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TFN > Health assessment > Flashcards

Health assessment Flashcards

1
Q

The very elements of nursing are all but unknown

A

Florence Nightingale 1859

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2
Q

Nursing is the diagnosis and treatment of human responses to health and illness

A

ANA 1995

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3
Q

Nursing is both A SCIENCE and AN ART that is concerned with the individual’s

A
  1. Physical
  2. Phychological
  3. Sociological
  4. Cultural
  5. Spiritual
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4
Q

The first step if the nursing process

A

Health assessment

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5
Q

The most important because it DIRECTS the rest of the process

A

Health assessment

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6
Q

Identify the normal and DIFFERENTIATE it from the abnormal

A

Health assessment

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6
Q

The client is a human being who has ? and has ?

A

worth and has dignity.

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7
Q

The ? is important in the nursing process.

A

therapeutic nurse-client relationship

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8
Q

“Combines the most desirable elements of the art of nursing with the most relevant elements of systems
theory, using the scientific method” – Shore 1988

A

THE NURSING PROCESS

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9
Q

“This process incorporates an interactive/interpersonal approach with a problem solving and decisionmaking process” was stated by?

A

– Peplau 1952

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10
Q

✓ G -
✓ O -
✓ S -
✓ H -

A

✓ G - oal oriented
✓ O - rganized
✓ S - ystematic
✓ H - umanistic care

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11
Q

THE NURSING PROCESS IS A (?)

A

SYSTEMATIC PROBLEM-SOLVING APPROACH

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12
Q

5 steps of the Nursing Process (ADPIE)

A
  1. ASSESSMENT
  2. DIAGNOSIS
  3. PLANNING
  4. INTERVENTION
  5. EVALUATION
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12
Q

refers to the body, this marvelous container and complex, finely tuned, machine with
which we interface with our environment and fellow beings. The physical self is the concrete
dimension, the tangible aspect of the person that can be directly observed and examined.

A

PHYSICAL

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13
Q

pertaining to the mind or to mental phenomena as the subject matter of
psychology. of, pertaining to, dealing with, or affecting the mind, especially as a function of
awareness, feeling, or motivation: psychological play; psychological effect.

A

PSYCHOLOGICAL

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14
Q

of or relating to sociology or to the methodological approach of sociology. Oriented
or directed toward social needs and problems.

A

SOCIOLOGICAL

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15
Q

the characteristics and knowledge of a particular group of people, encompassing
language, religion, cuisine, social habits, music and arts

A

CULTURAL

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16
Q

(?) need enhanced assessment skills to safely assess
critically ill clients who are outside the structured intensive care environment (Coombs &
Moorse, 2002).

A

Critical care outreach nurses

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16
Q

relating to religion or religious belief. Relating to or affecting the human spirit or soul as
opposed to material or physical things.

A

SPIRITUAL

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16
Q

The (?) performs a focused assessment, and then incorporates
assessment findings with a multidisciplinary team to develop a comprehensive plan of
care.

A

acute care nurse

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16
Q

assess and screen clients to determine the need for physician
referrals.

A

Ambulatory care nurses

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16
Q

make independent nursing diagnoses and referrals for collaborative
problems as needed.

A

Home health nurses

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17
Q

assess the needs of communities, school nurses monitor the
growth and health of children, and hospice nurses assess the needs of the terminally ill
clients and their families.

A

Public health nurses

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18
Q

is a very rapid assessment performed in life-threatening situations. In such
situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt
treatment. An example of an emergency assessment is the evaluation of the client’s airway, breathing,
and circulation (known as the ABCs) when cardiac arrest is suspected. The major and only concern
during this type of assessment is to determine the status of the client’s life sustaining physical functions.

