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ECU Dept. of Nursing, Nursing Process 2104
Terms in this set (36)
ADPIE is the step by step clinical layout of the nursing process, it consists of?
Assessment, Diagnosis, Planning Interventions, Implementation, and Evaluating Outcomes.
What is the purpose of a nursing assessment?
To collect data relevant to delivering nursing care.
How is assessment relevant to the rest of the nursing process?
It is the foundation for the remainder of the process, it provides data needed to identify actual or potential health problems.
What are the four types of data sources?
primary, secondary, subjective, objective.
Define subjective data.
It is information gathered directly from the pt.
Define objective data.
It is information gathered through your 5 senses.
Define primary data.
Comes directly from the source.
Describe secondary information.
Data that comes form outside the source.
The comprehensive assessment is composed of 3 points, they are?
Observation, Physical Exam, and Nursing interview
During assessment what should the nurse look for when collecting data?
Discrepancies
What is Maslow's Hierarchy of needs?
non-nursing model that is holistic based used to help prioritize data collected.
The most basic need in Maslow's Hierarchy is?
Physiologic
What are the 4 common assessment techniques?
Inspection, Palpation, Percussion, Auscultation
Diagnosis is the?
Is the Analysis of assessment data to form a suitable nursing diagnosis
Nursing diagnosis focuses on?
signs and symptoms, effects of disease
A medical diagnosis focuses on the__________ of the disease.
Pathophysiology
What are the 5 types of nursing diagnoses?
Risk (potential), Actual, Possible, Wellness, and Syndrome
An actual diagnosis is/
The problem that exists
Syndrome diagnosis is a diagnosis that involves?
A series of Dx. that usually occur together
A wellness diagnosis is used when there is no present illness but, the pt. is?
Ready to move to a new level of wellness
Define Etiology.
- Cause of the Problem
What is the basic format for a diagnosis statement?
P.E.S. (Problem r/t Etiology as evidenced by S/S)
ADL's promote what for a patient?
Self-esteem, Independence, Promote increased activity
What are 4 features common to the assessment process?
collecting data, ongoing and systematic, categorization of data, recording data
Guidelines for delegation are set by what act in Oklahoma?
Oklahoma Nurse Practice Act
Define a Risk Diagnosis.
is an evaluation of a problem that could happen, also known as a potential diagnosis.
Define a Possible Diagnosis.
it is when intuition leads the nurse to suspect a problem
Diagnostic Reasoning happens in the format of?
Assessment Data, Clustering Data, Identifying Inconsistencies, Draw Conclusions
Personal hygiene is influenced by?
Personal Preference, Culture and Religion, Economic Status, Developmental level, and Knowledge
Chain of Infection is a continuous cycle, the levels include?
Infectious agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host
The most prevalent cause of accidental death in the U.S. across the lifespan is?
MVC ( motor vehicle crash)
Older adults (65+ y/o) have a higher risk for what accidental injury?
Falls
Once a patient has had a fall they are?
Automatically at risk for a fall
Safety is part of the _________ level of Maslow's Hierarchy of Needs.
Physiologic
Excoriation is?
The breakdown of tissue due to compacted fecal matter.
When excess moisture is present due to diaphoreisis or urine, it can lead to?
Maceration or breakdown of the skin
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