Ch: 14 assessing Flashcards
How would you describe assessing (what are you doing technical definition)
what is assessing a bigger part of
what does assessing allow you to do as far as the nursing process (P&P)
Assessing: a systemic and continuous collection, analysis, validation, communication of patient data
Assessing is part of ADPIE
Assessing allows you to collect data to prioritize and plan care to patient
What do you want to get as much information as possible (to develop what)
What does assessing =
As much information as possible to develop a relationship and comprehensive plan of care
Assessing = data
Under the picture in the chapter what do you do when you assess
(6 things)
- Prepare for data collection
- Collect data
- ID cues/make inferences
- Validate data
- Cluster data /identify patterns
- Report and record Data
Give the five types of nursing assessments
- Comprehensive (ongoing + health history) 
- Focused
- Emergency
- Time lapse
- Assessment of communities in special populations
Describe the comprehensive nursing assessment
- data
- provides?
- make and deliver?
- what does it let you do?
(Include ongoing and health history)
- Comprehensive: INITIAL
- BULKof data
- provides BASELINE
- can make judgment of patient’s health, plan and deliver patient centered care -refer patient out
-Ongoing assessment: alert nurse changes in patient response to health and illness
- Health history how patient got there, previous conditions
- identify health status, strengths, risks
Describe assessments
focused
emergency
time lapsed
assessment of communities and special populations
- Focused: specific pathological condition/Symptoms
-  gathering data on previous diagnosed condition as well if exacerbated causing symptoms - Emergency: emergent issue
- time lapse: assessment after certain time to compare baseline to current
5.assessment of community and special populations done in hospital community

What does the physical assessment allow
The physical assessment allows to get new data that the patient left out and to validate 
What does the entire nursing process rest on
How do we want to assess the patient to identify nursing/medical concerns
what do you want to determine within the patient’s information
what do you want to distinguish from within your findings and identify
what do you want to make regarding patient information given
what do you want to distinguish
The entire nursing process rests on initial and ongoing assessment

-assess the patient in a systematic and comprehensive way (HEAD TO TOE) to identify nursing and medical concerns
-  determine credibility of information
- distinguish the normal V abnormal identify risks
- make judgments about the significance of the data PRIORITIZE!!!
-  distinguish relevant V irrelevant
What are a few characteristics of the nursing assessment
Purposeful: identify purpose of assessment  prioritized: most important  complete : COMPLETE as much as possible
systematic: Head to toe allows to see if you missed anything

factually accurate: patient or family

relevant : what type and how much data to collect from patient
recorded in a standard Manner: document the whole picture without questions
What was the all data be in reference to other healthcare professionals
what do we want to learn for higher quality of care
All data must be documented and communicated to other healthcare professionals
We want to learn how to collect, validate, communicate data with all characteristics for higher quality care
What is a medical assessment (focus)
What does the nursing assessment focus on
what does the nursing assessment not do in reference to the medical assessment
The medical assessment focuses on the pathological patient condition
Nursing assessments focuses on the response to the health problem
The nursing assessment DOES NOT DUPLICATE THE MEDICAL ASSESSMENT 
When is interpersonal competence most important
what does a patient’s initial impression of a nurse resulting
how must do nurses remain
Interpersonal competence most important during initial assessment
Patient’s initial impression = all nursing impressions
Nurses must remain professional, interpersonal (approachable) respectful
What must you as a nurse show your patient+ encourage
What does an successful assessment begin with
You must show genuine concern for patients have and encourage more conversation about health concerns
Successful assessment begins with trust and confidence (rapport)
Comprehensive =?
When is the initial comprehensive assessment performed
what is it performed to establish (two things)
What does the initial comprehensive health assessment help establish for the ongoing assessment and create
Comprehensive = head to toe
Initial comprehensive assessment performed shortly post admitting to hospital (within 1st 8ish hours) 
Initial comprehensive assessment establishes
- complete database for problem
- database for care planning
Finish your comprehensive health assessment establishes PRIORITIES For ongoing assessment and creates BASELINE for comparison
Focused assessment =?
When can a focus assessment be performed
What is one of the purposes of the focus assessment
What are good questions to ask for the focus assessment
Focused assessment = specific
Focus assessments can be performed:
- during initial assessment
- during routine ongoing data collection
Purpose of focus assessment specific problem OR IDENTIFY NEW OR OVERLOOKED PROBLEM
 good questions to ask: OLDCARTS