A

emergency assessment

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19
Q

Consists of data collection that occurs after the comprehensive database is established. This
consists of a mini-overview of the client’s body systems and holistic health patterns as a followup on health status. Any problems that were initially detected in the client’s body system or holistic
health patterns are reassessed to determine any changes (deterioration or improvement) from
the baseline data. In addition, a brief reassessment of the client’s body systems and holistic health
patterns is performed to detect any new problems. This type of assessment is usually performed
whenever the nurse or another health care professional has an encounter with the client. This
type of assessment may be performed in the hospital, community, or home setting. The frequency
of this type of assessment is determined by the acuity of the client.

  • Eg.
    o A client admitted to the hospital with lung cancer requires frequent assessment of lung
    sounds. A total assessment of skin would be performed less frequently, with the nurse
    focusing on the color and temperature of the extremities to determine level of oxygenation.
A

Ongoing or Partial Assessment

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20
Q

An (?) identifies an occuring health problem for your patient

A

Actual nursing diagnosis

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21
Q

A (?) identifies a high-risk health problem that most likely will occur unless preventive measures are taken

A

Potential nursing diagnosis

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22
Q

A (?) is one that needs further data to support it

A

Possible nursing diagnosis

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23
Q

Full range of human experiences and responses to health and illness w/o restriction to a problem
focused orientation

A

Attention

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24
Q

Caring relationship that facilitates (?) and (?)

A

health and healing

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25
Q

Understanding and integration of objective data based on (?)

A

client’s subjective experience

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26
Q

Knowledge (?) for diagnosis and treatment

A

scientific

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27
Q

Human experience is (?) and (?) defined.

A

contextually and culturally

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28
Q

Observable assessment cues such as patient behavior, physical signs

A

Signs and Symptoms

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29
Q
  • Desired outcomes
  • Appropriate interventions
  • Involves setting goals and outcomes
  • Individualized plan of care for your patient is ready once diagnosis have been prioritized
A

PLANNING

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30
Q

Broad statement that describes a desired change in a patient’s condition, perceptions or
behavior

A

Goals

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31
Q

objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks or months

A

Long term goals

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32
Q

objective behavior or response that you expect the patient to achieve in
short time usually few hours or less than a week

A

Short term goals

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33
Q

Planning should be (SMART)

A

✓ Specific
✓ Measurable
✓ Attainable
✓ Realistic
✓ Time-bound

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34
Q
  • Defined as any treatment based on clinical judgment and knowledge that a nurse performs to
    enhance patient outcomes
  • Putting the plan of care into action
  • Also called IMPLEMENTATION
  • Involves carrying out your plan to achieve goals and outcomes
  • The “doing” phase
A

INTERVENTION

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35
Q

▪ Direct intervention
▪ Interventions are treatment performed through interaction with patient
▪ Ex. Medication administration, VS checking, insertion of IFC

A

Direct Care

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36
Q

▪ Interventions are treatments performed away from a patient but on behalf of the
patient or group of patient
▪ Ex. Safety and Infection control, Delegating nursing care

A

Indirect care

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37
Q

▪ Action that the nurse initiates without supervision or direction from others

A

Independent

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38
Q

▪ Actions that require an order from a health care provider

A

Dependent

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39
Q

▪ Interdependent interventions
▪ Therapies that require the combined knowledge, skills, and expertise of multiple
health care providers

A

Collaborative

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40
Q
  • Final step of the nursing process
  • Crucial to determine if the patient’s condition improved or worsen after application of the first four
    steps of nursing process
  • Monitoring of client’s progress
  • Alter the plan as indicated
  • Involves determining the effectiveness of your plan.
  • Once again, assess your patient’s response based on the criteria you set for the outcome.
A

Evaluation

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41
Q

PURPOSES OF THE NURSING PROCESS

A
  1. To identify a client’s health status; his Actual/Present and potential/possible health problems or
    needs.
  2. To establish a plan of care to meet identified needs.
  3. To provide nursing interventions to meet those needs.
  4. To provide an individualized, holistic, effective and efficient nursing care.
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42
Q

According to (?) and (?): Assessment is a part of each activity the nurse does for and
with the patient.

