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Chapter 1 The Nurse’s Role in Health assessment (The Nursing Process) – Flashcards

James Hopper

7 July 2022

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The many levels in which nurses asses health

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psychosocial, physical, emotional and spiritual

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how you will use the nursing process to care for patients

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you will care for patients by assessing completely, making nursing diagnoses, developing outcomes, planning for care, performing interventions, evaluating effectiveness, and revising interventions as needed

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The role of the professional nurse (ANA)

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Nursing is the protection, promotion, and optimization of health care abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individual families, communities, and populations"

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The four main goals of nursing

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1. To promote health( state of optimal functioning or well being with physical, social, and mental components) 2. to prevent illness ( primary, secondary, and tertiary) 3.to treat human responses to health or illness 4.to advocate for individuals, families, communities, and populations

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examples of appropriate nursing interventions

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implementation of educational programs, coordination of community resources, and patient and family teaching

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Care responsibilities

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Nurses provide direct care to help restore health for ill patients in hospitals, clinics, long-term care facilities and schools. Nurses work in rehabilitation and hospice centers to facilitate the most comfortable death for patients. Nurses focus on how diseases are affecting activity levels and abilities to perform a specific task as well as how patients are coping with their health issues and any related loss of function.

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independent nursing preventions

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patient teaching, therapeutic communication, and physical procedures

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Advocacy

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nurses take responsibility to protect the legal and ethical rights of patients

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Nursing values

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respect unity Diversity Integrity excellence

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The RN

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is licensed nationally and practices independently within the scope of nursing practice and diagnosis.

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The Advanced Practice Nurse

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an RN who has achieved a bachelor's degree in nursing science ( which includes educational and clinical practice requirements as well as a masters of science degree in nursing)

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Wellness

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an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable . The role of the nurse is to facilitate this achievement through health promotion and teaching

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health

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the absence of illness

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Risk Reduction (healthy people)

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The goal of this project is to increase the length and quality of life and to eliminate health disparities among different segments of the population -the 10 leading areas of focus are :physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization and access to health care

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Primary prevention

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involves strategies aimed at preventing problems. immunizations, health teaching, safety precautions and nutrition counseling and examples

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Secondary prevention

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includes early diagnosis of health problems and prompts treatments treatment to prevent complication. Vision screening, pap smears, BP screening, hearing testing and etc are examples

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tertiary prevention

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focuses on preventing complications of an existing disease prompting health at the highest level. Diet teaching for patients with diabetes is an example

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health assessment

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is gathering information about the health status of the patient analyzing and synthesizing those data, and making judgements about nursing interventions based on findings , and evaluating patients outcomes. It includes a health history and a physical assessment. assessment includes not only physiological data, but also psychological, sociocultural , spiritual, economic and life-style factors as well.

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health history

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includes interviewing to collect patient's past medical and surgical histories, risk factors, and current symptoms. a comprehensive health history also includes nutrition, development, mental health, social, cultural, and spiritual dimensions/ safety issues

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for healthy patients

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you focus the assessment on screening for high-risk conditions( e.g. overweight) and teaching health promotion associated with common issues ( e.g. nutrition)

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The Nursing Process

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it is a systematic problem-solving approach to identifying and treating human responses to actual or potential health difficulties. It serves as a framework for providing individualized care not only to individuals but also to families and communities. It is patient centered and focuses on solving problems and enhancing strengths

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parts of the nursing process

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assessment diagnosis outcome identification planning implementation evaluation

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Assess

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Because all future care is based on the health assessment, it is extremely important that the health assessment data are complete and accurate. It is one of the most important activities of the professional nurse. the nursing process involves interrelated , sometimes overlapping steps. as you collect assessment data you simultaneously provide educational or emergency interventions. You set outcomes collaboratively with patients

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diagnosis

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clustering of data to make a judgement or statement about the patient's difficulty or condition. it provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable . they may identify actual problems, risks for developing problems, and possible difficulties , or they may be wellness oriented

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outcomes

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identification includes the formulation of measurable, realistic, patient-centered goals. goals are broader than outcomes. patient outcomes are more specific than goals; they are realistic and measurable.

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planning

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these activities include determining resources, targeting nursing interventions and writing the plan of care. the nursing care plan requires that you analyze the individual patient and his or her needs in order to provide individualized care and holistic care. you communicate the care plan verbally and also document it so that the next care provider is aware of the plan.

