Health Assessment - NUR 2092 Exam 1 (Muskus)
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What are the 6 steps of the nursing process? 1. Assessment 2. Diagnosis 3. Outcome 4. Planning 5. Implementation 6. Evaluation Assessment Definition (nursing process) 1. Collect data 2. Use... evidence-based assessment techniques 3. Document relevant data Diagnosis Definition (nursing process) 1. Compare clinical findings with normal and abnormal variation and developmental events 2. Interpret data-- make & test hypotheses 3. Validate diagnoses 4. Document diagnoses Outcome Identification Definition (nursing process) 1. Identify expected outcomes 2. Individualize to the person 3. Culturally appropriate 4. Realistic and measurable 5. Include a timeline Planning Definition (nursing process) 1. ESTABLISH PRIORITIES 2. Develop Outcomes 3. Set timelines for outcomes 4. IDENTIFY interventions 5. Integrate evidence-based trends and research 6. Document plan of care Implementation Definition (nursing process) 1. Implement in a safe and timely manner 2. Use evidence-based interventions 3. Collaborate with colleagues 4. Use community resources 5. Coordinate care delivery 6. Provide health teaching and health promotion 7. Document implementation and any modifications. Evaluation Definition (nursing process) 1. Progress toward outcomes 2. Conduct systematic, ongoing, criterion-based evaluation. 3. Include patient and significant others 4. Use ongoing assessment to revise diagnoses, outcomes, and plan 5. Distribute results to patient and family Acute pain 1. Is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. 2. Self-protective purpose; it warns the individual of actual or threatened tissue damage. Chronic Pain 1. Over 6 months in duration 2. Adaptive responses Phantom pain 1. Pain where limb used to exist Malignant pain Vs nonmalignant pain 1. Malignant pain is cancer-related and is caused by tumor cells that cause necrosis or stretching. 2. Nonmalignant pain is often associated with musculoskeletal conditions. Visceral pain Originates from internal organs. Somatic pain and deep somatic pain 1. Somatic pain originates from musculoskeletal tissues or the body surface 2. Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone. Referred pain Pain that is felt at a particular site but originates from another location. Nociceptive pain 1. Develops when functioning and intact nerve fibers in CNS are stimulated. 2. They are triggered by events outside nervous system from actual or potential tissue damage. 3. Nociception can be divided into four phases: (1) Transduction: (2) Transmission: the pain impulse moves from the level of the spinal cord to the brain. (3) Perception: signifies the conscious awareness of a painful sensation (4) Modulation: a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus Neuropathic pain 1. Pain caused by a lesion or disease of the somatosensory nervous system. 2. This implies an abnormal processing of pain message from an INJURY to the NERVE FIBERS. 3. This pain is very difficult to treat and assess. Subjective Data Pain is always subjective. What the patient is complaining of; SYMPTOM Objective data What the nurse observes; SIGN [Show More]
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