Exam3: Chapter 14 Assessing

Question 1

What is Assessing?

Answer 1

Systematic and continuous collection, analysis, validation, and communication of patient data.

Question 2

Assessment: What does data refelct?

Answer 2

Reflects how health functioning is enhanced by health promotion or compromised by illness/injury

Question 3

Assessment: Data includes

Answer 3

all the pertinent patient information collected by the nurse and other health care professionals

Question 4

What are medical assessments?

Answer 4

Medical assessments target data pointing to pathologic conditions

Question 5

What are nursing assessments?

Answer 5

Focus on the patients response to health problems

Question 6

What are the Characteristics of Nursing Assessments?

Answer 6

Purposeful
Prioritized
Complete
systematic
Accurate
Relevant
Recorded in a Standard Matter

Question 7

Characteristics of Nursing Assessments: Purposeful

Answer 7

When preparing for data collection, identify the purpose of the nursing assessment and gathehr the appropriate data

Question 8

Characteristics of Nursing Assessments: Prioritized

Answer 8

It is essential to get hte most important information first.

Question 9

Characteristics of Nursing Assessments: COmplete

Answer 9

As much as possible, identify all the patient data needed to understand a patient health problem and develop a care plan

Question 10

Characteristics of Nursing Assessments: Systematic

Answer 10

Using a systematic way to gather data

Question 11

Characteristics of Nursing Assessments: Factual and Accurate

Answer 11

Both you and the patient may intentionally or unintentionally misrepresent or distort patient information.

Question 12

Characteristics of Nursing Assessments: Relevant

Answer 12

Because recording comprehensive data can be time consuing, determine what type of data to document

Question 13

Characteristics of Nursing Assessments: Recorded in a Standard Matter

Answer 13

Data cannot be efficiently used unless you record the information according to the facilities policy.

Question 14

What are the four types of nursing assessments?

Answer 14

Initial Comprehensive
Focused
Emergency
Time-Lapsed

Question 15

Assessment: Initial Comprehensive

Answer 15

Performed shortly after the patient is admitted to a health care facility or service. Purpose iss to establish a complete database for problem identification and care planning

Question 16

Assessment: Focused

Answer 16

Nurse gathers data about a specific problem that has already been identified. Usually part of an on going data collection

Question 17

Assessment: Emergency

Answer 17

When a patient presents with a physiologic and psychological crisis, this is performed to identify life-threatening problems.

Question 18

`Assessment: Time-Lapsed

Answer 18

Scheduled to compare a patients current status to the baseline data obtained earlier.

Question 19

What is a Patient-Centered Assessment Method (PCAM)?

Answer 19

A tool health care practioners can use to assess patient complexity using the oscial determinants of health; can explain why some patient engage and respond well in managing their health while others do not experience the same outcomes

Question 20

What are the two days of data?

Answer 20

Objective vs Subjective

Question 21

What is Objective Data?

Answer 21

Observable and Measureable data that can be seen, heard, or felt by someone other than the person experiencing them. Can be verified by another person.

Question 22

What is Subjective Data

Answer 22

Information perceived only by the affected person. This cannot be perceived or verified by another person.

Question 23

What are vitals considered to be?

Answer 23

Objective, because you yoursef can see it. A rash would fall under this as well.

Question 24

Example of Subjective Data?

Answer 24

Feeling Nervous, Narseated, Chilly, or Experiencing Pain

Question 25

What can sources of data come from?

Answer 25

``` Patient Family and Significant Others Patient Record Other Health Care Profesionals Nursing and Other Health Care Literature ```

Question 26

What is a Physical Assessment?

Answer 26

The examination of the patient for objective data that may better define the patients condition and help the nurse plan care.

Question 27

Purpose of a Nursing Physical Assessment

Answer 27

Appraisal of Health Status Identifcation of Health Problems Establishment of a database for nursing intervention

Question 28

What is the Review of Systems?

Answer 28

When the nursing physical assessment involves the examination of all body systems. This includes four methods: Inspection, Palpation, Percussion, and Auscultation

Question 29

What is Inspection

Answer 29

The process of performing deliberate, purposeful observations in a systematic manner

Question 30

What is Palpation

Answer 30

Use of the sense of touch to assess skin temperature, turgor, texture, moisture as well as vibrations within the body

Question 31

What is Percussion

Answer 31

The act of striking one object against another to produce sound

Question 32

What is Auscultation

Answer 32

The act of listening with stethoscope to sounds produced within the body

Question 33

Problems Related to Data Collection

Answer 33

Inappropriate Organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data Failure to establish rapport and partnership Failure to update database