HEALTH ASSESSMENT LAB Flashcards
is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
Nursing process
is a systematic method of providing care to clients
Nursing process
is a systematic method of planning and providing individualized nursing care
Nursing process
PURPOSES OF NURSING PROCESS
- To identify a client’s health status and actual or potential health care problems or needs.
- To establish plans to meet the identified needs.
- To deliver specific nursing interventions to meet those needs.
CHARACTERISTICS OF NURSING PROCESS
- Cyclic
- Dynamic nature
- Client centeredness
- Focus on problem solving and decision making
- Interpersonal and collaborative style
- Universal applicability
- Use of critical thinking and clinical reasoning.
- Collect data
- Organize data
- Validate data
ASSESSMENT
is the systematic and continuous collection, organization, validation, and documentation of data (information).
Assessment
TYPES OF ASSESSMENT
- Initial nursing assessment
- Problem-focused assessment
- Emergency assessment
- Time-lapsed reassessment
Performed within specified time after admission
Initial nursing assessment
To establish a complete database for problem identification
Initial nursing assessment
Eg: Nursing admission assessment
Initial nursing assessment
To determine the status of a specific problem
identified in an earlier assessment.
Problem-focused assessment
Eg: hourly checking of vital signs of fever patient
Problem-focused assessment
During emergency situation to identify any life
Emergency assessment
Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest.
Emergency assessment
Several months after initial assessment
Time-lapsed reassessment
To compare the client’s current health status with the data previously obtained.
Time-lapsed reassessment
is the process of gathering information about a client’s health status
Data collection
It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
Data collection
also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person
Subjective data
Itching, pain, and feelings of worry are examples of
Subjective data
also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard
Objective data
They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination
Objective data
For example, a discoloration of the skin or a blood pressure reading is
Objective data
It is the direct source of information
Primary
It is the indirect source of information
Secondary
All sources other than the client are considered
Secondary
Observation, interview and examination are
METHODS OF DATA COLLECTION
It is gathering data by using the senses. Vision, Smell, and Hearing are used.
Observation
is a planned communication or a conversation with a purpose
Interview
is highly structured and directly asks the questions. And the nurse controls the interview.
directive interview
or rapport building interview and the nurse allows the client to control the interview.
nondirective interview
STAGES OF AN INTERVIEW
- The opening or introduction
- The body or development
- The closing
is a systematic data collection method to detect health problems
physical examination
uses techniques of inspection, palpation, percussion and auscultation.
physical examination
uses a format that organizes the assessment data systematically
Organization of data
often referred to as nursing health history or nursing assessment form
Organization of data
The information gathered during the assessment is “double-checked” or verified to confirm that it is accurate and complete
Validation of data
To complete the assessment phase, the nurse records client data
Documentation of data
- Analyze data
- Identify health problems, risks, and strengths
- Formulate diagnostic statements
DIAGNOSIS
is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems
Diagnosis
“a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”
The official NANDA definition of a nursing diagnosis
is a client problem that is present at the time of the nursing assessment
actual diagnosis
relates to clients’ preparedness to improve their health condition
health promotion diagnosis
is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given
risk nursing diagnosis
A nursing diagnosis has three components
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
statement of the client’s health problem
Problem
causes of the health problem
Etiology
defining characteristics manifested by the client
Signs and symptoms
is a statement of nursing judgment that made by nurse, by their education, experience, and expertise, are licensed to treat.
nursing diagnosis
describe the human response to an illness or a health problem
Nursing diagnoses
may change as the client’s responses change
Nursing diagnoses
EXAMPLES OF NURSING DIAGNOSIS
- Ineffective breathing pattern
- Activity intolerance
- Acute pain
- Disturbed body image
diagnosis is made by a physician
Medical diagnoses
diagnoses refer to disease processes
Medical diagnoses
remains the same for as long
as the disease is present.
