Chapter 16: Nursing Assessment

Question 1

An assessment must be:

Answer 1

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

Question 2

Assessment is the:

Answer 2

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

Question 3

Nursing assessment includes 2 steps:

Answer 3

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

Question 4

Sources of data (6)

Answer 4

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

Question 5

Types of assessments: (3)

Answer 5

Patient centered interview during a nursing health history

Physical examination

Periodic assessments you make during rounding or administering care

Question 6

A cue is ____

Answer 6

information that you obtain through use of the senses

Question 7

An inference is:

Answer 7

judgment or interpretation of these cues

Question 8

First 5 Functional Health Patterns:

Answer 8

Health perception-health management patterns

Nutritional-metabolic pattern

Elimination pattern

Activity-exercise pattern

Sleep-rest pattern

Question 9

Last 6 Functional Health patterns

Answer 9

Cognitive-perceptual pattern

Self-perception-self-concept pattern

role-relationship pattern

sexuality-reproductive pattern

coping-stress tolerance pattern

value-belief pattern

Question 10

Problem and Associated factors of pain (problem focused patient assessment)

Answer 10

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

Question 11

2 primary sources of data:

Answer 11

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

Question 12

Primary objective during an initial history taking is to

Answer 12

discover details about a patients concerns, explore expectations for the encounter you are having and display genuine interest and partnership

Question 13

Effective communication skills needed during an assessment interview (4)

Answer 13

Courtesy

Comfort

Connection

Confirmation

Question 14

Phases of an interview (3):

Answer 14

Orientation and setting an agenda

Working phase
-Collecting assessment or nursing health history

Termination

Question 15

Interview techniques (5)

Answer 15

Observation

Open-ended questions

Leading questions

Back channeling

Direct closed-ended questions

Question 16

To conduct an accurate and complete assessment, you need to consider a patient’s

Answer 16

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!!!!

Question 17

Components of the Nursing Health History (9)

Answer 17

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

Question 18

PQRST to guide an assessment:

Answer 18

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?

Question 19

Concomitant symptoms

Answer 19

Does he or she experience other symptoms along with the primary symptom? For example, does nausea accompany pain?

Question 20

It is important to closely observe a patients ______

Answer 20

verbal and nonverbal behaviors

-adds depth to objective database

Question 21

Observations direct you to ____

Answer 21

gather additional objective information to form accurate conclusions about the patient’s condition

Question 22

An important aspect of observation includes a:

Answer 22

patient’s level of function

• physical
• developmental
• psychological
• social aspects of everyday living

Question 23

Nursing Health History includes: (4)

Answer 23

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