Assessing Flashcards
A systematic, rational method of planning and providing individualized nursing care
Nursing Process
PURPOSES OF NURSING PROCESS
- Identify a client’s (1) __________ and actual or potential healthcare problems
- Establish plans to meet identified (2) ___________
- Deliver specific (3) ____________
(1) health status
(2) needs
(3) nursing interventions
Collecting, organizing, validating, and documenting data
Assessing
Analyzing and synthesizing data
Diagnosing
Determining how to prevent, reduce, or resolved identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner
Planning
Carrying out or delegating and documenting the planned nursing interventions
Implementing
Measuring the degree to which goals or outcomes have been achieved and identifying factors that postively or negatively influence goal achievement
Evaluating
To establish a database about the client’s responses to health concerns or illness and the ability to manage healthcare needs
Assessing
To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions
Diagnosing
To develop an individualized care plan that specifies client goals or desired outcomes and related nursing interventions
Planning
To assist the client to meet desired goals or outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning
Implementing
To determine whether to continue, modify, or terminate the plan of care
Evaluating
The nursing process is __________. The nurse organizes the plan of care according to client problems rather than nursing goals
client centered
The nursing process is an adaptation of __________ and __________ theory.
problem solving / systems
Is involved in every phase of the nursing process
Decision-making
The nursing process is __________ and __________. It requires the nurse to communicate directly and consistenly with clients and families to meet their needs.
interpersonal and collaborative
The _____________ characteristic of the nursing process means that it can be used as a framework for nursing care in all types of healthcare settings.
universally applicable
Nurses must utilize __________ throughout the delivery of nursing care. By reflecting, the nurse determines whether the outcome of care was appropriate
clinical reasoning
Assessing is the systematic and continuous:
C - __________
O - __________
V - __________
D - __________ of data
Collection
Organization
Validation
Documentation
Nursing assessments focus on a client’s ___________. It should include, the client’s perceived needs, health problems, related experience, health practices, values, and lifestyle.
responses to a health problem
Is the process of gathering information about a client’s health status
Data Collection
Contains all the information about a client
Database
TRUE OR FALSE:
The database of a patient includes the following:
- Nursing health history
- Physical assessment
- Primary care provider’s history and physical examination
- Results of laboratory and diagnostic tests
- Material contributed by relatives
FALSE
It should include MATERIAL CONTRIBUTED BY OTHER HEALTH PERSONNEL
Performed within specified time after admission to a healthcare agency
Initial assessment
Ongoing process integrated with nursing care
Problem-focused assessment
During any physiologic or psychologic crisis of the client
Emergency assessment
Several months after initial assessment
Time-lapsed reassessment
To establish a complete database for problem identification, reference, and future comparison
Initial assessment
To determine the status of a specific problem identified in an earlier assessment
Problem-focused assessment
To identify life-threatening problems and new or overlooked problems
Emergency assessment
To compare the client’s current status to baseline data previously obtained
Time-lapsed reassessment
Nursing admission assessment
Initial assessment
Hourly assessment of client’s fluid intake and urinary output in an intensive care unit (ICU)
Problem-focused assessment
Assessment of client’s ability to perform self-care while assissting a client to bathe
Problem-focused assessment
Rapid assessment of an individual’s ABCs during a cardiac arrest
Emergency assessment
Assessment of suicidal tendencies or potential or violence
Emergency assessment
Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change
Time-lapsed reassessment
Client’s name, address, age, sex, marital status, occupation, religious preference, healthcare financing, and usual source of medical care
Biographic Data
“What is troubling you?”
“Describe the reason you came to the hospital or clinic today.”
Chief Complaint
Illness
Immunizations
Allergies
Accidents
Hospitalizations
Medications
Past History
To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current state of health, or, if they are deceased, the cause of death, are obtained
Family History of Illness
Personal Habits
Diet
Sleep patterns
Activities
Instrumental ADLs
Recreation
Lifestyle
Family relationships and friendships
Ethnic affiliation
Educational history
Occupational history
Economic status
Home and neighborhood conditions
Social Data
Major stressors
Usual coping pattern
Communication style
Psychologic Data
All healthcare resources the client is currently using and has used in the past
Patterns of Healthcare
Symptoms or covert data that are apparent only to the individual affected and can be described or verified only by that individual
Subjective Data
Signs or overt data that are detectable by an observer or can be measured or tested against an accepted standard
Objective Data
The best source of data is usually the __________, unless they are too ill, young, or confused to communicate clearly
client
Family members, friends, and caregivers who know the client well often can supplement or verify information provided by the client
Support People
Are especially important source of data for a client who is very young, unconscious, or confused.
