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
When is the emergency assessment completed what is it used to identify
What do you do first what do you do second
Emergency assessment completed during crisis identifies life-threatening problems
Assess 1st THEN Intervene

Time lapse assessment =?
Why is the time lapse assessment done
(What does it compare)
What is the purpose of the time lapse assessment
Time lapse assessment = current
Time lapsed assessment done for:
-compare current status of v initial baseline
Purpose of time lapse assessment: -reassess health status
-make necessary revisions to care plan
Who and why do people use the patient centered assessment method (PCAM)
What does the PCAM Help ask questions and getting understanding for (3 topics)
what does the PCA method recognize about patient’s response to health issues 
Practitioners use PCAMto assess patient complexity
PCAM helps us questions and gain understanding about:
-Health and well-being
• lifestyle behaviors (mental health)
-social environment
• employment housing transportation
-Health literacy/communication
• does patient understand?
PCAM recognizes response to health issues related to :
- multiple chronic conditions
- social/environmental factors or both
How is the PCAM. oriented
what is the final section focused on
PCAM = ACTION ORIENTED
Final section focused on
-actions taken to address needs/issues identified in assessment
What are the types of data gathered to establish priorities
(four types)
What is the purpose for which an assessment is performed offer
Health oriented: actual the potential
Developmental stage: needs of patient according to stage
Culture: race, ethnicity, socioeconomic
Need for nursing: duration of nursing interaction

Purpose of which assessment performed offers guidance to see how much and what data is needed to collect
How must data collection for assessment be structure What does ensure
 what is the minimum data to be collected from every patient
When structuring the assessment what are good questions to ask
Data collected must be structured systematically (HEAD TO TOE) insurers comprehensive holistic Data 
Minimum data to be collected:
-information from EVERY Patient, using structure assessment to organize/cluster Data
Ask:
- is there anything else they’d like us to know
- is there anything they would like to add
Defined the HELP acronym to structure data
H: Sign patient may need HELP
E: environment equipment (safety hazard
L: look (examine pt thoroughly)
P: people (who is in room what are they doing)
Define objective data define subjective data
Objective: observe
-can be seen, heard, felt by ANOTHER
Subjective: says
- perceived only by affected person
- PAIN
What are sources of data
What are the primary components of Data collection
Patient: primary
Family/SO: for kids/limited capacity
Medical record: -med history, -consultations -labs - therapies with others (nutrition/RT)
Nursing history and physical assessment = primary components of data collection
Give the four phases of the nursing interview
- pre interaction(Preparatory phase)
- when seen diagnosis think of questions -  beginning(Introduction)
- Working phase
- bulk of data!!! - Closing (termination)
What can the physical assessment better define
what does it help get
What is the purpose of the physical assessment:
What does the physical assessment involve, in what manner
Give the four methods (Think Health assessment)
Physical assessment better defines patient’s condition and helps nurse plan care, helps get information not gotten from an interview
 purpose:
- appraisal of health status
- identification of health problems -establishment of database for nursing intervention
Physical assessment involves ALL Body systems in systemic manner
Four methods: inspect, Palpate, percuss, auscultate
What are a few problems related to data collection
- inappropriate organization of data
- Omission of pertinent data
- inclusion of irrelevant/duplicate data -error/misinterpreted data
- failure to establish rapport with patient -recording and interpreting data rather than observed behavior
- failure to update database
How are cues/Inferences used by by nurses
What is the judgment you reach about the queue known as
Cues/inferences describe early analysis data

The judgment you reach about the queue is known as an inference
How can you validate inferences
- Physical examination
- Clarifying statements
- Sharing inferences with others and seeking consensus
- Comparing cues to knowledge base of normal function
- Checking consistency of cues
When do you start assessing the patient
What do you determine during your nursing observations
Begin assessing the patient the second you see them
- Determine patient’s current responses (physical/emotional)
- Determine patient’s current ability to manage care
- determine immediate environment and safety
- determine larger environment if anything needs to be addressed
What is validating

What are two circumstances were data needs to be verified

Validating = confirm/ verify
Circumstances:
- discrepancy between what the person is saying and with the nurses of serving
• patient says are fine but you note discover
-Where data lacks objectivity
• patient here’s good and one ear but not well in the other

What is the purpose of gathering data
What does data help plan
Once you’ve organizer that it would you be in to look for a test
Purpose of gathering data: to organizing cluster
Danna helps plan care of patient
Would you organize data look for an test initial impressions about patterns of human functioning
 what do you do if you see a critical change in patient health status
when must you enter the initial database (assessment)
what kind of grammar and abbreviations are allowed 
What do you want to avoid
If critical change in status immediately give verbal reporting
Enter the initial database (comprehensive assessment) the same day of admission
Use good grammar/standard medical abbreviations
AVOID non-specific terms subject to individual interpretation and definition

Describe the ongoing assessment (what does it alert to?)
-Ongoing assessment: alert nurse changes in patient response to health and illness
What does the health history identify (three things)
- Health history how patient got there, previous conditions
- identify health status, strengths, risks
