Nursing process - ANS A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.
Nursing Process Five Steps - ANS Def. Fundamental blueprint for how to care for a p...
Potter/Perry Chapter 16: Nursing
Assessment Exam Questions And
Answers
Nursing process - ANS A critical thinking process that professional nurses use to apply the
best available evidence to caregiving and promoting human functions and responses to health
and illness.
Nursing Process Five Steps - ANS Def. Fundamental blueprint for how to care for a patient.
"Standard of Practice"
1. Assessment - Collection, verification, and analysis of data.
2. Diagnose - identify the patient's problems
3. Plan- Set goals of care and desired outcomes and id appropriate nursing actions
4. Implement- perform the nursing actions id in planning
5. Evaluate- determine if goals and expected outcomes are achieved
Assessment - ANS Def. The deliberate and systematic collection of information about a
patient to determine his or her current and past health and functional status and his or her
present and past coping patterns.
Nursing Assessment includes two steps:
1. Collection of information from a primary source (the patient) and secondary sources (e.g.
family members, health professionals, and medical record)
2. The interpretation and validation of data to ensure a complete database.
Database - ANS The purpose of assessment is to establish a database about the patient's
perceived needs, health problems, and responses to these problems. In addition, the data
reveal related experiences, health practices, goals, values, and expectations about the health
care system.
Data Collection - ANS Gather information (assessment) to make an accurate judgment
about a patient's current condition.
Your information comes from:
1. The patient, through interview, observations, and physical examinations
2. Family members or significant others' reports and response to interview
3. Other members of healthcare team
4. Medical records (patient history, labs, x-ray)
5. Scientific Literature (evidence about assessment techniques and standards)
, Cue - ANS Information that a nurse obtain through the use of the senses (hearing, visual
observations, touch, and smell).
Inference - ANS Your judgment or interpretation of the cues
Example: A patient crying is a cue that possibly implies fear or sadness
Observational overview using cues and forming inferences. - ANS Male patient in bed,
looks uncomfortable. Patient presents with discomfort in surgical area.
Cues
- Lies still with arms along sides; tense
- States has not turned for some time
- Reports pain a 7 on a scale of 0 to 10
Inferences
- Pain is severe
- Pain limits patient's ability to move and reposition self
11 Functional health patterns - ANS An example of a structured database format, one
approach to perform a comprehensive assessment. Gordon's functional health patterns model
offers a holistic framework for assessment of any health problem. The health patterns are listed
below.
1. Health perception-health management pattern - ANS Describes patient's self-report of
health and well-being; how patient manages health. Example: frequency of health care provider
visits, adherence to therapies at home; knowledge of preventative health practices
2. Nutritional-metabolic pattern - ANS Describes patient's daily/weekly pattern of food and
fluid intake. Example: food preferences or restrictions, special diet, appetite; actual weight,
weight loss or gain
3. Elimination pattern - ANS Describes pattern of excretory function. Example: bowel,
bladder, and skin
4. Activity-exercise pattern - ANS Describes patterns of exercise, activity, leisure, and
recreation; ability to perform activities of daily living
5. Sleep-rest pattern - ANS Describes patterns of sleep, rest, and relaxation.
6. Cognitive-perceptual pattern - ANS Describes sensory-perceptual patterns; language
adequacy, memory, decision-making ability
7. Self-perception-self-concept pattern - ANS Describes patient's self-concept pattern and
perceptions of self. Example: self-concept/worth, emotional patterns, body image
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