NUR 310-Med Surg 1 Mid term
Medical Diagnosis ️identifying a disease, condition or injury from its signs and symptoms
Nursing Diagnosis ️used to evaluate the response of the whole person to actual or potential health
problems
Nursing Definition ️care provided to a person as they respo...
NUR 310-Med Surg 1 Mid term
Medical Diagnosis ✔️identifying a disease, condition or injury from its signs and symptoms
Nursing Diagnosis ✔️used to evaluate the response of the whole person to actual or potential health
problems
Nursing Definition ✔️care provided to a person as they respond to alterations in health
The Nursing Process ✔️five-step systematic method for giving patient care:
involves assessing, diagnosing, planning, implementing, and evaluating
Assessment ✔️Gather information about the patient
Diagnosis ✔️identify the patient's problem
Planning ✔️set goals of care and desired outcomes and identify appropriate nursing actions
Implementation ✔️To perform or carry out nursing measures in the care plan
Evaluation ✔️determine if goals and expected outcomes are achieved
Two stages of assessment ✔️-Collection of information from a primary source (a patient) and
secondary sources
-The interpretation and validation of data to determine whether more data are needed or the database
is complete.
Types of assessments ✔️-Patient-centered interview (conducted during a nursing history)
-Periodic assessments (conducted during ongoing contact with patients)
, -Physical examination (conducted during a nursing history and at any time a patient presents a
symptom)
Subjective data ✔️-Patients' verbal descriptions of their health problems
-Includes patient feelings, perceptions, and self-reported symptoms
-Also known as "symptom"
Objective data ✔️-Findings resulting from direct observation
-When you collect objective data, apply critical thinking intellectual standards so that you can correctly
interpret your findings.
-Also known as "sign"
Effective Communication ✔️Foundation for creating nurse-patient relationships
Phases of the interview ✔️-Orientation and setting an agenda
-Working phase: collecting data
-Termination phase
Nursing Health History ✔️-Key component of a comprehensive assessment
-Covers all health dimensions: Physical, developmental, intellectual, spiritual, emotional, social
Cultural competence ✔️Involves self-awareness, reflective practice, and knowledge of a patient's core
cultural background
Cultural humility ✔️Requires you to recognize your own knowledge limitations and cultural perspective
and thus be open to new perspectives
Concept mapping ✔️Placing all of the cues together into the clusters that form patterns leads you to
the next step of the nursing process, nursing diagnosis
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