Unit 2 Exam

cognitive-perceptual pattern

Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability

Sources of Diagnostic Errors in Interpreting/Analyzing Data

- Inaccurate interpretation of cues - Failure to consider conflicting cues - Using an insufficient number of cues - Using unreliable or invalid cues - Failure to consider cultural influences or developmental stage

Sources of Error in Clustering Data

- Insufficient cluster of cues - Premature or early closure - Incorrect clustering

Sources of Diagnostic Errors in Collecting Data

- Lack of knowledge or skill - Inaccurate data - Missing data - Disorganization

Errors in Labeling Data

- Wrong diagnostic label selected - Evidence that another diagnosis is more likely - Condition a collaborative problem - Failure to validate nursing diagnosis with patient - Failure to seek guidance

The nursing diagnosis readiness for enhanced communication is an example of a(n): A) Risk nursing diagnosis. B) Actual nursing diagnosis. C) Health promotion nursing diagnosis D) Wellness nursing diagnosis.

Correct Answer(s): C A patient's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient's motivation and desire to strengthen his health.

identify problem, collect data, formulate hypothesis, test hypothesis, evaluate results

5 steps of scientific method

probing

A __ question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements.

health perception-health management pattern

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?

problem-focused

A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment?

basic critical thinking

A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is:

analyticity and self-confidence

A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show?

problem-focused approach and using multiple visits to gather a complete database

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in what assessment approaches at this time?

evaluation

A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of:

conducting reflective practice

A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are:

is anything else bothering you?

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. What response by the nurse is an example of probing?

health perception-health management pattern

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess?

Nursing Diagnosis Format (example)

AT RISK OF ________ (ex INJURY), RELATED TO ___________ (ex DIZZINESS), AS EVIDENCED BY ____________ (ex HISTORY OF PREVIOUS FALLS). - use of BOTH subjective and objective data help to form nursing diagnosis.

validation

Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan.

critical thinking

Active, purposeful, organized, cognitive process used to carefully examine one's thinking and the thinking of other individuals.

complex

Analyzing and examining choices and weighing benefits and risks are characteristic of __ critical thinking

commitment

Anticipating when to make choices during decision making is unique to the __ level of critical thinking

concept map

Care-planning tool that assists in critical thinking and forming associations between a patient's nursing diagnoses and interventions.

scientific method

Codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas.

Sources of Diagnostic Errors

Collecting data, data clustering, labeling data, interpreting/analyzing data

clinical decision making for groups of patients

Considering how to involve patients in decisions and how to combine nursing activities to be more organized and allow for resolving more than one problem at a time are examples of:

The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format.

Correct Answer(s): P, acute pain; E, related to incisional trauma; S, evidenced by pain reported at 7, with guarding, and restricted turning and positioning. The PES format stands for: P (problem), E (etiology or related factor), and S (symptoms or defining characteristics).

Match the activity on the left with the source of diagnostic error on the right: Activity a. Nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. b. After reviewing objective data, nurse selects diagnosis of fear before asking patient to discuss feelings. c. Nurse identifies incorrect diagnostic label. d. Nurse does not consider patient's cultural background when reviewing cues. e. Nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern. Source of Diagnostic Error __ 1. Collecting data __ 2. Interpreting __ 3. Clustering __ 4. Labeling

Correct Answer(s): 1 a, 2 b and d, 3 e, 4 c. Choice a is an example of lack of skill, an error in collecting data. Choice b is an example of using an insufficient number of cues, an error in interpretation. Choice c is an example of not accurately identifying the problem, a labeling error. Choice d is an example of not incorporating cultural information into the diagnostic process, an error in interpretation. Choice e is an example of incorrect clustering, a clustering error.

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. _____ 1. Considers context of patient's health problem and selects a related factor _____ 2. Reviews assessment data, noting objective and subjective clinical criteria _____ 3. Clusters clinical criteria that form a pattern _____ 4. Chooses diagnostic label

Correct Answer(s): 2, 3, 4, 1

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which additional data do you collect to add to the cluster of information?

