What are the 4 goals of the American Nurses Association (ANA)?
- 1. promote health
- 2. prevent illness
- 3. treat human responses to health or illness
- 4. advocate for individuals, families, communities, and populations
Each states ______ and ______ form the legal framework for practice.
- Nursing Practice Act
- Standards of Nursing Practice
What are the roles performed by the nurse that relate to legal accountability?
- 1. provider of direct and indirect care
- 2. forensic specialist
- 3. expert witness
- 4. reporting responsibilites related to cases of abuse, rape, and sexual assault
The nurse has a _____ obligation to take action to protect a client's privacy and confidentiality.
The concept of privacy includes:
- right to be left alone
- give or refuse consent for treatment
- control of how personal information is shared
What are the 4 areas of legal risk with regards to maintaining a client's safety in practice?
- failure to monitor client's status
- medication errors
- use of restraints
Entails purposeful, outcome-directed (result oriented) thinking
What is critical thinking driven by? Based on? Guided by?
- driven by patient, family, and community needs
- based on nursing process, scientific method, evidence-based thinking
- guided by professional standards and codes of ethics
What are the 5 steps of the nursing process?
- 1. assessment
- 2. nursing diagnosis/analysis
- 3. planning
- 4. implementation
- 5. evaluation
_____ functional health patterns is a _____ approach to human functional assessment.
How many functional health patterns does Gordon assess and what do these pattern's look at?
- self-care ability
- ability to perform ADL's
- skills needed for independent living
- social relationships, self-concept, & coping
- home environment
What are Gordon's 11 functional health patterns?
- health perception/management
- self perceptions/concept
______ is the process of reviewing a situation for the purpose of identifying the client's needs or problems
Assessment is a _______ process of gathering, verifying, and communicating data about a client's health status
The nursing process begins with what?
a complete and accurate health assessment
What are the components of a health assessment?
- health history
- physical examination
What kind of data is taken from a health history vs a physical examination?
- health history-subjective data that a client or family member tells you
- physical examination-objective data that is observable and measurable
What is a therapeutic dialogue?
used to enhance the subjective data we receive from a patient during a health history
What are the types of assessment data bases?
What is a comprehensive assessment and when is it taken? What does it provide?
- complete health history and physical examination
- provides baseline data to measure future changes
Whar is a focused assessment?
- based on patient issues
- usually contains only one problem, one cure complex, or one body system
What is an emergency assessment abd what does it involve?
- life-threatening or unstable situation
- rapid assessment of: general appearance (color, skin perfusion, level of activity, level of consciousness, position of comfort), ABC's (airway/aeration/aggitation, breathing sounds/respiratory rate, circulation/color/capillary refill), pulses (central, peripheral), vital signs
What are Erikson's stages of psychosocial development?
- infancy: trust v. mistrust
- toddler: autonomy v. shame & doubt
- early childhood: initiative v. guilt
- early school years: industry v. inferiority
- adolescence: identity v. role confusion
- early adulthood: intimacy v. isolation
- middle-age: generativity v. stagnation
- elderly: integrity v. despair
According to Erikson, which stage of psychosocial development is a person that requests assistance, shares time, and expresses belief in another person?
According to Erikson, which stage of psychosocial development is a person that refuses to provide information and is unable to accept assistance?
According to Erikson, which stage of psychosocial development is a person that expresses one's own opinion?
According to Erikson, which stage of psychosocial development is a person that fails to express their needs and is over-concerned about being clean?
toddler: shame & doubt
According to Erikson, which stage of psychosocial development is a person that expresses curiosity and demostrates original thoughts?
early childhood: initiative
According to Erikson, which stage of psychosocial development is a person that imitates others and is fearful of starting new projects.
early childhood: guilt
According to Erikson, which stage of psychosocial development is a person that completes a task, works well with others, and uses their time effecively?
early school years: industry
According to Erikson, which stage of psychosocial development is a person that does not complete tasks, not organized, and does not like to work with others?
early school years: inferiority
According to Erikson, which stage of psychosocial development is a person that independent and plans for the future?
According to Erikson, which stage of psychosocial development is a person that fails to set goals for the future.
adolescence: role confusion
According to Erikson, which stage of psychosocial development is a person that establishes a close, intense relationship with another person.
early adulthood: intimacy
According to Erikson, which stage of psychosocial development is a person that avoids close interpersonal relationships.
early adulthood: isolation
According to Erikson, which stage of psychosocial development is a person that guids others and is willing to share with another person?
middle age: generativity
According to Erikson, which stage of psychosocial development is a person that worries about their own needs and ignores the needs of others.
According to Erikson, which stage of psychosocial development is a person that uses past experiences to assit others and accepts their limitations.
According to Erikson, which stage of psychosocial development is a person that does not accept change very well and demands unnecessary assistance and attention.
What is a follow-up/ongoing assessment?
follow-up on a specific problem such as someone with a chronic problem, pregnant, receiving their test results, after surgery, pediatrics
What did Erikson integrate into the assessment?
- age and physical development
- psychosocial development
- cognitive development
- behavioral development
- cultural and environmental considerations
What did Erikson focus on and how many stages did he describe? What is each stage characterized by?
- focused on societal and cultural influences as determinants of behavior
- growth of the "ego"
- described 8 stages of ego development to encompass the lifespan
- each stage is characterized by a distinct conflict that can result in either negative or positive resolution
Why should we consider a patient's cultural and environmental backgrounds?
- cultural factors influence the beliefs of patients about thier health status
- illnesses that are more common among groups of patients
- patient's environment might include safety in the home, transportation issues, or community involvement
- exposure history
What are psychosocial and lifestyle factors that we should consider when taking a health history?
- social, cultural, and spiritual assessment
- mental health
- human violence
- sexual history and orientation
What is a primary v. a seconday data source?
- secondary-charts & family members
What considerations should you give to the setting when collecting a health history?
- comfort (temperature, avoid interruptions)
______ provides information that is consistent with existing records and comprehensive in scope
_____ provides information that differs from past descriptions or changes details each visit.
What are the components of a health history?
- demographical data
- reason for seeking care
- history of present illness (symptom analysis, pain (scale 0-10)
- past health history (current medications, allergies, family history)
- functional health assessment (Gordon)
- growth and development
- review of systems
What is involved in a symptom analysis?
- onset, location, duration, character, associated or aggrivating factors, relieving factors, timing, severity
- provocative/palliative, quality, region, severity, timing, understanding patients perception
_____ is a series of questions about all the body systems that helps to reveal concerns/problems as part of a comprehensive health assessment
review of systems (ROS)
What systems are involved in the review of systems during a health assessment?
- general health status
- nutrition & hydration
- skin, hair, nails
- head & neck (eyes, ears, nose, mouth, throat)
- thorax & lungs
- heart & neck vessels
- peripheral vascular
- male and femal genitalia
- anus, rectum, prostate
- endocrine & hematologic systems
- teaching opportunity/health promotion