Health and Physical Assessment Flashcards
Who spends the most time with the client, knows the most about the client, and is able to communicate the client’s needs to the rest of the healthcare team the most effectively ?
The nurse
What are the 3 areas of assessment the nurse focuses on in order to get a complete picture of the client ?
- Body: assess the physical symptoms
- Mind: assess mental health
- Spirit: assess for religious or spiritual beliefs
What is the ADPIE nursing process?
- Assess: gather data
- Diagnosis: client problems that are based on medical diagnosis
- Plan: goals
- Implement: interventions
- Evaluate: how the client responded to the intervention
The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.
What are nursing clinical judgement skills?
- interpreting sign and symptom data
- prioritizing what is important
- generating solutions by making a plan
- understanding why an intervention is done
- gathering more information if there is not enough to make an informed decision
- evaluating if interventions or teaching was effective
What is a clinical pathway or care plan?
A plan that the healthcare team agrees to for guiding client care and is based on evidence based practice (EBP).
When does teaching and discharge planning by the nurse begin with a client ?
During the assessment even while the client is being admitted.
During the admission, assessment data is gathered by the nurse such as home environment and available ressources so that teaching can begin right away, if there are needs.
How should you identify a client before giving meds, doing a procedure, or performing an assessment ?
By using 2 client identifiers:
1. name and
2. date of birth, social security number, phone number, or address
Name and date of birth is most typically used.
What are the two purposes of doing a nursing assessment on a client ?
- gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.
- notify the health care provider (HCP) of immediate complications or changes in the client’s condition in order to update the care plan
The HCP can be a doctor, nurse practitioner or physician assistant.
What is the typical assessment order for most body systems?
- inspect
- palpate
- percuss
- auscultate
What is the difference between a focused health assessment and a comprehensive health assessment?
• Focused health assessment: Focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.
• Comprehensive health assessment: When the nurse assesses the entire client head to toe.
Which main physical systems are assessed in a comprehensive assessment starting from head to toe?
• neuro
• respiratory
• cardiac
• gastrointestinal
• kidneys
• musculoskeletal
• skin
In addition to the physical assessment of the client, what additional data does the nurse look at to get an overall picture of the client?
• labs
• CBC, BMP or CMP
• labs specific to problem
• imaging diagnostic tests
• x-rays, CT scan, MRI, etc
• medical and surgical history and physical from HCP
• medication administration record (MAR)
How often should a typical nursing physical assessment be done on each of the following units:
- Post-operatively
- ICU
- Progressive or Step-down unit
- Medical-surgical unit
- Post-Op: focused assessments every 5 - 15 minutes
- ICU: every 1 - 2 hours
- Progressive or Step-down unit: about every 2 - 4 hours
- Medical-surgical unit: about every 4 - 8 hours
What is subjective and objective data?
Subjective data: what the client tells you
Objective data: what anyone can observe
Subjective data example: the client’s stated pain level
Objective data example: a set of vital signs
What conditions cause a higher than normal body temperature?
• dehydration
• stress
• ovulation
• strenuous exercise
