Chapter 16: Nursing Assessment Flashcards
An assessment must be:
complete, relevant to patients condition and accurate for you to correctly identify a person’s desire to improve his or her health or identify any health problem
Assessment is the:
deliberate and systematic collection of information about a patient to determine the patient’s current and past health and functional status and his or her present and past coping patterns
Nursing assessment includes 2 steps:
Collection of information from a primary source (a patient) and secondary sources (family and friends, health professionals, medical record)
Interpretation and validation of data to ensure a complete database
Sources of data (6)
Patient (interview, observation, physical examination) BEST SOURCE OF INFORMATION
Family and significant others (obtain a patient’s agreement first)
Health care team
Medical records
Scientific literature
Database
Types of assessments: (3)
Patient centered interview during a nursing health history
Physical examination
Periodic assessments you make during rounding or administering care
A cue is ____
information that you obtain through use of the senses
An inference is:
judgment or interpretation of these cues
First 5 Functional Health Patterns:
Health perception-health management patterns
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Sleep-rest pattern
Last 6 Functional Health patterns
Cognitive-perceptual pattern
Self-perception-self-concept pattern
role-relationship pattern
sexuality-reproductive pattern
coping-stress tolerance pattern
value-belief pattern
Problem and Associated factors of pain (problem focused patient assessment)
Nature of pain
- Ask patient to describe pain
- Observe nonverbal cues, where patient points to pain
Precipitating factors
- Ask if patient notices if pain worsens during any activities or time of day
- Observe nonverbal signs of pain during movement, positioning, swallowing
Severity
- Ask patient to rate pain 0-10
- Inspect area of discomfort, palpate for tenderness
2 primary sources of data:
Subjective and objective
Subjective: patient’s verbal descriptions of their health problems (feelings, perceptions, self-report of symptoms)
Objective: observations or measurements of a patient’s health status
Primary objective during an initial history taking is to
discover details about a patients concerns, explore expectations for the encounter you are having and display genuine interest and partnership
Effective communication skills needed during an assessment interview (4)
Courtesy
Comfort
Connection
Confirmation
Phases of an interview (3):
Orientation and setting an agenda
Working phase
-Collecting assessment or nursing health history
Termination
Interview techniques (5)
Observation
Open-ended questions
Leading questions
Back channeling
Direct closed-ended questions
To conduct an accurate and complete assessment, you need to consider a patient’s
CULTURAL BACKGROUND!
When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patient’s uniqueness
Ask for clarification to prevent making the wrong diagnostic conclusion!!!!
Components of the Nursing Health History (9)
Biographical information
Reason for seeking health care
Health history
Psychosocial history
Patient expectations
Present illness or health concerns
Family history
Spiritual health
Review of systems
PQRST to guide an assessment:
P- Provoke: What is causing symptom? What makes it better or worse? Are there activities that affect it?
Q- Quality: What does symptom feel like? Sharp? Dull? Burning?
R- Radiate: Where is symptom located? Does it go anywhere else? Have patient be precise as possible
S- Severity: Ask patient to rate severity of a symptom on a scale of 0-10. Gives you baseline with which to compare in follow up
T- Time: Assesses onset and duration of symptom. When did it start? Does it come and go?
Concomitant symptoms
Does he or she experience other symptoms along with the primary symptom? For example, does nausea accompany pain?
It is important to closely observe a patients ______
verbal and nonverbal behaviors
-adds depth to objective database
Observations direct you to ____
gather additional objective information to form accurate conclusions about the patient’s condition
An important aspect of observation includes a:
patient’s level of function
- physical
- developmental
- psychological
- social aspects of everyday living
Nursing Health History includes: (4)
Diagnostic and laboratory data
-results provide further explanation of alterations or problems identified during the health history and physical examination
Interpretating and validating assessment data
- ensures collection of complete database
- Leads to second step of nursing process
Data documentation
- clear, concise terminology
- baseline for care
Concept mapping
-visual representation that allows you to graphically show connections among a patient’s many health problems