Correct Answer(s): The best way to understand the answer to this question is to have a list of NANDA-I nursing diagnoses and their defining characteristics. For example, the nursing diagnosis of constipation is a possible choice. Examples of additional defining characteristics for which the nurse might assess include checking the quality of bowel sounds, palpating the abdomen for a possible mass, observing the character of any stool that is passed, asking the patient if she is passing flatus.

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A) Risk for aspiration B) Acute confusion C) Readiness for enhanced coping D) Sedentary lifestyle

Correct Answer(s): A A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) A) Acute pain related to lumbar disk repair B) Sleep deprivation related to difficulty falling asleep C) Constipation related to inadequate intake of liquids D) Potential nausea related to nasogastric tube insertion

Correct Answer(s): A, B, D Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such as "excess noise in environment." Potential nausea related to nasogastric tube insertion uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A) Anxiety related to fear of dying B) Fatigue related to chronic emphysema C) Need for mouth care related to inflamed mucosa D) Risk for infection

Correct Answer(s): A, D The diagnosis "Anxiety related to fear of dying" is stated correctly, with the related factor being the patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing diagnosis.

Which of the following are examples of collaborative problems? (Select all that apply.) A) Nausea B) Hemorrhage C) Wound infection D) Fear

Correct Answer(s): B, C Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient's status. Nausea and fear are both NANDA-I approved nursing diagnoses.

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.) A) Daughter's concern of mother's risk for injury B) Pacing C) Patient getting lost easily D) Daughter working part time E) Getting up frequently

Correct Answer(s): B, C, E Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering.

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.) A) Vital sign results B) Abdominal distention C) Age of patient D) Change in bowel elimination pattern E) Abdominal pain F) No past history of hospitalization

Correct Answer(s): B, D, E The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.

sleep-rest pattern

Describes patterns of sleep, rest, and relaxation

value-belief pattern

Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient's choices or decision

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: A) Need for improved bowel function related to change in diet. B) Patient needs improved bowel function related to alteration in elimination. C) Constipation related to inadequate fluid intake. D) Constipation related to hard infrequent stools.

Correct Answer(s): C Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign.

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A) Data collection. B) Data clustering. C) Data interpretation. D) Making a diagnostic statement.

Correct Answer(s): C In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A) The nurse who listens to lung sounds after a patient reports "difficulty breathing" B) The nurse who considers conflicting cues in deciding which diagnostic label to choose C) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D) The nurse who identifies a diagnosis on the basis of a single defining characteristic

Correct Answer(s): C, D When the nurse assesses edema without knowing how to assess the severity, the nurse fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the patient reports "difficulty breathing" the nurse validates findings to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis.

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A) Identifying the clinical sign instead of an etiology. B) Identifying a diagnosis based on prejudicial judgment. C) Identifying the diagnostic study rather than a problem caused by the diagnostic study. D) Identifying the medical diagnosis instead of the patient's response to the diagnosis.

Correct Answer(s): D In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.

nursing health history

Data collected about a patient's present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

coping-stress tolerance pattern

Describes patient's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance

nutritional-metabolic pattern

Describes patient's daily/weekly pattern of food and fluid intake (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain.

role-relationship pattern

Describes patient's patterns of role engagements and relationships

sexuality-reproductive pattern

Describes patient's patterns of satisfaction and dissatisfaction with sexuality pattern; patient's reproductive patterns; premenopausal and postmenopausal problems

self-perception-self-concept pattern

Describes patient's self-concept pattern and perceptions of self (e.g., self-concept/worth, emotional patterns, body image)

health perception-health management pattern

Describes patient's self-report of health and well-being; how patient manages health (e.g., frequency of health care provider visits, adherence to therapies at home); knowledge of preventive health practices

elimination pattern

Describes patterns of excretory function (bowel, bladder, and skin)

activity-exercise pattern

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

concomitant symptoms

Does the patient experience other symptoms along with the primary symptom? For example, does nausea accompany pain?

