NUR 3130 - Foundations Final. Study Guide (Detailed).

NUR 3130 - Foundations Final. Study Guide (Detailed). The Nursing Process Explain each component of the nursing process  Assessment: systematic and continuous collection, analysis, validation, and communication of patient data, or information o Collecting patient information is a vital step in the nursing process because the remaining steps depend on purposeful, prioritized, complete, systematic, accurate, and relevant data o Results in baseline data that enable the nurse to:  Make a judgment about the individual’s health status  Plan and deliver thoughtful, person-centered care  Refer patient to physician o The nurse will interview the patient to receive the most accurate information o To promote clinical reasoning, your nursing assessments should have the following characteristics:  Purposeful  Prioritized  Complete  Systematic  Factual and accurate  Relevant  Recorded in a standard manner o Types of nursing assessments:  Initial assessment: performed shortly after the patient is admitted to a health care agency or service. The purpose of this is to establish a complete database for problem identification and care planning  Focused assessment: gathers information about a specific problem that has already been identified  Can be done during the initial assessment  Quick priority assessments: short, focused, prioritized assessments  Emergency assessment: physiologic or psychological crisis to find life-threatening problems  Time-Lapsed assessment: scheduled to compare a patient’s current status to the baseline data obtained earlier o When establishing assessment priorities, it is important to take inconsideration the health orientations (health risks, habits, behaviors, beliefs, attitudes, and values that influence wellness), developmental stage, culture, and need for nursing o Subjective data: information perceived only by the affected person o Objective data: observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them o Sources of data:  Patient: primary and best source of information  Family or significant other: helpful sources of data when the patient is a child or has limited capacity to share information with the nurse  Patient record: prepared by different members of the health care team provide information for nursing care  Assessment technology: ex cardiac and respiratory monitors  Other health care professionals  Nursing and other health care literature: patient database o Methods of collecting data:  Examination  Observation  Physical and emotional  Determine patient’s current ability to manage care  Determines immediate environment and its safety  Determines the larger environment ex: hospital or community  Interview  Focus on the patient during the interview  Listen to patient attentively  Ask about patient’s main problem first  Pose questions and comments in appropriate manner  Avoid comments and questions that impede communication  Use silence and touch appropriately o In an interview be sure to understand the below:  Open ended- allow patient to verbalize freely  Closed- elicit specific information  Validating- validate what is heard  Clarifying- avert misconceptions  Reflective- encourage patient to elaborate on thoughts and feelings  Sequencing- place events in chronological order  Directing- obtain more patient information o Documenting data  Immediately give verbal reporting of data whenever critical change in the patient’s health status is assessed  Enter initial database into computer or record in ink on designated forms the same day patient is admitted  Summarize objective and subjective data in concise comprehensive, and easily retrievable manner  Use good grammar and standard medical abbreviations  Whenever possible, use patient’s own words  Avoid nonspecific terms subject to individual interpretation or definition