Exam3: Chapter 14 Assessing Flashcards
What is Assessing?
Systematic and continuous collection, analysis, validation, and communication of patient data.
Assessment: What does data refelct?
Reflects how health functioning is enhanced by health promotion or compromised by illness/injury
Assessment: Data includes
all the pertinent patient information collected by the nurse and other health care professionals
What are medical assessments?
Medical assessments target data pointing to pathologic conditions
What are nursing assessments?
Focus on the patients response to health problems
What are the Characteristics of Nursing Assessments?
Purposeful Prioritized Complete systematic Accurate Relevant Recorded in a Standard Matter
Characteristics of Nursing Assessments: Purposeful
When preparing for data collection, identify the purpose of the nursing assessment and gathehr the appropriate data
Characteristics of Nursing Assessments: Prioritized
It is essential to get hte most important information first.
Characteristics of Nursing Assessments: COmplete
As much as possible, identify all the patient data needed to understand a patient health problem and develop a care plan
Characteristics of Nursing Assessments: Systematic
Using a systematic way to gather data
Characteristics of Nursing Assessments: Factual and Accurate
Both you and the patient may intentionally or unintentionally misrepresent or distort patient information.
Characteristics of Nursing Assessments: Relevant
Because recording comprehensive data can be time consuing, determine what type of data to document
Characteristics of Nursing Assessments: Recorded in a Standard Matter
Data cannot be efficiently used unless you record the information according to the facilities policy.
What are the four types of nursing assessments?
Initial Comprehensive
Focused
Emergency
Time-Lapsed
Assessment: Initial Comprehensive
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
Assessment: Focused
Nurse gathers data about a specific problem that has already been identified. Usually part of an on going data collection
Assessment: Emergency
When a patient presents with a physiologic and psychological crisis, this is performed to identify life-threatening problems.
`Assessment: Time-Lapsed
Scheduled to compare a patients current status to the baseline data obtained earlier.
What is a Patient-Centered Assessment Method (PCAM)?
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
What are the two days of data?
Objective vs Subjective
What is Objective Data?
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.
What is Subjective Data
Information perceived only by the affected person. This cannot be perceived or verified by another person.
What are vitals considered to be?
Objective, because you yoursef can see it. A rash would fall under this as well.
Example of Subjective Data?
Feeling Nervous, Narseated, Chilly, or Experiencing Pain
What can sources of data come from?
Patient Family and Significant Others Patient Record Other Health Care Profesionals Nursing and Other Health Care Literature
What is a Physical Assessment?
The examination of the patient for objective data that may better define the patients condition and help the nurse plan care.
Purpose of a Nursing Physical Assessment
Appraisal of Health Status
Identifcation of Health Problems
Establishment of a database for nursing intervention
What is the Review of Systems?
When the nursing physical assessment involves the examination of all body systems. This includes four methods: Inspection, Palpation, Percussion, and Auscultation
What is Inspection
The process of performing deliberate, purposeful observations in a systematic manner
What is Palpation
Use of the sense of touch to assess skin temperature, turgor, texture, moisture as well as vibrations within the body
What is Percussion
The act of striking one object against another to produce sound
What is Auscultation
The act of listening with stethoscope to sounds produced within the body
Problems Related to Data Collection
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