nurse

During the interview who is responsible for directing the flow of the discussion so your patient has the opportunity to freely contribute stories about his or her health problems to enable you to get as much detailed information as possible?

diagnostic conclusion

EX. Turn a pt, notice a redden area on the coccyx (tailbone), press it, redden color does not go away, form a __ that the pt has a pressure ulcer.

complex critical thinking

EX: Pt refusing to take medication, trouble shooting an IV pump, caring for a pt how leaves the room al the time.

basic critical thinking

Ex: Hygiene/Creating a Sterile Field - follow return demonstration step by step - DO NOT DEVIATE. Once have more experience - may change procedure slightly to individualize patient care. Clean to Dirty

assessment

First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.

closed-ended questions

Form of question that limits a respondent's answer to one or two words.

open-ended questions

Form of question that prompts a respondent to answer in more than one or two words.

functional health patterns

Gordon's model =

subjective data

Information gathered from patient statements; the patient's feelings and perceptions. Not verifiable by another except by inference.

cue

Information that a nurse acquires through hearing, visual observations, touch, and smell.

objective data

Information that can be observed by others; free of feelings, perceptions, prejudices.

inference

Judgment or interpretation of informational cues

evidence-based knowledge

Knowledge that is derived from the integration of best research, clinical expertise, and patient values.

functional health patterns

Method for organizing assessment data based on the level of patient function in specific areas (e.g., mobility).

problem solving

Methodical, systematic approach to explore conditions and develop solutions, including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem.

clinical decision making

Problem-solving approach that nurses use to define patient problems and select appropriate treatment.

decision making

Process involving critical appraisal of information that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion. Comes at the end of critical thinking

reflection

Process of thinking back or recalling an event to discover the meaning and purpose of that event. Useful in critical thinking.

diagnostic reasoning

Process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking.

decision making

Product of critical thinking that focuses on problem resolution. Does not have to be a problem.

Clinical Criterion

either an objective or subjective sign, symptom, or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion.

database

Store or bank of information, especially in a form that can be processed by computer.

nursing process

Systematic problem-solving method by which nurses individualize care for each patient. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

knowledge application

The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is:

collecting the assessment

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview?

problem solving

The nurse collects information and tries options until she is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the patient's IV and not on solving the patient's health problem; thus this is an example of __.

probing

encourage a full description without trying to control the direction the story takes. This requires you to probe with further open-ended statements such as, "Is there anything else you can tell me?" or "What else is bothering you?"

concomitant symptom

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is a __

stereotyping influenced her assessment

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest?

integrity

The nurse reviews the position of requiring exercises to restore function and decides to try a different approach to proceed, which is an example of:

inference

your judgement or interpretation of the cues you just gathered (a conclusion)

diagnostic reasoning

The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:

consistent

The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?

patient-directed eye gaze

This allows the nurse or patient who is speaking to check whether information is understood. It is a signal for readiness to initiate interaction with a patient. Eye contact shows that you are interested in what the other person is saying.

affirmative head nodding

This has an important social function. It helps to regulate an interaction (especially when alternate people speak), supports spoken language, and allows for comment on the interaction concerning the rapport and content of the communication.

forward leaning

This shows awareness, attention, and immediacy. During an interaction it also clearly suggests interest in that person.

close-ended

This type of questioning helps you acquire specific information about health problems such as symptoms, precipitating factors, or relief measures.

consistent

Use of the same pain scale for assessing pain acuity is an example of being

precipitating factors

What makes symptoms worse? Are there activities (e.g., exercise) that affect the symptoms?

active listening, back channeling, open-ended questions

What technique(s) best encourage(s) a patient to tell his or her full story?

closed-ended and problem oriented questioning

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?"

problem solving

While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:

Nursing Diagnosis

a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. **what makes it unique is having patients involved in the process (if/when possible)**

Health Promotion Diagnosis

a clinical judgment of a person's, family's or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. - can be used in any health state, do not require current levels of wellness. ex: readiness for enhanced family coping, readiness for enhanced nutrition

Related Factor

a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis; needed to individualize and formulate a nursing diagnosis.

reflective practice

a conscious process of thinking, analyzing, and learning from previous work situations.

