NCM 103 AD QUIZ

• assessing

  • is the systematic and continuous collection, organization, validation and documentation of date
  • a continuous process carried out during all phases of the nursing process
• Gordons 11 functional health patterns

  • uses a series of questions which assist in formulating a nursing diagnosis
  • problem-focused assessment
  • focuses on the patients problem and develop you plan of care around the problem
• initial assessment

  • performed within specified time after admission to a healthcare agency
  • done to establish complete database for problem identification, reference and future comparison
• focused assessment

  • ongoing process integrated with nursing care
  • done to determine the status of specific problem identified in an earlier assessment
• emergency assessment

  • during any physiological or psychological crisis of the client
• time-lapsed assessment

  • several months after initial assessment
  • done to compare client's current status to baseline data previously obtained
• data collection

  • is the process of gathering information about clients health status
  • must be both systematic and continuous to prevent emission of significant date and reflect a client's changing health status
• subjective data (symptoms)

  • information perceived only the affected person
  • cannot be perceived or verified by another person
• objective data (signs)

  • observable and measurable data
  • data that can be seen, heard or felt by someone other than the person experiencing it
• primary

  • patient
• secondary

  • family members
  • significant others
  • other healthcare professionals
  • health records
  • literature
• observing - using the senses to observe client data (vision, smell, hearing, touch)
• interviewing - is a planned communication or a conversation with a purpose (focused, directive, nondirective interview)
• examining - the physical examination or physical assessment is a systematic data collection method that uses observation to detect health problems.
• organizing data - the nurse uses a written or electronic format that organizes the assessment data systematically
• validating data - the act of "double-checking" or verifying data to confirm that it is accurate and factual
• documentation of data - accurate documentation is essential and should include all data collected about client
• diagnosis - an important part of nursing practice is determining what the client needs
• health problem - a condition that necessitates intervention to prevent or resolve the disease or illness or to promote coping and wellness
• nursing diagnosis - a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes
• medical diagnosis - identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures
• NANDA

  • north american nursing diagnosis association
  • established in 1973 to identify standards and classify health problems treated by nurses
• defining characteristics - assessment data which supports the nursing diagnosis
• risk factors - clues which point to potential problems
• diagnostic label - name of the nursing diagnosis with descriptors
• related factors - included factors which contribute to the problem and are not the cause but are associated with it. THESE ARE NOT MEDICAL DIAGNOSIS
• actual nursing diagnosis - describe human response to a health problem that is being manifested. they are written as three part statements diagnostic label, related, factors, defining characteristics
• risk nursing diagnosis - as defined by NANDA, describes human responses to health conditions that may develop in a vulnerable individual, family or community. it is supported by risk factors that contribute to increased vulnerability
• wellness nursing diagnosis - is a diagnostic statement that describe the human response to levels of wellness in an individual, family, or community that have a potential enhancement to a higher state
• nurse - can only identify problems within the scope of practice
• self-actualization - recognition and realization of one's potential, growth, health and autonomy
• self esteem - sense of self worth, self respect, independence, dignity, privacy and self reliance
• love and belonging - affiliation, affection, intimacy, support and reassurance
• safety and security - safety from physiologic and psychological threat, protection, continuity, stability and lack of danger
• physiologic needs - oxygen, food, elimination, temperature control, movement, rest, and comfort
• planning three phases

  initial, ongoing, discharge
• initial planning - involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data
• ongoing planning - entails continuous updating the clients plan of care. every nurse who cares for the client is involved in ongoing planning
• discharge planning - discharge planning involves critical anticipation and planning for the clients needs after discharge
• SMART

  specific, measurable, appropriate, realistic, timely