A

Atkinson and Murray (1991)

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43
Q

According to (?)
“Assessment is the deliberate and systematic collection of data to determine a
client’s current and past health status and functional status and to determine the client’s present and
coping patterns.”

A

Carpenito

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44
Q

The four basic types of assessment are:

A
  1. Initial comprehensive assessment
  2. Ongoing or partial assessment
  3. Focused or problem-oriented assessment
  4. Emergency assessment
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45
Q
  • Involves collection of subjective data about the client’s perception of his or her health of all body
    parts or systems, past health history, family history, and lifestyle and health practices (which
    includes information related to the client’s overall function) as well as objective data gathered
    during a step-by-step physical examination.
  • The nurse typically collects subjective data and objective data in many settings (hospital,
    community, clinic, or home). Depending on the setting, other members of the health care team
    may also participate in various parts of the data collection.

Eg.
o In a hospital setting the physician usually performs a total physical examination when the
client is admitted (if this was not previously done in the physician’s office). In this setting,
the nurse continues to assess the client as needed to monitor progress and client
outcomes. A physical therapist may perform a musculoskeletal examination, as in the case
of a stroke patient, and a dietitian may take anthropometric measurements in addition to
a subjective nutritional assessment.
o In a community clinic, a nurse practitioner may perform the entire physical examination.
o In the home setting, the nurse is usually responsible for performing most of the physical
examination.

A

Initial Comprehensive Assessment

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46
Q

Another crucial part of the first step in the nursing process

A

DOCUMENTING DATA

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47
Q

The common term used in the field of nursing when it comes to documentation

A

CHARTING

48
Q
  • It is a permanent record of patient’s information.
  • Tracks the progress of the patient’s condition during the hospitalization as well as the status upon
    discharge. It serves as an information sheet of the medications and procedures rendered to the
    patient.
  • Legal evidence for cross-examination whenever complaints or malpractice claims have been
    sighted out.
  • It serves as the evidence of continuity of care.
  • It serves as a research material for retrospective study.
A

Charting

49
Q

o traditional form of charting
o source-oriented record
o advantage is that it provides organized section for each member of the healthcare team
o disadvantage in using this type of recording is that the information is scattered throughout
the chart

A

Narrative charting

50
Q
  • give focus on the problems that patients face
  • each medical personnel can contribute and collaborate on the plan of care
  • advantage seen in this type of charting is collaboration among medical personnel
  • the disadvantage here is that it takes complete and on time assessment of problem lists
A

Problem-oriented charting

51
Q
  • usually used since it gives a quick look at the observation of each nurse as well as the
    nursing action on each observation.
A

SOAP formats

52
Q

S -
O -
A -
P -

A

S - Subjective
O - Objective data
A - Assessment
P - Plan

53
Q

S -
O -
A -
P -
I -
E -
R -

A

S - Subjective
O - Objective data
A - Assessment
P - Plan
I - Intervention
E - Evaluation
R - Revision

54
Q

includes the patient’s complaints or perception of the present
problem sited.

A

Subjective

55
Q

includes the nurse’s observation using his or her clinical eye

A

Objective

56
Q

includes the inference made by the nurse from the two types of
data. This is the part wherein the problem is stated. The nursing problem is stated
in a form of nursing diagnoses using the NANDA.

A

Assessment

57
Q

this includes the nursing actions to be made in order to solve the stated
problem. This part can be revised.

A

Plan

58
Q

This is the part wherein specific nursing actions are stated

A

Intervention

59
Q

This is the part wherein the nurse evaluates the reaction
of the patient or progress of the problem being solved.

A

Evaluation

60
Q

This is the section that states the changes made in order to
further resolve the problem.

A

Revision

61
Q

Ex: My skin is so itchy, especially on the skinfolds.”

A

Subjective

62
Q

Ex: Skin appears to be flushed with bumps. Irritation noted on the
armpit and inner thighs.

