Ch. 3: Assessment-MJ Flashcards
What is the definition of assessment?
The systematic gathering of information related to physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community
What are some of the features of an assessment?
Collecting data
Categorizing data
Recording data
Using a systematic and ongoing process
What is the purpose of assessment?
To obtain enough data to allow you to help the patient
Assessment is the first phase of the nursing process. Why must data be accurate and complete during this step?
Because the remainder of the nursing process rests on this foundation of data
Define: The information communicated to the nurse by the client, family, or community
Subjective data
Define: Data gathered through physical assessment or from lab or diagnostic tests
Objective
Subjective or objective: Covert data
Subjective
Subjective or objective: Overt data
Objective
Subjective or objective: Signs
Objective
Subjective or objective: Symptoms
Subjective
Subjective or objective data:
“I’ve been having a lot of pain in my abdomen”
“My throat hurts when I swallow”
Subjective
Subjective or objective data:
“Suprapubic area firm to light palpation. Lower abdomen semisoft”
“White patches noted at the back of the throat and tonsillar area reddened and swollen”
Objective
_____ data can be measured or observed by the nurse or other healthcare providers
Objective
What are examples of objective data?
Vitals
X-ray results
Skin color
Urine output
You need to sometimes use _____ data to validate ____ data.
Use objective data to validate subjective data
What kind of assessment is this: Completed when the client first comes to the healthcare agency
Initial (admission) assessment
What do you do for the initial assessment?
- Obtain data for why the person came in for nursing/medical assistance
- Complete comprehensive assessment if clients condition permits
- Data gathered here provides guidance for care and need for further assessment
When is an ongoing assessment preformed?
As needed at any time after the initial database is completed; make at least some observations at every contact with the client
Initial or ongoing assessment: Which one reflects the dynamic state of the client? Example?
Ongoing; vital signs may rapidly change and serve as important indicators of developing or resolving health problems
A _____ assessment is also called a global assessment, patient database, or nursing database.
Comprehensive
A comprehensive assessment provides ______ information about the clients overall health status
Holistic
What does the comprehensive assessment include?
- Sub and obj data about the clients body systems and functional abilities
- Emotional status
- Spiritual health
- Psychosocial health
Observation, physical assessment, and the nursing interview are all included in the ______ assessment
Comprehensive
Define: The deliberate use of all of your senses to gather and interpret patient and environmental data
Observation
Physical assessment (or examination) produces primarily OBJECTIVE data and uses 4 techniques. What are they?
Inspection
Palpation
Percussion
Auscultation
What is the nursing interview?
A purposeful, structured communication in which you question the patient to gather SUBJECTIVE data for the nursing database
Why is a focus assessment preformed
Preformed to obtain data about an actual, potential, or possible problem that has been identified or is suspected; focuses on a particular topic, body part, or functional ability rather than overall health status
When is the initial focused assessment used?
To follow up on client-reported symptoms or unusual findings during the first exam (admission to hospital)
When is an ongoing focused assessment used?
To evaluate the status of existing problems and goals
What kind of assessment is a special needs assessment?
A type of FOCUSED assessment
What type of assessment provides in-depth information about a particular area of client functioning and often involves using a specially designed form.
Special needs assessment
The Joint Commission requires certain special needs assessments for all clients. Examples?
Nutrition status and pain
When should you preform a special needs assessment?
Any time assessment cues suggest risk factors or problems in an area of client functioning
What are 9 types of special needs assessments?
Functional ability assessment Nutritional assessment Pain assessment Cultural assessment Spiritual health assessment Psychosocial assessment Wellness assessment Family assessment Community assessment