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implement

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you use nursing interventions to monitor health status; prevent, resolve or control a problem; assist with activities of daily living; or promote optimal health and independence . it is important to be aware of the standards of care within the agency where you work because these standards define normal activities

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types of nursing interventions

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assessment, education, supervision, coordination referral, support, therapeutic communication

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evaluation

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it is the judgement off the effectiveness of nursing care in meeting the patient's goal and outcomes based on the patient's responses to the interventions .the purpose of evaluation is to make judgements about the progress of the patient, analyze the effectiveness of nursing care, review potential areas of collaboration and referral to other health care professionals, and monitor the quality of nursing care and its effect on the patient

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to effectively evaluate

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you must have knowledge of the standards of care, expected patient response, and conceptual models and theories

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critical thinking

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1. entails purposeful, outcome-directed (result oriented) thinking 2. is driven by patient, family, and community needs 3. is based on the nursing process, evidence based thinking and the scientific method 4.requires specific knowledge skills and experience 5. is guided by professional standards and codes of ethics 6.is constantly reevaluating, self-correcting, and striving to improve * if you do not think critically you will deliver incomplete or misguided care

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diagnostic reasoning

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this process is based on critical thinking. it includes gathering and clustering data to draw inferences and propose diagnoses.

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the 7 steps of diagnostic reasoning

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1.identifying abnormal data and strengths 2. cluster data 3.draw inferences 4.propose nursing diagnoses 5. check for presence of defining characteristics 6. conform or rule out the nursing diagnosis 7.document conclusions

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collaborative problems

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those that you are monitoring that require the expertise of other health care providers and interventions

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emergency and urgent assessment

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involves a life threatening or unstable situation. Staff members at the ED use triage to determine the level or urgency by considering assessments based on the A, B, C ,D E

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A,B,C,D,E,

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A-Airway( with cervical spine protection if any injury is suspected) B- Breathing; rate, depth and use of accessory muscles] C-circulation-pulse rate and rhythm, skin color D-disability-level of consciousness, pupils, movement E-exposure

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critical interventions ( performed after life-threatening difficulties are treated.

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-provide assistance with circulation -open the patient's airways -assist the patients breathing -protect the cervical spine if the patient is injured -ensure that the disoriented and suicidal patient is safe -provide pain management and sedation

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Comprehensive Assessment

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includes a complete health history and physical assessment. It is done annually on an on patient basis, following the admission to a hospital or a long term care facility. Or every 8 hours for patients in intensive care. As part of this assessment you assess the patient's health beliefs and discuss health promotion measures

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focused assessment

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priorities depend on the gravity of the patient's health care situation. You use clinical experience, knowledge, expertise and judgement to determine priorities. Life-threatening situations or any issue that needs immediate attention are addressed first. ( ex: circulation, airway and breathing)

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frequency of assessment

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varies with the patient's needs purpose of data collection, and health care setting

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lifespan issues

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from infancy to adolescence, growth and development are marked by rapid spurts. From adolescence through 25 years of age, growth and development proceed more slowly. Motor development occurs rapidly from birth through school age following maturation of the nervous system. Language skills develop rapidly in toddlers and preschool children as vocabulary increases and sentences become more grammatically complex.

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cultural considerations

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cultural competence refers to the complex combination of knowledge, attitudes, and skills that a health care provider uses to deliver care that considers that the total context of the patients situation across cultural boundaries.

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culture

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is defined as the traits that a group of people share and pass from one generation to the next, including values, beliefs, attitudes and customs

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subjective data

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the primary source of this data is the patient. it is based on patient experiences and perceptions. the individual describes the feelings sensations or expectations.

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objective data

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are measurable forms of data

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documentation

answer

of both subjective and objective findings is essential for legal purposes and also to communicate findings to others. it provides a baseline so that changes are noted between assessments

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examples of documentation

answer

flow sheets, case notes, or care planning

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communication

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can also be verbal.

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functional assessment

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focuses on the functional patterns that all humans share; health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress violence, sexuality and reproduction and values and beliefs.

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head-to-toe assessment

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the most organized system for gathering comprehensive physical data.

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body systems assessment

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is a logical tool for organizing data when documenting and communicating findings. this method promotes critical thinking and allows you to analyze findings as you cluster similar data.

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evidence based practice

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an approach to patient care that minimizes intuition and personal experience and instead relies on research findings and high-grade scientific support.