A

Objective

63
Q

Ex: Altered comfort secondary to food intake

A

Assessment

64
Q

Ex:
o Inform the patient not to scratch the skin.
o Apply cold compress on the hot spots
o Cut nails in order to prevent skin scratches
o Refer to the physician
o Assess for progress of skin rash

A

Planning

65
Q

Ex:
o Instructed not to scratch the skin.
o Cut the fingernails short
o Applied cold compress
o Referred to the physician

A

Intervention

66
Q

Ex:
“I feel more comfortable and I do not have the urge to scratch my
skin.”

A

Evaluation

67
Q

Ex:
Give antihistamine (Antamin) 1mg/mL as deep intramuscular
injection to left deltoid muscle.

A

Revision

68
Q

o This type of charting involves Data, Action and Response category.
o This is a client-focused charting
o Since it the client being talked about most of the documentation, this is a form of holistic
perspective of client’s needs.

A

Focus charting (FDAR)

69
Q

F -
D -
A -
R -

A

Focus
Data
Action
Response

70
Q
  • Nursing Dx, Client Concern, S&S, Event
A

Focus

71
Q
  • Facial grimacing, graded the nape pain as 7 in the scale of 1 to 10 with 10
    as severe pain
A

Data

72
Q
  • Given Norgesic Forte per orem as now dose.
A

Action

73
Q
  • Rated pain as 2 and able to walk on her own.
A

Response

74
Q
  • a model of communication
  • one of the most common handover
    mnemonic models used in health care
  • improve quality and patient safety
    outcomes when used by health team
    members to communicate or hand-off
    client information
A

The SBAR

75
Q

The SBAR

A

Situation, Background, Assessment,
Recommendation

76
Q
  • Focused on one major area of the body for clients who have a particular problem
  • Examples
    ▪ Cardiovascular assessment forms
    ▪ Neurologic assessment forms
A
  • Focused or Specialty Area Assessment Form
77
Q
  • Flowcharts that help staff record and retrieve data for frequent reassessments
  • Examples
    ▪ Vital signs sheet
    ▪ Assessment flowchart
  • Emphasis is placed on quality, not quantity of documentation
A

Frequent or Ongoing Assessment Form

78
Q
  • Is called a nursing admission or admission database
    o 4 types
    ▪ Open – Ended Forms (Traditional form)
    ▪ Cued or Checklist Forms
    ▪ Integrated Cued Checklist
    ▪ Nursing Minimum Data Set
A

Initial Assessment Form

79
Q
  • Used to manage the huge volume of information required in contemporary health care
  • Can integrate all pertinent client information into one record
  • Nurse’s responsibilities include storing client’s database, add new data, create and revise
    care plans and document client progress
  • Makes care planning and documentation relatively easy
  • Transmit information from one care setting to another
A

Electronic health records (EHRs)

79
Q
  • Widely used, concise method of organizing and recording data about a client, making
    information accessible to all health professionals
  • Consists of series of cards kept in a portable index file which is particular for a client
  • Can be quickly accessed to reveal specific data
  • May or may not become a part of the client’s permanent record
A

Kardex

80
Q
  • Graphic record
  • Intake and Output Record
  • Medication Administration Record (MAR)
  • Skin Assessment Record
A

Flow sheets

81
Q
  • Completed when the client is being discharged and transferred to another institution or to a
    home setting where a visit by a community health nurse is required
A

Nursing Discharge / Referral Summaries

82
Q

Best source of data, subjective data

A

Client

83
Q

o Family members, friends and caregivers
o Important source of data if the client is young
o unconscious or confused

A

Support people

84
Q

o Information documented by other healthcare professionals

A

Client records

85
Q

journals, reference texts, published studies

A

Literature

85
Q

-verbal reports

A

Health care professionals

86
Q

o To gather data using the senses
o A conscious, deliberate skill
o 2 aspects
▪ Noticing the data
▪ Selecting, organizing and interpreting the data

A

Observing

87
Q

o Planned communication or conversation with a purpose
o To get or give information
o Identify problems of mutual concern
o Evaluate change, teach, provide support
o Provide counselling or therapy

