Exam 1 - AMSN 7016C

Exam 1 - AMSN 7016C What is the nursing process? - >>>>1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation Assessment - >>>>this is the data-gathering stage, where you obtain information from man ...

Exam 1 - AMSN 7016C What is the nursing process? - >>>>1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation Assessment - >>>>this is the data-gathering stage, where you obtain information from many sources. purpose is to gather data which is used to draw conclusions about the patient's health status Diagnosis - >>>>- after analyzing the assessment data, synthesizing and clustering information, and hypothesizing about the patient's health status, you identify the patient's health needs and state this in the form of a problem - nursing diagnosis's reflect the patient's response to actual or potential health problems and are different from medical diagnoses Planning (outcomes and interventions) - >>>>this step can be divided into 2 phases - working with the patient to decide upon goals for your care. these are the patient outcomes you want to achieve through your nursing activities. - you develop a list of individualized interventions that will assist the patient in meeting the stated goals. the best interventions are evidenced-based (supported by research) Implementation - >>>>action phase - you implement or delegate the interventions that you planned in step 3. in this phase, you msust document your actions and the patients response to them Evaluation - >>>>determine whether the desired outcomes have been achieved and also whether your outcomes have successfully treated or prevented the patients health problems. if the outcome was not achieved, you need to determined "why" and modify the plan of care (for example - add a new intervention) characteristics of the nursing process - >>>>systematic, dynamic, interpersonal, outcome oriented, universally applicable systemic - >>>>part of an ordered sequence of activities dynamic - >>>>great interaction and overlapping among the 5 steps interpersonal - >>>>human being is always at the heart of nursing outcome oriented - >>>>nurses and patients work together to identify outcomes universally applicable - >>>>a framework for all nursing activities What are the sources of data collection? - >>>>subjective and objective data subjective data - >>>>- what the patient (or family member, neighbor, etc.) says - pertinent diagnostic indicators from verbal reports of individual or family - record quotes when applicable - check for consistency with objective data - resolve in congruencies or inconsistencies objective data - >>>>- what the health professional observes - lab data, vital signs, test results - medical record - pertinent diagnostic indicators from direct observation and examination of individual and family, observations of context or milieu, and observational reports of other care providers types of health assessment - >>>>1. complete - initial, comprehensive 2. episodic - problem oriented 3. interval or follow up - changes from baseline 4. emergency - ABC's communication goals - >>>>- discover information that leads to the nursing diagnosis and plan of care - provide the patient with information regarding the diagnosis - negotiate with the patient regarding healthcare management - counsel about disease prevention non-directive interviewing - >>>>use to build rapport, promote communication or help the patient express feelings open ended questions - specify topic to be explored but patient must elaborate directive interviewing - >>>>use to obtain factual, easily categorized information or in an emergency setting closed questions - yes, no questions other communication techniques - >>>>facilitation - encourage to say more silence - provide patient with time to think and organize thoughts reflection - repeating part of what the person just said and can help expressing feelings behind a person's words empathy - recognize a feeling and put into words; helps the patient to feel accepted and deal with the feeling openly clarification - use this when the patient's word choice is ambiguous or confusing communication techniques (frame of reference shifts from patient's perspective to yours) - >>>>confrontation - you have observed a certain action, feeling or statement and you focus the person's attention to it interpretation - based on your inference or conclusion. helps the person understand his/her own feelings in relation to the verbal message explanation - inform, sharing factual and objective information summary - final review of what you understand the person has said; condenses facts and presents your perception of the health problem or need interviewing tips - >>>>do not want: false reassurance, giving unwanted advice, using authority, avoidance language, distancing, professional jargon, leading questions, talking too much, interrupting, why? the most important question... - >>>>is there anything else? summary - >>>>final statement of what you and the patient agree the health state to be should include... - positive health aspects - any identified health problems - plans for action - explanation of the upcoming PE always thank your patient for their time and cooperation critical characteristics - COLD SPA - >>>>C = character or quality (ask patient questions and