Chapter 1 Nurse's Role in Health Assessment: Collecting and Analyzing Data

Question 1

What are the phases of the nursing process?

Answer 1

Assessment, diagnosis, planning, implementation and evaluation.

Question 2

Describe the assessment phase of the nursing process.

Answer 2

The most important of the phases, it consist of Collecting subjective and objective data. If data collection is inaccurate or inadequate it could adversely affect the other phases in the nursing process

Question 3

Describe the diagnosis phase of the nursing process.

Answer 3

Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem or referral).

Question 4

Describe the planning phase of the nursing process.

Answer 4

Determining outcome criteria and developing a plan.

Question 5

Describe the implementation phase of the nursing process.

Answer 5

Carrying out the plan.

Question 6

Describe the evaluation phase of the nursing process.

Answer 6

Assessing whether outcome criteria have been met and revising the plan as necessary.

Question 7

What is Standard 1 of Nursing: Scope and Standard of Practice (American Nurses Association)?

Answer 7

The registered nurse collects comprehensive data pertinent to the patient’s health or situation.

Question 8

What is Standard 2 of Nursing: Scope and Standard of Practice ( American Nurses Association)

Answer 8

The registered nurse analyzes the assessment data to determine the diagnosis or issues.

Question 9

What is the Nurse Practice Act?

Answer 9

Enacted by each states legislature it determines and regulates nursing practice and scope, licensure, and regulates hospitals, medical practices, and schools of Nursing

Question 10

What is the framework of health assessment?

Answer 10

It helps to organize information and collect data.
Examples: Hx of present health concern. COLDSPA
Personal health history. Family history. Lifestyle and health practice.

Question 11

What are the types of health assessment?

Answer 11

Initial comprehensive assessment (complete history and head to toe).
Ongoing or partial assessment ( mini-overview).
Focused or problem-oriented assessment (focused history and exam based on problems).
Emergency assessment (rapid assessment)

Question 12

Initial comprehensive assessment

Answer 12

Involves collection of subjective data re: clients health of all body parts or systems, past health history, family history, and lifestyle and health practices. (info r/t pt’s overall function). Also involves objective data obtained from physical exam. Can be performed by various health team members. in a variety of health care settings. Always performed when pt first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. This depends on pt’s age, risk factors, health status, health promotion practices and lifestyle.

Question 13

Ongoing or partial assessment

Answer 13

This is data collection after the comprehensive database is established. Consist of a mini overview of pt’s body systems and holistic health patterns as a follow up on health status. Any problems initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes from baseline data. New problems can be detected from brief reassessment of body systems and holistic health patterns. The frequency of this type of assessment depends upon the acuity of the pt.

Question 14

Focused or problem-oriented assessment

Answer 14

This is performed when a comprehensive database exists for a pt that comes in with a specific health concern. It consists of a thorough assessment of the particular problem and does not cover areas not related to the problem

Question 15

Emergency assessment

Answer 15

A rapid assessment performed in life-threatening situations. An immediate assessment is needed to provide prompt tx.

Question 16

What are the steps of a health assessment?

Answer 16

Collection of subjective data.
Collection of objective data.
Validation of data.
Documentation of data.

Question 17

What is subjective data?

Answer 17

Sensations, symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the pt.

Question 18

What are the major types of subjective information?

Answer 18

Biographical information (name, age, religion, occupation).
History of preset health concern (physical symptoms related to each body part or system).
Personal health history.
Family history.
Health and lifestyle practices (nutrition, physical activity, relationships, cultural beliefs or practices, family structure or function, community environment).

Question 19

What are types of objective data?

Answer 19

Physical characteristics. 
Body functions. 
Appearance. 
Behavior. 
Measurements. 
Results of lab testing.

Question 20

Validating assessment data.

Answer 20

It serves to ensure that the assessment process is not ended before all relevant data have been collected and helps to prevent documentation of inaccurate data.

Question 21

Documenting data.

Answer 21

It forms a database for the entire nursing process and provides data for all other members of the health care team. Thorough and accurate documentation is vital to ensure that valid conclusions are made when the data are analyzed in the second step of the nursing process.

Question 22

Analysis of assessment data.

Answer 22

AKA the nursing diagnosis. The data is analyzed and synthesized to determine whether the data reveal a nursing concern (nursing diagnosis), a collaborative concern (collaborative problem), or a concern that needs to be referred to another discipline (referral).

Question 23

What is the definition of a nursing diagnosis?

Answer 23

A clinical judgment about individuals, family or community responses to actual and potential health problems and life processes. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

Question 24

What is the definition of a collaborative problem?

Answer 24

Certain physiological complications that nurses monitor to detect their onset or changes in status. Nurses manage collaborative problems by implementing both physician-and nurse-prescribed interventions to reduce further complications.

Question 25

What initiates a referral?

Answer 25

Referrals occur because nurses assess the “whole” (physical, psychological, social, cultural, and spiritual) pt, often identifying problems that require the assistance of other health care professionals.

Question 26

Steps of data analysis (critical thinking skills).

Answer 26

Identify abnormal data and strengths. 
Cluster the data. 
Draw inferences and identify problems. 
Propose possible nursing diagnosis. 
Check for defining characteristics of those diagnoses. 
Confirm or rule out nursing diagnoses. 
Document conclusions.