
    • several types can be used for organizing
    • all have common thread ~ they address physical, psychosocial and spiritual needs of pt in holistic approach
  33. source-oriented documentation
    • done by department, so each healthcare group has a section to document findings
    • easily identifies each discipline but tends to fragment the data, making it difficult to follow the sequencing events
  34. POMR
    • problem oriented medical records
    • everyone involved in the care of pt charts on the same form
    • allows better communication of data to resolve the pt's problems collaboratively
  35. DAR
    • method of documentation
    • Data, Action, Response
  36. PIE
    • Problem
    • Interventions
    • Evaluation