describe what is wrong - ex. cough - explain if dry, etc.) O = onset (when did it begin) L = location (where? deep in the throat, etc.) D = duration (how long does it last) S = severity of symptoms (on a scale of 1-10 how severe is it?) P = pattern (2 parts -> what makes it better/what makes it worse) A = associated factors/how it affects the client (affecting their ability of daily living) gravida - >>>>number of pregnancies para - >>>>number of births abortions - >>>>Number of terminated pregnancies, spontaneous or induced (includes miscarriages) family history assessment - >>>>specifically ask about: genetic disorders, heart disease, high BP, blood disorders, cancer, sickle-cell anemia, seizure disorder, arthritis, allergies, obesity, alcoholism, mental illness, kidney disease, TB physical assessment - >>>>utilizes special techniques to gather objective data about the patient's body (get baseline information) Nursing assessments focus on... - >>>>1. client's functional ability 2. physical response to illness and other stressors purpose of physical assessment - >>>>1. obtain baseline data 2. identifying nursing diagnosis 3. monitor the status of previously identified problems 4. screen for health problems prepare to perform a physical assessment - >>>>1. develop a systemic approach to physical assessment 2. prepare yourself 3. prepare the environment 4. prepare the patient Marjory Gordon - >>>>created the 11 functional health patterns What are the 11 functional health patterns? - >>>>1. Health perception - Health Management 2. Activity - Exercise 3. Nutritional - Metabolic 4. Elimination 5. Sleep - Rest 6. Cognitive - Perceptual 7. Self-Perception - Self-Concept 8. Coping - Stress Tolerance 9. Sexuality - Reproductive 10. Role - Relationship 11. Value - Belief 1. Health Perception - Health Management - >>>>how does client mage health? health values and beliefs visit with health care provider? 2. Activity - Exercise - >>>>typical day ADL's. IADL's leisure activities exercise pattern 3. Nutritional - Metabolic - >>>>24 hour recall appetite who buys/prepares food? adequate finances? skin problems 4. Elimination - >>>>bowel/bladder habits 5. Sleep - Rest - >>>>sleep patterns, aids, naps 6. Cognitive - Perceptual - >>>>hearing or visual problems changes in memory how do you learn? pain or discomfort 7. Self-Perception - Self-Concept - >>>>describe yourself how do you feel about yourself/body? education financial status - adequate income for lifestyle/health 8. Coping - Stress Tolerance - >>>>describe life stresses changes in past year use of alcohol, tobacco, caffeine or recreational drugs stress relief - helpful? 9. Sexuality - Reproductive - >>>>any problems with your sexuality? if sexually active - practice safe sex? use of birth control? 10. Role - Relationship - >>>>who lives with you? do you have friends? other responsibilities? type of work engaged in 11. Value - Belief - >>>>religious practices values perception of personal strengths physical assessment skills - >>>>1. inspection 2. palpation 3. percussion 4. auscultation 5. olfaction inspection - >>>>observe with eyes and nose throughout the structured interview and the physical examination palpation - >>>>use hands and fingers to touch - light and deep examine texture, size, consistency, masses, fluid and crepitus percussion - >>>>striking one object against another, producing vibration and sound waves which are heard as "percussion tones" or resonance tone is determined by the density auscultation - >>>>direct auscultation - listening without instrument indirect auscultation - listening for sounds inaudible to the unassisted ear stethoscope bell - low-pitched sounds stethoscope diaphragm - high-pitched sounds (heart, lungs and bowel sounds) General Survey - >>>>overall impression of the patient - objective data physical - age, race, gender, ethnicity, level of consciousness body structure - height, weight, symmetry, posture, physical deformities, hearing or visual problems mobility behavior - facial expressions and speech mood/affect - cooperative, pleasant? dress - appropriate to climate? hygiene - cleanliness, grooming 4 realms of orientation - >>>>1. person 2. place 3. time 4. situation (what brings them here) vital signs - >>>>take in this order: (TPR) 1. temperature 2. pulse 3. respirations 4. blood pressure General Survey example - >>>>"78 year old AAM in NAD, A&0. Ambulates easily without assist. Sitting upright with good posture. Appears younger than chronological age; speech/expression congruent. Maintained eye contact throughout interview. Pleasant and cooperative; groomed/dressed appropriate to weather and situation" Documentation of Data from the Assessment - >>>>S.O.A.P. subjective data objective data assessment - functional health patterns, nursing diagnosis plan What are the 5 vital signs? - >>>>1. temperature 2. pulse 3. respiration 4. blood pressure 5. pain When do you assess vital signs? - >>>>- upon admission to any healthcare agency - at the beginning of the shift for inpatients - based on agency institutional policy and procedures - anytime there is a change in the patient's condition - before, during and after surgical or invasive diagnostic procedures - before and after activity that may increase risk - before administering medications that affect ca