Support People
To gather data by using the senses
Observing
Planned communication, or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy
Interview
In a __________, the nurse asks the client specific questions to collect information related to the client’s problem. This allows for collection of information previously missed and yields more in-depth information
Focused Interview
- Is highly structured and elicits specific information
- Nurse established and controls the interview
- Clients have limited opportunity to ask questions or discuss concerns
- Used when time is limited
Directive Interview
- Rapport-building interview
- The nurse allows the client to control the purpose, subject matter, and pacing
Nondirective Interview
Is an understanding between two or more people
Rapport
A combination of __________ and __________ approaches is usually appropriate during the information-gathering interview
directive and nondirective
- Used in the directive interview
- Restrictive and generally require only “yes” or “no” or short factual answers
Closed Questions
- Associated with the nondirective interview
- Invites clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings
- Specifies only the broad topic to be discussed
Open-ended Questions
“What medication did you take?”
“Are you having pain now?”
“How old are you?”
“When did you fall?”
Closed Questions
“How have you been feeling lately?”
“What brought you to the hospital?”
“What would you like to talk about today?”
Open-ended questions
- A question the client can answer without direction or pressure from the nurse
- Open-ended and used in nondirective interviews
- “How do you feel about that?”; “What do you think led to the operation?”
Neutral Question
- Questions that are usually closed and directs the client’s answer
- Directive interview
- “You’re stressed about the surgery tomorrow, aren’t you?”
Leading Question
Try to avoid asking __________ questions. These questions can be perceived as a form of interrogation by the client.
“why”
Nurses need to plan interviews with clients when the client is physically comforable and free of pain, and when interruptions by friends, family, and other health professionals are minimal
Time
A well-lit, well-ventilated room that is relatively free of noise, movements, and distractions encourages communication
Place
By standing and looking down at a client who is in bed or in a chair, the nurse risks intimidating the client.
Seating Arrangement
When a client is in bed, the nurse can sit at a __________ angle to the bed.
45-degree
The __________ between the interviewer and interviewee should be neither too small nor too great.
distance
Is the study of use of space
Proxemics
Most people feel comfortable maintaining a distance of __________ during an interview.
2-3 feet
Failure to communicate in _________ the client can understand is a form of discrimination.
language
TRUE OR FALSE:
The nurse must convert complicated medical terminology into common English usage, and interpreters or translators are needed if the client and the nurse do not speak the same language or dialect.
TRUE
Can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview
The Opening
The purpose of the opening are to establish _________ and _________ the interviewee
rapport and orient
Is a process of creating goodwill and trust
Establishing rapport
Where the client communicates what he or she thinks, feels, knows, and perceives in response to questions from the nurse
The Body
The nurse terminates the interview when the needed information has been obtained
The Closing
TRUE OR FALSE:
In some cases, the client terminates the interview, for example, when deciding to not give any more information for some other reason
TRUE
The ___________ or head-to-toe approach begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes
cephalocaudal
- Is a brief review of essential functioning of various body parts or systems
- Data is measured against norms or standards
- Nursing admission assessment form
Screening Examination / Review of Systems
Used to assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values, and attitudes that influence the level of wellness
Wellness Model
Frameworks and models form other disciplines that are narrower than the model required in nursing
Nonnursing Models
Model focused on abnormalities of the following anatomic systems
Body Systems Model
Model the clusters data pertaining to the following:
- Physiologic needs
- Safety and security needs
- Love and belonging needs
- Self-esteem needs
- Self-actualization needs
Maslow’s Hierarchy of Needs
The act of “double-checking” or verifying data to confirm that it is accurate and factual
Validation
- Are subjective or objective data that can be directly observed by the nurse
- What the client says or what the nurse can see, hear, feel, smell, or measure
Cues
- Are the nurse’s interpretation or conclusions made based on the cues
- e.g. Nurse observes the cues that an incision is red, hot, and swollen; thus saying that the incision is infected
Inferences
- Completes the assessment phase
- Is essential and should include all data collected about the client’s health status
Documentation
TRUE OR FALSE:
Data are recorded in a factual manner and interpreted by the nurse
FALSE
The nurse must NOT INTERPRET THE DATA maintain accuracy of it