Data Cluster

a set of signs or symptoms gathered during assessment that you group together in a logical way. ex: nurse reports symptoms of: "patient wincing when incision palpated," "patient acknowledges discomfort over incision," "patient rates discomfort at 7 on scale of 0 to 10," "pain increases with movement." Analyzing data: pattern of a comfort problem.

concept map

a visual representation that allows nurses to graphically illustrate the connections between a client's health problems

Types of Nursing Diagnoses (3)

actual diagnoses, risk diagnoses, and health promotion diagnoses

concept map

allows nurses to obtain a holistic perspective of health care needs

Collaborative Problem

an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status.

interview

an organized conversation with the patient

complex critical thinking

analyzes and examines choices independently. Students learn to think beyond and synthesize knowledge

analyticity

analyzing information, gathering additional findings, and sensing a problem

problem-oriented approach

approach for conducting a comprehensive assessment where you focus on the patient's presenting situation and being with problematic areas such as incisional pain or limited understanding of postoperative recovery

Defining characteristics

found within data clusters; patterns of data that contain the clinical criteria that are observable and verifiable.

full name

if it is the first time you have met the patient, you should greet him/her using his/her __

back channeling

includes active listening prompts such as "all right," "go on," or "uh-huh." These indicate that you have heard what the patient says and are interested in hearing the full story. Encourages a patient to give more details.

drawing conclusions

inference

cue

information that you collect through the use of your senses. Ex. pain

data cluster

is a set of signs or symptoms that you group together in a logical way

review of systems (ROS)

is a systematic approach for collecting the patient's self-reported data on all body system

patient centered interview

is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness. It is the basis of a conceptual model used by nurse practitioners to form long-term therapeutic relationships with patients

smiling

is positive and considered as a sign of good humor, warmth, and immediacy. It is most important when first establishing the nurse-patient relationship.

physical examination

observation of patient behavior, diagnostic and lab data, interpreting assessment data and making nurse judgments

objective data

observations or measurements a health care provider obtains. Inspection of a wound, description of an observable behavior. Vital signs, etc

gordon's functional health patterns model

offers a holistic framework for assessment of any health problem

subjective data

patient's verbal descriptions of their own health problems, provided by the patient. Includes feelings, perceptions, self-report of symptoms

patient

primary source of assessment info

bedside rounds

promote patient centered care.

Etiology

related factor of a nursing diagnosis; always within the domain of nursing practice and a condition that responds to nursing interventions.

family members, hc professionals, medical record

secondary source of assessment info

set the stage, set an agenda, collect assessment, terminate the interview

steps of an interview

data documentation

the last part of a complete assessment

Diagnostic Label

the name of the nursing diagnosis as approved by NANDA International; describes the essence of a patient's response to health conditions in as few words as possible.

commitment

the third level of critical thinking. Students (soon to be future nurses) anticipate needs and make choices without assistance from others. You choose an action or belief based on the alternatives.

basic critical thinking

think concretely and on the basis of a set of rules or principles. Follow step-by-step process without deviation. Trust expert has the right answers.

basic

thinking concretely is __ critical thinking

Gordon's Typology and Problem Oriented

two ways to complete assessment:

Actual Diagnosis

type of nursing diagnosis; describes human responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics support the diagnostic judgement. ex. wandering, impaired social interaction, stress urinary incontinence.

Risk Diagnosis

type of nursing diagnosis; describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. - do NOT have related factors or defining characteristics because they have not occurred yet; instead they have risk factors. ex.: risk for lonliness, risk for acute confusion

open-ended

when collecting the assessment, always open with __ questions

as soon as you receive info about a patient

when does Diagnostic reasoning & inference begin?

diagnostic reasoning process

when you are trying to solve the patient's health problem, you use the __