NURS 3320 Exam – Accurate Answers To All
Questions
Save
Terms in this set (489)
Pay attention to detail Professional Compassion
What makes a good nurse? Patience Strong assessment skills- most critical Client
teaching abilities
American Nurses Association (ANA) defines nursing as:
"the protection, promotion, and optimization of health
and abilities, prevention of illness and injury, alleviation
of suffering through the diagnosis and treatment of
Definition of Nursing
human responses and advocacy in the care of
individuals, families, communities and populations." Must
have accurate client assessments in order to make
decisions
American Nurses Association (ANA, 2010) Assessment is
Health Assessment in
collection by the RN of comprehensive data pertinent
Nursing
to the patient's health or situation.
Collects data in a systematic manner, prioritizes data
Nursing: Scope and collection; involves the patient and family Uses
Standards of Practice: The evidence-based assessment techniques Synthesizes
RN data and documents findings Derives diagnoses based
on assessment data
Factors Affecting Health The client's Culture Family Community where they live
Assessment Spirituality
"The comprehensive assessment is the first step, and
lays the foundation for the nursing process.....is the initial
Texas BON and Assessment
and ongoing, extensive collection, analysis and
interpretation of data."
"The RN must anticipate
and recognize changes in
patient conditions and
determines when
reassessments are needed."
, RNs perform comprehensive nursing assessments and
synthesize data to formulate the plan of care.
Scope of Practice for RNs
http://www.bon.texas.gov/practice/p dfs/scope-of-
practice.pdf
Migrated from acute setting to the community Critical
pathways/care maps to guide the plan of care
Advanced practice nurses roles developed; nurse
practitioners and Clinical Nurse specialists Assess
Evolution in Health
populations of clients across the continuum of health
Assessment
Play a role in technology, online data retrieval and
documentation Acuity is increasing; nurses perform
physiologic and psychosocial assessments while
integrating technological data
Nurses must perform focused assessments and develop
related nursing diagnoses Work with multidisciplinary
team Ambulatory care nurses assess/screen clients to
Rapidly Evolving Roles determine the need for physician referrals Home health
nurses make independent nursing dx and referrals
Public health nurses, school nurses and hospice nurses
assess the needs of patients in their setting
PURPOSE- collect holistic subjective & objective data to
Focus of Health
determine a client's overall level of functioning in order
Assessment
to make a professional clinical judgment (nursing
PURPOSE
diagnosis)
Physical medical Focuses primarily on the client's physiologic status
assessment
Assessment: Collecting subjective and objective data
Diagnosis: Analyzing subjective and objective data to
make a professional nursing judgment (nursing
Nursing Process & diagnosis, collaborative problem, or referral) Planning:
Assessment - ADPIE Determining outcome criteria and developing a plan
Implementation: Carrying out the plan Evaluation:
Assessing whether outcome criteria have been met and
revising the plan as necessary
, Evaluation involves examining ALL the previous steps,
but focuses on achieving desired outcomes. •
Nursing Process • Each step
Assessment and evaluation goes in BOTH directions,
depends on the accuracy
ONGOING processes. • If outcomes not as anticipated,
of the preceding step
nurses reassess steps, collect new data, and formulate
adjustments to the plan of care.
