Intro Flashcards

1
Q

What is the definition of Health Assessment?>

A

objective data to collect information about clients

  • process of systematically collecting and analyzing data to make judgements about wellness
  • May involve family, individuals, or communities
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2
Q

4 purposes of health assessment

A

HOLISTIC

  1. understanding of person’s experience of health and life processes
  2. identify strengths that promote health
  3. identify needs and clinical problems
  4. evaluate the effects therapeutic plans and interventions
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3
Q

6 types of assessment

A
  • admission
  • focus
  • time lapse
  • emergency
  • basic nursing assessment: head to toe
  • observation
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4
Q

This type of assessment is comprehensive and done in several settings. It includes insurance, providers, surgeries, history, faith

A

Admission Assessment

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5
Q

This type of assessment is for a particular set of circumstances relevant to patient condition

A

Focus assessment

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6
Q

This kind of assessment looks at patient over time

A

Time Lapse Assessment

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7
Q

This kind of assessment is focused on life or death problem like airway and overlooks other details

A

Emergency Assessment

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8
Q

This kind of assessment is a head to toe model

A

Basic Nursing Assessment

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9
Q

This kind of assessment involves use of all the sense to collect data

A

Observation assessment

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10
Q

4 phases of interviewing a patient

A
  1. preparatory phase
  2. introductory phase
  3. maintenance phase
  4. concluding phase
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11
Q

What kind of data are you collecting during interviewng?

A

subjective data

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12
Q

this phase of the interview occurs before the nurse meets the patient

A

prepatory

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13
Q

this phase begins when the nurse and the patient meet

A

introductory

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14
Q

this phase begins when nurse and patient work toward achieving a specific goal

A

maintenance

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15
Q

this phase completes the interview

A

concluding phase

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16
Q

Subjective vs Objective data

A
Subjective = patients feelings and statements about their health problems
Objective= observable, perceptible and measurable data like VS, labs, diagnostics
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17
Q

2 sources of data

A
Primary = patient
Secondary= all other sources including diagnostic tests
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18
Q

1 cm or 1/2 inch depression is ____ palpation

A

Light

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19
Q

5 cm or 2 inches using both or one hand is ____ palpation

A

Deep

20
Q

What part of hand do you use to assess skin temperature during palpation?

A

Dorsal

21
Q

What areas do you palpate last?

A

tender areas

22
Q

What part of hand do you use to assess texture, moisture, or areas of tenderness?

A

Fingers

23
Q

2 types of percussion

A

Direct or indirect

24
Q

What makes a resonant sound during percussion?

A

air

25
Q

what makes a flat, thud, dull sound during percussion?

A

bone

26
Q

Produces different notes depending on underlying mass
-used to determine size, shape, density of underlying structure by establishing their borders and indicates if tissue is air filled, fluid filled, or solid

A

percussion

27
Q

Act of listening to sounds with the body to evaluate the condition of body organs

A

auscultation

28
Q

Sound characteristic: high or low

A

=frequency/pitch

29
Q

Sound characteristic: soft or loud

A

= intensity

30
Q

Sound characteristic: types: gurgling, blowing, musical=

A

= quality

31
Q

Sound characteristic:: short, medium, long, specific time

A

=duration

32
Q

4 characteristics to consider when auscultating

A

frequency/pitch
intensity
quality
duration

33
Q

When do use flat side of diaphragm?

A
  • high pitched sounds

- bowel, breath, normal cardiac

34
Q

When do you use bell side of stethoscope?

A

low pitched sounds

-heart murmurs

35
Q

Which way do ear pieces point on stethoscope?

A

forward into ears

36
Q

I’m available if you need to talk =

A

offering self

37
Q

What is on your mind today=

A

opening remarks

38
Q

during the past hour, you and i have discussed….

A

summarizing

39
Q

A client says , “I am ready to do walk” and the nurse says “did i hear you say you are ready to walk now? “

A

restatement

40
Q

Patient “ What do yo think I should do about telling my employer about my illness”
Nurse “What have you been thinking about this situation”

A

reflection

41
Q

Lets stop and look more closely at your feeling about managing your medication

A

focusing

42
Q

Tell me more about…

A

encouraging elaboration

43
Q

I am not sure I follow you. What would you say the main point of what you said was?

A

seeking clarification

44
Q

The medication is for your high blood pressure

A

giving information

45
Q

Maintain an interested expectant silence

A

silence