Introduction to Assessment Flashcards
Human caring
How to demonstrate caring in the assessment process
Communication
Demonstrate effective communication during the assessment process
Professional behaviors
Focus on time management as a nursing student
Safety
Factors that affect safety and fall prevention
Holistic nursing process
ADPIE (assessment, diagnosis, planning, implementation, evaluation)
Is the holistic nursing process linear?
no
Critical thinking
The process of intentional and reflective judgment about nursing problems, where the focus is on clinical decision-making to provide safe and effective
What question does critical thinking answer
“What if”
What does critical thinking guide and anticipate
guides actions and interventions, anticipates needs
Grounding
connecting to the Earth’s energy to focus on the task at hand
Creating intention
Direction of one’s awareness
Be CLEAR acronym
C - center yourself
L - listen wholeheartedly
E - empathize
A - Attention (be fully present)
R - Respect
What is collaborative professional communication characterized by
Assertive communication and standard communication tools (patient rounding, hand off report, SBAR documentation)
How is subjective data collected
through interviews with patients
What are some examples of subjective data
current state of health, medications, previous illnesses, surgeries, review of symptoms, and family history
How is objective data collected
through physical examinations and vital signs
What is objective data
Data that can be seen, felt, heard, or measured. It validates subjective data
Ongoing assessment
an assessment that is performed as needed, after the initial database is completed and ideally at every interaction with the client
When are ongoing assessments performed
at the start of a nurse’s shift
Comprehensive assessment
an assessment including a health history, interview, and a complete head-to-toe examination of every body system
Focused assessment
An assessment that pertains to a particular topic, body part, or functional ability rather than overall health status. It adds to the database created by the comprehensive assessment
When are comprehensive assessments performed
for an outpatient annual physical, an admission into an inpatient setting, in a long-term care facility, or in an initial home healing visit
When are focused assessments performed
In an emergency situation where the assessment would be rapid and focused on the presenting problem
What is a system-specific assessment
A focused assessment limited to one body system
What is a health assessment
A systematic method of collecting and analyzing data for the purpose of planning client-centered care
When does assessment begin
The first moment that a nurse meets their patient
What is a good assessment able to do
paint a clear picture of the patient
What is the purpose of a health assessment
to obtain baseline data, monitor a patient status, screen for health problems, and identify nursing diagnoses
supine
patient on back
fowler’s
head of bed elevated 30-45 degrees
prone
on stomach
lateral
on side
Sim’s
laying on stomach/side with leg bent
Lithotomy
on back with legs in the air
Palpation
uses touch to gather information
How to palpate correctly
Start with light palpation, end with deep. Use different parts of hands to detect different characteristics. Hands should be warm and fingernails short
Percussion
taping skin to vibrate underlying tissue and organs
What does percussion do
determines the location, size, and density of structures
Auscultation
listening to sounds that the body generates
what is direct auscultation
just using ears
what is indirect auscultation
using stethoscope
inspection
visual examination that is deliberate, purposeful, and systematic
What is a general survey
An overall impression of a client, beginning at the first contact, continuing throughout the exam
What are the 8 components of a general survey
1.) physical appearance/behavior
2.) body type/posture
3.) gait and movement
4.) speech
5.) mental state and affect
6.) dress/grooming/hygiene
7.) vital signs
8.) height/weight