History of Present Health Concern (chief complaint)
Framework for Health
Personal Health History Family History Lifestyle and
Assessment in Nursing
Health Practices
Many models to analyze We will focus on Healthy People 2020 developed by
health promotion and the DHHS to increase lifespan and improve quality of
disease prevention life
Collection of subjective data about the client's
Initial comprehensive perception of health of all body parts or systems, past
assessment medical history, family history, and lifestyle and health
practices.(admission to facility)
Ongoing or partial Data collection that occurs after the comprehensive
assessment: database is established.(reassessment, shift assessment)
: assessment of a particular client problem, which does
Focused/problem-oriented
not cover areas not related to the problem.(pain
assessment:
assessment)
Very rapid assessment performed in life-threatening
Emergency assessment:
situations.( rapid response, chest pain, ABC)
Collection of subjective data Collection of objective
data Validation of assessment data for accuracy
Steps of Health Assessment
Documentation of data which forms the database for
communication with the health team
Gives info- educational level, occupation Background-
chronic diseases, ADLs (activities of daily living), current
Preparing for the
health status Educate yourself about diagnoses, tests
Assessment Review the
Avoid premature judgments Chronic diseases,
client's record FIRST
drug/alcohol use, lifestyle Gather supplies for
assessment
Biographical information History of present health
concern Physical symptoms related to each body part
Collection of Subjective
or system Feelings, perceptions, preferences, beliefs
Data
Personal health history Family history Health and
lifestyle practices
, Physical characteristics (skin color, posture) Body
Collection of Objective functions (vital signs) Appearance Behavior
Data Measurements Results of laboratory or diagnostic
testing
Elicited & verified by the client in interview Obtained
from client record/or health professionals Skills:
Subjective
effective communication, empathy, good listener "I have
a headache"
Measurement (direct/ indirect) from nurse or others
Observations, physical assessment findings of nurse or
Objective
other provider Skills: inspection, palpation, percussion,
auscultation VS, irregular pulse, x- ray
Serves to ensure that the assessment process is not
ended before ALL relevant data have been collected
Validation and Helps prevent documentation of inaccurate data
Documentation of Data Documentation forms the database for the nursing
process and provides data for all other members of the
health team Validation & documentation (See Ch. 4)
Identify abnormal data and strengths. Cluster the data.
Draw inferences and identify problems. Propose
Analysis: Step 2 of Nursing
possible nursing diagnoses. Check for defining
Process
characteristics of those diagnoses. Confirm or rule out
nursing diagnoses. Document conclusions.
• Includes: •
Symptoms/feeling/perception/desire/preferenc
SUBJECTIVE DATA e/ideas/beliefs/ values • Personal information- obtained
in interview • Elicited and verified by the client • Provide
clues to various problems and risk for problems
• Need to obtain a valid nursing health history(hx) •
Establish rapport, trusting relationship • Gather info on
INTERVIEWING physiologic, psychological, sociocultural, spiritual status
• Phases of the interview • Introductory • Working •
Summary and closing
Pre-intro phase: Review health record • Explaining the
purpose of the interview • Assuring the client
INTRODUCTORY PHASE confidentiality (HIPAA) • Making sure client is
comfortable and has privacy • Develop trust & rapport
with verbal/nonverbal skills
Questions
Save
Terms in this set (489)
Pay attention to detail Professional Compassion
What makes a good nurse? Patience Strong assessment skills- most critical Client
teaching abilities
American Nurses Association (ANA) defines nursing as:
"the protection, promotion, and optimization of health
and abilities, prevention of illness and injury, alleviation
of suffering through the diagnosis and treatment of
Definition of Nursing
human responses and advocacy in the care of
individuals, families, communities and populations." Must
have accurate client assessments in order to make
decisions
American Nurses Association (ANA, 2010) Assessment is
Health Assessment in
collection by the RN of comprehensive data pertinent
Nursing
to the patient's health or situation.
Collects data in a systematic manner, prioritizes data
Nursing: Scope and collection; involves the patient and family Uses
Standards of Practice: The evidence-based assessment techniques Synthesizes
RN data and documents findings Derives diagnoses based
on assessment data
Factors Affecting Health The client's Culture Family Community where they live
Assessment Spirituality
"The comprehensive assessment is the first step, and
lays the foundation for the nursing process.....is the initial
Texas BON and Assessment
and ongoing, extensive collection, analysis and
interpretation of data."
"The RN must anticipate
and recognize changes in
patient conditions and
determines when
reassessments are needed."
, RNs perform comprehensive nursing assessments and
synthesize data to formulate the plan of care.