A

Interview

88
Q

o Nurse reviews the medical record before meeting with the client
o If a medical record is not established, the nurse will need to rely on interview skills to elicit
valid and reliable data from the client and that individual’s family or significant other

A
  • Pre -Introductory Phase
89
Q

o The nurse explains the purpose of the interview, discusses the types of questions that will
be asked, explains the reason for taking notes, and assures the client that confidential
information will remain confidential
o The nurse makes sure that the client is comfortable (physically and emotionally) and has
privacy
o The nurse should develop trust and rapport at this point in the interview

A

Introductory phase

90
Q

o Longest Phase
o Verbal / Nonverbal
o The nurse elicits the client’s comments about major biographic data, reasons for seeking
care, history of present health concern, past health history, family history, review of body
systems for current health problems, lifestyle and health practices, and developmental
level
o The nurse listens, observes cues, and uses critical thinking skills to interpret and validate
information received from the client
o The nurse and client collaborate to identify the client’s problems and goals

A

Working phase

91
Q

o Summarize / Restate
o Clarify
o The nurse summarizes information obtained during the working phase and validates
problems and goals with the client
o The nurse identifies and discusses possible plans to resolve the problem (nursing
diagnoses and collaborative problems) with the client
o Finally, the nurse makes sure to ask if anything else concerns the client and if there are
any further questions

A

Summary and closing phase

92
Q

o Highly Structured
o Controlled by the Nurse
o Elicits specific information
o Nurse uses directive questions

A

Directive interview

93
Q

o Rapport – building interview
o Controlled by the client

A

Non-Directive interview

94
Q

o Combination of non – directive and directive interview

A

Information gathering interview

95
Q

o Used in directive interview
o Answerable only by Yes or No
o Often begin with where, who, what, do, is
o For patients who are highly stressed and has difficulty communicating
o Ex. “Do you feel pain?”

A

Closed questions

96
Q

o Used in non – directive interview
o Invites client to explore, elaborate, clarify thoughts or feelings
o Useful in eliciting attitudes and mental status
o Often begin with what and how
o Ex. “What brought you to the hospital?”

A

Open ended questions

97
Q

o A question that the client can answer without direction or pressure from the nurse

A

Neutral questions

98
Q

o Closed
o Directive
o Persuasive

A

Leading questions

99
Q

Distance:

A

Maintain a 2 to 3 feet distance during interview

100
Q

Place

A

Well – lighted, well – ventilated room, free of noise and distractions

101
Q

Time

A

When the client is physically comfortable and free of pain

102
Q
  • Physical Examination
    o Carried out systematically
    o Cephalocaudal or head to toe approach
A

Examining

103
Q

o Also called review of systems
o A brief review of essential functioning of various body parts or systems

A

Screening Examination

104
Q
  • Lays the groundwork for identifying nursing problems and provides a focus for the physical
    examination
  • The importance lies in its ability to provide information that will assist the examiner in identifying
    areas of strength and limitation in the individual’s lifestyle and current health status
A

Complete health history

105
Q
  • FOR: assessment of posture, gait & balance
  • CONTRAINDICATION (CI): Patients who
    are weak, disabled, or paralyzed may need
    assistance or may not be able to assume this
    position
A

Standing

106
Q
  • Back lying position
    with knees flexed
    and hips externally
    rotated; small
    pillow under the
    head; soles of the
    feet on the surface
  • FOR: Head and
    neck, axillae, anteror thorax, lungs, breasts, heart,
    extremities, peripheral pulses, vital signs and vagina
  • CI: clients with cardio pulmonary problems. Not used for
    abdominal testing because of the increased tension in
    abdominal muscles. If patient has abdominal pain, flexing
    knees is usually more comfortable
A

Dorsal Recumbent

106
Q
  • seated position, back unsupported
    and legs hanging freely
  • FOR: Head neck posterior and
    anterior thorax breast Breasts
    axillae
  • heart vital signs, upper extremities
    lower extremities and reflexes
  • CI: Elderly and weak clients may
    require support
A

