chapter 12 Flashcards
First phase of the nursing process in which data are gathered to identify actual or potential health problems is called?
assessment
pieces of data, subjective or objective, about a patient are?
cues
observable, measurable information that can be validated or verified is?
objective data
symptoms or covert cues that include the patients feelings and statements about his or her health problems is?
subjective data
assessment is done for the following reasons:
- to establish baseline information on the patient
- to determine the patients normal function
- to determine the patients risk for dysfunction
- to determine the presence or absence of dysfunction
- to determine the patients strengths
- to provide data for the diagnosis phase
What activités make up the assessment phase?
- collection of data
- validation of data
- organization of data
What is the phases of the nursing process in order?
Assessment > Diagnosis > Outcome identification > Planning > Implementation > Evaluation
What are the four types of assessment?
- admission assessment
- focus assessment
- time- lapse reassessment
- emergency assessment
Admission assessment
AIM:
TIME FRAME:
AIM: initial id of normal function, functional status, and collecting of data concerning actual or potential dysfunction, baseline for reference and future comparison.
TIME FRAME: Within the specified time frame after admission to a hospital, skilled nursing facility, ambulatory health care center, or home healthcare setting
Focus assessment:
AIM:
TIME FRAME:
AIM: Status determination of a specific problem identified during previous health assessment
TIME FRAME: Ongoing process; integrated with nursing care; a few minutes to a few hours between assessments
Time-lapse reassessment:
AIM:
TIME FRAME:
AIM: Comparison of the patients current status to baseline obtained previously; detection of changes in all functional areas after an extended period of time has passed
TIME FRAME: Several months (3, 6, or 9 months or more) between assessments
Emergency assessment:
AIM:
TIME FRAME:
AIM: Identification of life threatening situation
TIME FRAME: Any time a physiologic, psychological, or emotional crisis occurs
In an emergency assessment setting the patients difficulties are often the ABC’s. What are the ABC’s?
airway, breathing, and circulatory problems.
Is an emergency assessment comprehensive?
NO
Nurses use the clinical skills of ______, ______, ______, and intuition to assess patients across the lifespan in various settings.
observation, interviewing, physical examination
The act of noticing patient cues is?
observation
The interaction and communication process for gathering data by questioning and information exchange is called?
interviewing
The analysis of bodily functioning using the techniques or inspections, palpation, percussion, and auscultation is called?
physical examination
Observation of a patient includes?
- vision
- smell
- hearing
- touch
The interview can be divided into four phases what are they?
- preparatory
- introductory
- maintenance
- concluding
What is done in the preparatory phase:
- Review as much information as possible about the patient.
- Decide what data are needed and what type of data collection form will be used.
- Review the literature pertinent to the patient’s developmental age, psychosocial aspects, and pathophysiologic considerations, if needed.
- Assess your own feelings or reactions to previous patients that might interfere with the nurse–patient relationship.
- Seek assistance from more experienced nurses, mentors, or supervisors if concerned about how to carry out the interview.
- Plan for a private, quiet setting for the interview; schedule a mutually convenient time of day; and determine the length of time needed for data collection.
- Modify the environment to facilitate the interview.
What is done in the introductory phase?
- Introduce yourself by name and position, and explain the purpose and content of the interview.
- Begin to establish rapport with the patient by conveying a caring, interested attitude; rapport is essential for a trusting, helpful nurse–patient relationship.
- Observe the patient’s behavior, and listen attentively to determine the patient’s self-perceptions and how the patient views his or her health problems; validate the patient’s perceptions as the interview progresses.
- Let the patient know how long the interview is expected to last.
- Inform the patient how the information collected will be used and that confidentiality will be maintained.
- Start with nonthreatening, specific questions and proceed to open-ended questions.
- Establish a verbal contract with the patient, incorporating the goals of the interview.
What is done in the maintenance phase?
- Keep focused on the tasks or goals to ensure that needed data are obtained and goals are achieved.
- Encourage the patient to express his or her feelings, concerns, and questions.
- Use techniques that facilitate communication between the nurse and patient (e.g., silence, general leads, validation).
- Observe the nonverbal behavior that accompanies verbal responses (e.g., a patient may say she is not nervous, worried, or anxious while biting her fingernails or moving constantly).
- Assess the patient’s ability to continue the interview (e.g., grimace of pain, shortness of breath, fatigue).
- Facilitate goal attainment by moving to the next topic of discussion after needed data are collected.
What is done in the concluding phase?
- Review goal or task attainment; such a review can foster a sense of achievement in the patient and nurse.
- Summarize the highlights of the interview and its meaning to the nurse and the patient.
- Encourage the patient to express and share his or her feelings regarding the termination of the interview.
- Use language congruent with the patient’s cultural background and local custom (e.g., “goodbye” may mean a final farewell in some cultures; promises to contact the patient in the future may be taken literally).