Scope of Practice for RNs
http://www.bon.texas.gov/practice/p dfs/scope-of-
practice.pdf
Migrated from acute setting to the community Critical
pathways/care maps to guide the plan of care
Advanced practice nurses roles developed; nurse
practitioners and Clinical Nurse specialists Assess
Evolution in Health
populations of clients across the continuum of health
Assessment
Play a role in technology, online data retrieval and
documentation Acuity is increasing; nurses perform
physiologic and psychosocial assessments while
integrating technological data
Nurses must perform focused assessments and develop
related nursing diagnoses Work with multidisciplinary
team Ambulatory care nurses assess/screen clients to
Rapidly Evolving Roles determine the need for physician referrals Home health
nurses make independent nursing dx and referrals
Public health nurses, school nurses and hospice nurses
assess the needs of patients in their setting
PURPOSE- collect holistic subjective & objective data to
Focus of Health
determine a client's overall level of functioning in order
Assessment
to make a professional clinical judgment (nursing
PURPOSE
diagnosis)
Physical medical Focuses primarily on the client's physiologic status
assessment
Assessment: Collecting subjective and objective data
Diagnosis: Analyzing subjective and objective data to
make a professional nursing judgment (nursing
Nursing Process & diagnosis, collaborative problem, or referral) Planning:
Assessment - ADPIE Determining outcome criteria and developing a plan
Implementation: Carrying out the plan Evaluation:
Assessing whether outcome criteria have been met and
revising the plan as necessary
, Evaluation involves examining ALL the previous steps,
but focuses on achieving desired outcomes. •
Nursing Process • Each step
Assessment and evaluation goes in BOTH directions,
depends on the accuracy
ONGOING processes. • If outcomes not as anticipated,
of the preceding step
nurses reassess steps, collect new data, and formulate
adjustments to the plan of care.
History of Present Health Concern (chief complaint)
Framework for Health
Personal Health History Family History Lifestyle and
Assessment in Nursing
Health Practices
Many models to analyze We will focus on Healthy People 2020 developed by
health promotion and the DHHS to increase lifespan and improve quality of
disease prevention life
Collection of subjective data about the client's
Initial comprehensive perception of health of all body parts or systems, past
assessment medical history, family history, and lifestyle and health
practices.(admission to facility)
Ongoing or partial Data collection that occurs after the comprehensive
assessment: database is established.(reassessment, shift assessment)
: assessment of a particular client problem, which does
Focused/problem-oriented
not cover areas not related to the problem.(pain
assessment:
assessment)
Very rapid assessment performed in life-threatening
Emergency assessment:
situations.( rapid response, chest pain, ABC)
Collection of subjective data Collection of objective
data Validation of assessment data for accuracy
Steps of Health Assessment
Documentation of data which forms the database for
communication with the health team
Gives info- educational level, occupation Background-
chronic diseases, ADLs (activities of daily living), current
Preparing for the
health status Educate yourself about diagnoses, tests
Assessment Review the
Avoid premature judgments Chronic diseases,
client's record FIRST
drug/alcohol use, lifestyle Gather supplies for
assessment
Biographical information History of present health
concern Physical symptoms related to each body part
Collection of Subjective
or system Feelings, perceptions, preferences, beliefs
Data
Personal health history Family history Health and
lifestyle practices
, Physical characteristics (skin color, posture) Body
Collection of Objective functions (vital signs) Appearance Behavior
Data Measurements Results of laboratory or diagnostic
testing
Elicited & verified by the client in interview Obtained
from client record/or health professionals Skills:
Subjective
effective communication, empathy, good listener "I have
a headache"
Measurement (direct/ indirect) from nurse or others
Observations, physical assessment findings of nurse or
Objective
other provider Skills: inspection, palpation, percussion,
auscultation VS, irregular pulse, x- ray
Serves to ensure that the assessment process is not
ended before ALL relevant data have been collected
Validation and Helps prevent documentation of inaccurate data
Documentation of Data Documentation forms the database for the nursing
process and provides data for all other members of the
health team Validation & documentation (See Ch. 4)
Identify abnormal data and strengths. Cluster the data.
Draw inferences and identify problems. Propose
Analysis: Step 2 of Nursing
possible nursing diagnoses. Check for defining
Process
characteristics of those diagnoses. Confirm or rule out
nursing diagnoses. Document conclusions.
• Includes: •
Symptoms/feeling/perception/desire/preferenc
SUBJECTIVE DATA e/ideas/beliefs/ values • Personal information- obtained
in interview • Elicited and verified by the client • Provide
clues to various problems and risk for problems
• Need to obtain a valid nursing health history(hx) •
Establish rapport, trusting relationship • Gather info on
INTERVIEWING physiologic, psychological, sociocultural, spiritual status
• Phases of the interview • Introductory • Working •
Summary and closing
Pre-intro phase: Review health record • Explaining the
purpose of the interview • Assuring the client
INTRODUCTORY PHASE confidentiality (HIPAA) • Making sure client is
comfortable and has privacy • Develop trust & rapport
with verbal/nonverbal skills