Medical diagnoses
EXAMPLES OF MEDICAL DIAGNOSIS
- Asthma
- Cerebrovascular accident
- Appendicitis
- Amputation
- Prioritize problems/diagnoses
- Formulate goals/desired outcomes
- Select nursing interventions
- Write nursing interventions
PLANNING
involves decision making and problem solving
Planning
It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems
Planning
Planning which is done after the initial assessment
Initial Planning
It is a continuous planning
Ongoing Planning
Planning for needs after discharge
Discharge Planning
Planning includes;
- Establishing client goals/desired outcomes
- Selecting nursing interventions and activities
- Writing individualized nursing interventions on care plans
food, water, warmth, rest
Physiological needs
security, safety
Safety needs
intimate relationships, friends
Belongingness and love needs
prestige and feeling of accomplishment
Esteem needs
achieving one’s full potential, including creative activities
Self-actualization
is any treatment, that a nurse performs to improve patient’s health.
NURSING INTERVENTIONS
are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
Independent interventions
are activities carried out under the orders or supervision of a
licensed physician.
Dependent interventions
are actions the nurse carries out in collaboration with other
health team members
Collaborative interventions
is a written or computerized information about the client’s care
Nursing care plan
consists of doing and documenting the activities
Implementation
The process of implementation includes;
- Implementing the nursing interventions
* Documenting nursing activities
is a planned, ongoing, purposeful activity in which the nurse determines:
(a) the client’s progress toward achievement of goals/outcomes and
(b) the effectiveness of the nursing care plan.
Evaluation
The evaluation includes;
- Comparing the data with desired outcomes
* Continuing, modifying, or terminating the nursing care plan.
Communication is a series of experience of
- Hearing
- Smell
- Seeing
- Taste
- Touch
is the ability to use language (receptive) and express (expressive) information.
Communication skills
are a critical element in your career and personal lives
Effective communication skills
COMMUNICATION GOALS
- To change behavior
- To get action
- To ensure understanding
- To persuade
- To get and give information
MOST COMMON WAYS TO COMMUNICATE
- Speaking
- Writing
- Visual Image
- Body Language
-On The Basis Of Organization Relationship:
- Formal
* Informal
-On the basis of Flow:
- Vertical
- Crosswise/Diagonal
- Horizontal
-On the basis of Expression:
- Oral
- Written
- Gesture
> Symbols with different meaning > Badly expressed message > Faulty translation > Unclarified assumption > Specialist's language
Semantic Barriers
> Premature evolution > Inattention > Loss of transmission & poor retention > Undue reliance on the written word > Distrust of communication > Failure to communicate
Emotional Or Psychological Barriers
> Organizational policy
Organization rules & regulation
Status relation
Complexity in organization
Organizational Barriers
- Attitude of Superior
- Fear of challenge of authority
- Lack of time
- Lack of awareness
Barriers in Superior
- Unwillingness to communicate
* Lack of proper incentive
Barriers in Subordinates
the process of sending and receiving information among people
Communication
COMMUNICATION CODE SCHEME
- Codifying
- Sending the message
- Decodifying
the words we choose
Verbal Messages
how we say the words
Paraverbal Messages
our body language
Nonverbal Messages
EFFECTIVE VERBAL MESSAGES ARE
> Are brief, succinct, and organized
Are free of jargon
Do not create resistance in the listener
are the primary way that we communicate emotions
NONVERBAL MESSAGES
refers to the messages that we transmit through the tone, pitch, and pacing of our voices.
PARAVERBAL MESSAGES
Giving full physical attention to the speaker
Nonverbal
Paying attention to the words and feelings that are being expressed
Verbal
WHAT MAKES A GOOD COMMUNICATOR?
- Clarity
- Adequacy
- Timing
- Integrity
TIPS TO GOOD COMMUNICATION SKILLS
> Maintain eye contact with the audience > Body awareness > Gestures and expressions > Convey one's thoughts > Practice effective communication skills
EFFECTIVE COMMUNICATION IS
- It is two way.
- It involves active listening.
- It reflects the accountability of speaker and listener.
- It utilizes feedback.
- It is free of stress.
- It is clear.
