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higher than normal respiration; over 20
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1 Nursing Process 2 Physical assessment techniques
3 Implementation 4 Tachypnea
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Terms in this set (65)
Nursing Process ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment First step of nursing process, involves critical thinking skills,
data collection (subjective and objective)
Diagnosis Identification of an injury or disease
Planning where goals and outcomes are formulated that directly impact
patient care
Implementation action or doing the actual carrying out of nursing
interventions outlines in plane of care
, Evaluation Final step, reassess to ensure the desired outcome has been
met
Clinical Judgment Recognizing cues, analyzing cues, prioritizing hypothesis,
general solutions, take action, evaluate outcomes
SMART goals Specific, measurable, achievable, relevant, time-bound
Health History a collection of subjective information that provides
information about the patient's health status
Functional assessment activities of daily living, memory and cognition, psychosocial
and behavioral issues, functional health (e.g., vision, hearing,
communication), and health status
General survey vital signs, pain, inclusive approaches to health assessment
Anthropometric measurements height, weight, head circumference, body mass index (BMI),
body circumferences to assess for adiposity (waist, hip, and
limbs), and skinfold thickness
Physical assessment techniques
prioritization ABCs, Maslow's hierarchy of needs, urgent/non-urgent,
actue/chronic
undernutrition nsufficient intake of energy and nutrients to meet an
individual's needs to maintain good health
therapeutic communication open ended questions, empathy, eye contact, active listening,
clarification
nutritional assessment Evaluation of a patient's nutritional status
Definition of health a state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity
Levels of health prevention primary: intervene before health effects occur
secondary: screenings to identify disease or illness
tertiary: managing disease
Critical thinking solving problems of patients and decision-making process
with creativity to enhance the effect
clinical judgment refers to the result (outcome) of critical thinking or clinical
reasoning; the conclusion, decision, or opinion a nurse makes
intuitive thinking going with one's first instinct and reaching decisions quickly
based on automatic cognitive processes
Definition of pain an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms
of such damage
Physiology of pain activity in sympathetic nerves, peripheral branching of primary
afferent nociceptors, convergence projection, and
convergence facilitation