Collecting and Analyzing Data Flashcards
what is a holistic nursing assessment
collects holistic subjective and objective data to determine overall level of functioning in order to make professional clinical judgement
what is a physical medical assessment
focuses mainly on physiologic development status
what is a initial comprehensive assessment
collection of subjective data about perception of health of body parts/systems, past med hx, family hx, and lifestyle and health practices
what is an ongoing/partial assessment
data collection that occurs after comprehensive database is established
what is a focused/problem-orientated assessment
assessment of particular problem, doesn’t cover areas not related to problem
what is an emergency assessment
very rapid assessment used life-threatening situations
what are the 5 phases of nursing process
assessment, diagnosis, planning, implementation, evaluation (ADPIE)
what is phase I of nursing process
assessment: collecting subjective and objective data
what is phase II of nursing process
diagnosis: analyzing all data to make professional nursing judgment (diagnosis, collaborative problem, refferal)
what is phase III of nursing process
planning: determining outcome criteria and developing plan; SMART (specific, measurable, attainable, realistic, timely)
what is phase IV of nursing process
implementation: carrying out plan
what is phase V of nursing process
evaluation: assessing whether outcome criteria have been met and revising plan as necessary
what are the phases of subjective interviewing
pre-intro, intro, working, summary and closing
what happens in pre-intro phrase
nurse reviews med record which may reveal past health hx and CC before meeting with pt to assist with interview
what happens in intro phase
explain purpose of interview, discuss kind of questions being asked, explain note taking, assure HIPAA, develop trust and rapport
what happens in working phase
collection of following subjective data (complete/comprehensive health hx or CHH):
biographical data
CC
HPI
personal past health hx
family hx
lifestyle and health practices
developmental level (pediatrics)
review of body systems for health problems
what happens in summary and closing phase
summarize info obtained, validate problems and goals with pt
identify and discuss possible plans to resolve problem, other concerns/questions
what is biographical data
name, address, phone, self-identified gender and pronoun, identify hx provider, DOB, birthplace, race/ethnicity, primary and secondary languages, marital status, religious/spiritual practices, education, occupation, partners/support persons, insurance and/or availability
mnemonic used to gather HPI
COLDSPA (Concerns character, Onset, Location, Duration, Severity, Pattern, Associated factors)
what is reviewed during ROS
HEENT (Head/sinuses, eyes, ears, nose, throat/mouth), respiratory (lungs), cardiac, thorax/breasts, GI/GU, anus/rectum/prostate, musculoskeletal, integumentary/derm (skin, hair, nails), neurological, lymphatic
what should you do before physical exam (PE)
introduce yourself, describe steps of examination, respect client’s wishes, explain importance of exam and need for position changes, communicate timeline and purpose of exam phases, leave room when pt is changing, begin exam with less invasive procedures
how do you conduct a general survey
visually make observations of person/system being assessed, observe general disposition, demeanor, and behavior (mental health/neuro system), observe clothes and speech and responses, orientation to person and place and time and surroundings/location, look and observe before touching all systems, normal vs abnormal behavior for age and development
what are 4 PE techniques
inspection, auscultation, palpation, percussion