Sitting

107
Q
  • The client is lying on the back. The head and shoulders are
    usually elevated with a small pillow. The arms and legs are
    extended and the legs are slightly abducted
  • FOR: head neck axillae, anterior thorax, lungs, abdomen,
    extremities, peripheral pulses
  • CI: Tolerated poorly by clients with cardiovascular and
    respiratory problems
A

Supine

108
Q
  • The client is lying on the side with the body turned at 45
    degrees. The lower leg is extended, with the upper leg
    flexed at the hip and knee to a 45-to-90-degree angle.
  • FOR: assessment of rectum and vagina
  • CI: Difficult for elderly and people with limited joint
    movement
A

SIM’S

109
Q
  • The client is lying on the abdomen with head turned to the
    side.
  • FOR:
    Posterior
    thorax, hip joint movement
  • CI: Often not tolerated by the elderly and people with
    cardiovascular and respiratory problem
A

Prone

110
Q
  • The client is lying on the back with the hips and knees flexed
    at right angles and feet in stirrups.
  • FOR: assessment of female rectum and vagina. (for a brief
    period only)
  • CI: May be uncomfortable and tiring for elderly people. Often
    embarrassing
A

Lithotomy

111
Q
  • assessment of rectal area
  • assessment of rectal area (for brief period only)
  • Jack Knife
A

Knee chest

112
Q

➢ sense of touch
➢ The use of hand to touch and feel the patient’s skin,
organs, mass, and other delineated structures in the
body
➢ The pads of the fingers are used
➢ Assess temperature; turgor; texture; moisture;
vibrations; position, size, shape, consistency and
mobility of organ or masses; distention; pulsation;
and the presence pain upon pressure

A

Palpation

113
Q

➢ Striking of the body surface with short, sharp strokes
➢ Palpable vibrations and characteristic sound
➢ location, size, shape
➢ density of underlying structures
➢ to detect the presence of air or fluid in a body space
➢ elicit tenderness

A

Percussion

114
Q

▪ using sharp rapid movements from
the wrist, strike the body surface to be
percussed with the pads of two,
three, or four fingers or middle finger
alone
▪ Primarily used to assess sinuses in
the adult
▪ Using one hand to strike the surface
of the body

A

Direct percussion

115
Q

▪ percussion in which two hands are
used and the plexor strikes the finger
of the examiner’s other hand, which
is in contact with the body surface
being percussed (pleximeter- the
middle finger of the nondominant
hand)
▪ Using the finger of the one hand to
tap the finger of the other hand

A

Indirect percussion

116
Q

✓ Commonly called laboratory tests
✓ Used for basic screening as part of wellness check
✓ Used to help confirm diagnosis, monitor an illness, and provide valuable
information about the client’s response to treatment

A

Diagnostic tests

117
Q

✓ Commonly called laboratory tests
✓ Used for basic screening as part of wellness check
✓ Used to help confirm diagnosis, monitor an illness, and provide valuable
information about the client’s response to treatment

A

Pretest

118
Q

o specimen collection and performing or assisting with certain
diagnostic testing.
o The nurse uses standard precaution, sterile technique, provides
emotional and physical support while monitoring the client. Also the
nurse ensures correct labelling, storage, and transportation of
specimen to avoid invalid test result.

A

Intratest

119
Q

Post-test

A

o on nursing care of the client and follow-up activities and
observation.
o The nurse compares the previous and current test result and report
this to appropriate health team members.

120
Q

o commonly used diagnostic tests that can provide valuable
information about the hematologic system
o venipuncture (puncture of a vein for collection of a blood specimen)
is peformed

A

Blood test

121
Q

o includes hemoglobin and hematocrit measurements, erythrocyte
(red blood cells) count, red blood cell indices, leukocyte (white
blood cell) count, and a differential white cell count
o CBC is a basic screening test and one of the most frequently
ordered blood tests

A

Complete blood count (CBC)

TFN (31 decks)

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