Assessment Flashcards
What are the two main areas of assessment?
Health history and physical assessment
What begins the nursing process?
Assessment
What are the four major assessment activities?
Collection
Organization
Validation
Documentation
What is a collection or store of information?
Data base
Clients description of the problem
Subjective Data
Detectable by an observer. Something seen, heard, smelled, or felt.
Objective Data
Who states Administer assessment done to determine each persons need for nursing care?
Joint Commission
What is the purpose of assessment?
To enable the nurse to make a judgment or diagnosis about the patients health state.
What is identified as the purpose of assessment?
- The deviations from normal
- The clients health beliefs and patterns of health illness
- The presence of risk factors for physical and behavior health problems
- The patients resources for support and adaption
Is a continuous process carried out during all phases of the nursing process
Assessment
What are the 5 components of the nursing process?
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
What is collected so problems are identified?
Initial data
What are the 4 types of assessments?
- Initial
- Problem-focused
- Emergency
- Time-lapsed
All the information about a client including past history and current problems
Baseline data or database
What is the purpose of data collection?
To provide information or identify patient needs. It need to be continuous and symptomatic without omission.
Who is the primary source of data?
Client and they are the best source
Who is the secondary source of data?
Support people, medical charts, client records, diagnostic studies, record of therapies etc
What is the pupils normal size?
3-5mm
What does PERRLA stand for?
Pupils round reactive to light accommodation
Skin springs back
Elastic
Skin is slow to return
Tenting
20 - 30 seconds of skin tenting indicates what?
Dehydration