ASSESSMENT Flashcards
data collection to establish
database
is the systematic and continuous collection, validation, and documentation of data (information)
assessing
What are the activities of assessment?
Establish database
obtain a nursing health history
conduct physical assessment
review of patient records
review of nursing literature
consultation of support persons
consultation of health professionals
What are the components of assessment?
Data Collection
Data Validation
Data Organization
Communication of Data (Kozier)
Documentation of Data (Taylor)
What are the two types of data?
subjective and objective data
information perceived only by the client or by the affected person
subjective data
cannot be perceived or verified by another person
subjective data
Subjective data is also called as ?
symptoms or covert data
consist of information given verbally by the patient
subjective data
observable or measurable data that can be seen, heard, smelled, or felt by someone other than the person experiencing them
objective data
can be observed by one person and can be verified by another person observing the same patient
objective data
obtained through observation or physical examination (IPPA)
what is IPPA?
Objective data
Inspection
Palpation
Percussion
Auscultation
Objective data is also called as
Signs or Overt Data
What are the sources of data or information
client or patient
support people like family members, SO
Client or patient record like
- medical history
- consultations
- reports or laboratory
- reports of therapies by other health care professional
- nursing and other health care literature
What are the characteristics of data?
complete
factual and accurate
relevant
What are the types of assessment?
Initial assessment
Problem focused assessment
Emergency assessment
Time-lapsed Assessment
Nursing assessments focus on a ________ to a health problem.
client’s response
process of gathering information about client’s health status
systematic and continuous
Data collection
all information about the client
database
To gather data using senses
observation
What are the senses involved in observation of the patient?
vision
touch
hearing
smell
What should the nurse observe of the patient?
clinical signs of client distress
threats to clients safety, real or anticipated
presence and functioning of associated equipment
the immediate environment, including the people
it is a planned communication or a conversation with a purpose
interview
What are the three types of interview?
Focused interview
Directive interview
Nondirective interview
nurses ask specific questions to the client’s problem
focused interview
it is highly structured
elicits specific information
emergency situation
directive interview
rapport building interview
non-directive interview
an understanding between two people
rapport
What are the four types of interview question?
Closed
Open
Neutral
leading
In planning for the interview and setting, one must consider the following factors?
Time
place
seating arrangement
distance
language
The place where the interview is conducted must be
well-lighted
well-ventilated
free from noise, movement, distractions
What should be the appropriate distance of the patient from the nurse?
at least 3-4 feet
the study of use of space
proxemics
What are the stages of interview
Opening or introduction
body or development
closing
In closing the interview, what should a nurse do?
- offer to ask questions
- use “well_____ end”
- thank the client
- express concern for the person’s welfare and future
- plan for the next meeting
- summary to verify accuracy and agreement
Upon examining a patient, what should you do first?
first- observe the overall appearance and health status
second - vital signs
third - cephalocaudal or head to toe approach
brief review of essential functioning of various body parts or systems
screening examination or review of systems
Organizing data is also called as
nursing health history
nursing assessment
nursing database form
What are the conceptual models and Frameworks in organizing data?
Gordon’s 11 functional health
Orem’s Self Care Model
Roy’s Adaptation Model
What are the four observable categories according to Orem’s Self Care Model?
physiological
self-concept
role function
interdependence
Used to identify health risks and explore lifestyle
wellness models
act of double- checking or verifying data to confirm that it is accurate and factual
validation
subjective and objective data that can be directly observed by the nurse
cues
These are nurse’s interpretation or conclusions made on the cues
inferences
records client data
documenting data
Diagnosis is
analyzing and synthesizing
In this phase, nurses use critical thinking skills to interpret or analyze assessment data and identify client strength and health problems
diagnosis
is used to interpret or analyze assessment data and identify client strength and health problems
Diagnosis
The standard NANDA name for the diagnosis are called
Diagnostic Labels
causal relationship between a problem and its related or risk factors
etiology
a clinical judgment concerning a human response to health con- ditions/life processes, or a vulnerability for that response, by an indi- vidual, family, group, or community”
nursing diagnosis
are responsible for mak- ing nursing diagnoses
Registered nurse
is a judgment made only after thorough, sys- tematic data collection.
nursing diagnosis
is a client problem that is present at the time of the nursing assessment
actual diagnosis
relates to clients’ preparedness to implement behaviors to improve their health condition.
health promotion diagnosis
is a clinical judgment that a prob- lem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
risk nursing diagnosis
is assigned by a nurse’s clinical judg- ment to describe a cluster of nursing diagnoses that have similar interventions
syndrome diagnosis
What are the three components of nursing diagnosis
Problem and its definition
the etiology
the defining characteristics
is to direct the formation of client goals and desired outcome
diagnostic labels
are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
qualifiers
What are the qualifiers used in nursing diagnosis?
deficient
impaired
decreased
ineffective
compromised
identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care.
etiology
are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
defining characteristics
Nursing diagnosis describes a
client’s physical
socio-cultural
psychological
spiritual responses
CUC
Chronic Ulcerative Colitis
CA
Cancer
CVA
Cerebral Vascular Accident
What is the Diagnostic Process?
Analyzing data
Identifying health problem and risks and strength (focus area)
Formulating diagnostic statements
R/t
Related to
PIH
Pregnancy Induced Hypertension