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evidence based practice helps you solve common problems through these 4 steps

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1. clearly identify the issue or difficulties based on an accurate analysis of current nursing knowledge and practice. 2.search the literature for relevant research 3.evaluate the research evidence using established criteria regarding scientific merit 4.choose interventions and justify the selection with the most valid evidence

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question

The many levels in which nurses asses health

answer

psychosocial, physical, emotional and spiritual

question

how you will use the nursing process to care for patients

answer

question

The role of the professional nurse (ANA)

answer

question

The four main goals of nursing

answer

question

examples of appropriate nursing interventions

answer

implementation of educational programs, coordination of community resources, and patient and family teaching

question

Care responsibilities

answer

question

independent nursing preventions

answer

patient teaching, therapeutic communication, and physical procedures

question

Advocacy

answer

nurses take responsibility to protect the legal and ethical rights of patients

question

Nursing values

answer

respect unity Diversity Integrity excellence

question

The RN

answer

is licensed nationally and practices independently within the scope of nursing practice and diagnosis.

question

The Advanced Practice Nurse

answer

an RN who has achieved a bachelor's degree in nursing science ( which includes educational and clinical practice requirements as well as a masters of science degree in nursing)

question

Wellness

answer

question

health

answer

the absence of illness

question

Risk Reduction (healthy people)

answer

question

Primary prevention

answer

involves strategies aimed at preventing problems. immunizations, health teaching, safety precautions and nutrition counseling and examples

question

Secondary prevention

answer

includes early diagnosis of health problems and prompts treatments treatment to prevent complication. Vision screening, pap smears, BP screening, hearing testing and etc are examples

question

tertiary prevention

answer

focuses on preventing complications of an existing disease prompting health at the highest level. Diet teaching for patients with diabetes is an example

question

health assessment

answer

question

health history

answer

question

for healthy patients

answer

you focus the assessment on screening for high-risk conditions( e.g. overweight) and teaching health promotion associated with common issues ( e.g. nutrition)

question

The Nursing Process

answer

question

parts of the nursing process

answer

assessment diagnosis outcome identification planning implementation evaluation

question

Assess

answer

question

diagnosis

answer

question

outcomes

answer

question

planning

answer

question

implement

answer

question

types of nursing interventions

answer

assessment, education, supervision, coordination referral, support, therapeutic communication

question

evaluation

answer

question

to effectively evaluate

answer

you must have knowledge of the standards of care, expected patient response, and conceptual models and theories

question

critical thinking

answer

question

diagnostic reasoning

answer

this process is based on critical thinking. it includes gathering and clustering data to draw inferences and propose diagnoses.

question

the 7 steps of diagnostic reasoning

answer

question

collaborative problems

answer

those that you are monitoring that require the expertise of other health care providers and interventions

question

emergency and urgent assessment

answer

involves a life threatening or unstable situation. Staff members at the ED use triage to determine the level or urgency by considering assessments based on the A, B, C ,D E

question

A,B,C,D,E,

answer

question

critical interventions ( performed after life-threatening difficulties are treated.

answer

question

Comprehensive Assessment

answer

question

focused assessment

answer

question

frequency of assessment

answer

varies with the patient's needs purpose of data collection, and health care setting

question

lifespan issues

answer

question

cultural considerations

answer

question

culture

answer

is defined as the traits that a group of people share and pass from one generation to the next, including values, beliefs, attitudes and customs

question

subjective data

answer

the primary source of this data is the patient. it is based on patient experiences and perceptions. the individual describes the feelings sensations or expectations.

question

objective data

answer

are measurable forms of data

question

documentation

answer

of both subjective and objective findings is essential for legal purposes and also to communicate findings to others. it provides a baseline so that changes are noted between assessments

question

examples of documentation

answer

flow sheets, case notes, or care planning

question

communication

answer

can also be verbal.

question

functional assessment

answer

question

head-to-toe assessment

answer

the most organized system for gathering comprehensive physical data.

question

body systems assessment

answer

is a logical tool for organizing data when documenting and communicating findings. this method promotes critical thinking and allows you to analyze findings as you cluster similar data.

question

evidence based practice

answer

an approach to patient care that minimizes intuition and personal experience and instead relies on research findings and high-grade scientific support.

question

evidence based practice helps you solve common problems through these 4 steps

answer

Chapter 1 The Nurse’s Role in Health assessment (The Nursing Process) – Flashcards

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