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