Assessing

Question 1

What is the nursing process?

Answer 1

It is a systematic, rational method of planning and providing individualized nursing care

Question 2

What is the aim of the nursing process?

Answer 2

• to identify a client’s health status whether it is potential or actual and their problems or needs to establish plans to meet the identified needs
• to deliver specific nursing intervention to meet those needs
• the client may be an individual, a family, a community or a group

Question 3

What are the phases of the nursing process?

Answer 3

1. Assessing
2. Diagnosing
3. Identifying outcomes
4. Planning
5. Implementing
6. Evaluating

Question 4

What are the characteristics of the nursing process?

Answer 4

1. Cyclic & dynamic rather than static
2. Client centered
3. Problem-solving & systems theory
4. Decision-making
5. interpersonal & collaborative
6. Universal applicability
7. critical thinking skills
8. clinical reasoning process

Question 5

What is the assessing phase?

Answer 5

• It is the systematic and continuous collecting, organizing, validating and documenting of data
• all the nursing process depends on appropriate and accurate assessment

Question 6

What does assessment focus on?

Answer 6

The patients responses

Question 7

What does assessment depend on?

Answer 7

The patients need

Question 8

What are the types of assessments?

Answer 8

1. Initial assessment
2. Problem focused assessment
3. Emergency assessment
4. Time-lapsed assessment

Question 9

Initial assessment :

Answer 9

• performed within a specified time period
• Establishes complete database

Question 10

Problem-Focused assessment :

Answer 10

• ongoing process integrated with care
• determines status of a specific problem

Question 11

Emergency assessment :

Answer 11

• Performed during physiological or psychological crises
• identifies life-threatening problems
• identifies new or overlooked problems

Question 12

Time lapsed assessment :

Answer 12

• occurs several months after initial
• compares current status to baseline

Question 13

What does the assessment process involve?

Answer 13

1. collecting data
2. organizing data
3. validating data
4. documenting data

Question 14

How do we collect data for assessment ?

Answer 14

• by gathering information about client’s health status
• it must be systematic and continuous
• it includes past history and current problem
• it could be subjective or objective data
• it could be from a secondary or primary source
• it establishes database

Question 15

What is subjective data?

Answer 15

• it is the symptoms or covert data
• its apparent only to the person affected
• can only be described by the person affected
• includes :
  sensations
  values
  beliefs
  attitude
  perception of personal health status and life situations

Question 16

What is objective data?

Answer 16

• it is the signs or overt data
• it is detectable by an observer
• can be measured or tested against an accepted standard
• can be :
  seen
  heard
  felt
  smelled
• obtained through observation or physical examination

Question 17

What is a primary source of data?

Answer 17

The client

Question 18

What is a secondary source of data?

Answer 18

All other sources of data that aren’t the client
this data should be validated if possible

Question 19

What are the methods of data collection?

Answer 19

1. Observing
2. Interviewing

Question 20

How and when do we use observation to collect data?

Answer 20

• we observe and gather data using our senses
• we used observation to collect the following types of data :
  Skin color (vision)
  Body or breath odors (smell)
  Lung or heart sounds (hearing)
  Skin temperature (touch)

Question 21

What is an interview?

Answer 21

It is planned communication or a conversation with a purpose

Question 22

When do we use interviewing as a method to collect data?

Answer 22

• to get or give information
• to identify problems of mutual concern
• to evaluate change
• to teach
• to provide support
• to provide counseling or therapy

Question 23

What is a directive approach to interviewing?

Answer 23

• nurse establishes the purpose
• nurse controls the interview
• used to gather and give information when time is limited

Question 24

What is a nondirective approach to interviewing?

Answer 24

• Rapport building
• client controls the purpose, subject and pacing
  -combination of directive and non-directive approaches is usually appropriate for information gathering interview

Question 25

What are the types of interview questions?

Answer 25

1. open-ended questions
2. neutral questions
3. leading questions
4. closed questions

Question 26

Factors to consider in the interview settings

Answer 26

• the client is free of pain
• limited interruptions
• private place
• comfortable environment
• limited distractions
• Comfortable distance
• language

Question 27

What are the interview stages?

Answer 27

1. opening
2. body
3. closing

Question 28

How do you do a physical examination to collect data?

Answer 28

• systematic data-collection method
• use observation, inspection, auscultation, palpation, percussion
• vital signs, height, weight
• cephalocaudal approach
• screening examination

Question 29

What is the cephalocaudal approach?

Answer 29

It is a head to toe assessment

Question 30

What are the different nursing model frameworks that we can use to organize data?

Answer 30

1. Gordon’s functional health pattern framework : 11 functional health patterns
2. Orem’s self-care model : eight universal self-care requisites of humans.
3. Roy’s adaptation model : physiologic, self-concept, role function, and interdependence

Question 31

How do we validate data?

Answer 31

1. make sure assessment is complete
2. validation is done through determining whether subjective and objective data agree
3. clarify vague statements
4. double check extreme data & use references as needed
5. determine which data can be overlooked
6. differentiate between cues and inferences
7. avoid jumping to conclusions

Question 32

Documenting the assessment :

Answer 32

• Record the client’s data
• Record in a factual manner, do not state interpretations
• Record subjective data with quotes in clients own words