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HEALTH ASSESSMENT LEC (DOC CONDES) > LESSON 1 - BEGINNING THE ASSESSMENT > Flashcards

LESSON 1 - BEGINNING THE ASSESSMENT Flashcards

1
Q

A systematic, rational method of planning and providing individualized nursing care

A

NURSING PROCESS

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2
Q

3 Purpose of Nursing Process:

A
  1. Identify a client health status and actual or potential health care problems and needs.
  2. Establish plans to meet the identifying needs.
  3. Deliver specific nursing intervention to meet needs.
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3
Q

5 Characteristic of nursing process:

A

•planned.
•universally applicable.
•goal directed.
•cyclic and dynamic.
•client centered.

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4
Q

Benefits of Nursing Process:

A

•Provides an orderly & systematic method for planning & providing care

•Enhances nursing efficiency by standardizing nursing practice

•Facilitates documentation of care

•Provides a unity of language for the nursing profession

•Stresses the independent function of nurses

•Increases care quality through the use of deliberate actions

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5
Q

The Nursing Process consist of a series of five component or phases which are:

A

1- Assessing.
2- Diagnosis.
3- Planning.
4- Implementing.
5- Evaluating.

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6
Q

Is a systematic and continuous collection, organization, validation and documentation of data.

A

ASSESSMENT

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7
Q

Nursing ______ focus upon client’s responses to a health problem.

A

ASSESSMENT

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8
Q

The assessment process involve four closely activities which are:

A

I- Collecting data.
II- Organizing data.
III- Validating data.
IV- Documenting data.

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9
Q

Is the process of gathering information about clients, and health status.

A

COLLECTING DATA

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10
Q

these data that can be described or verified only by that person.
e.g itching, pain, feelings, stress.

A

Subjective data (symptoms)

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11
Q

obtained through OBSERVATION and are verifiable and that can be seen heard, felt, or smelled, by observation and physical examination.
e.g discoloration, lungs sounds, vomited 100ml.

A

Objective data (signs)

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12
Q

4 Sources of data:

A

a- client.
b- Health care professionals.
c- Support people
d- Client records.

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13
Q

a Data collection method where it gathers data by using the five senses.

A

Observing

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14
Q

in doing this, before you begin, you’ll need to create an environment in which the patient feels comfortable, establish rapport and explain what you’ll cover in the ________.

A

Interviewing

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15
Q

to make the most of your patient interview, before you begin, you’ll need to ________

A
  1. create an environment in which the patient feels comfortable
  2. establish rapport
  3. explain what you’ll cover in the interview.
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16
Q

The things to consider to create the proper environment are:

A
  1. Settling in
  2. Watch what you say
  3. Communicate Effectively
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17
Q

Settling in covers:

A
  1. choose a quite, private, well-lit interview setting
  2. make sure that the patient is comfortable
  3. introduce yourself and explain the purpose of the health history and assessment
  4. reassure the patient that everything he says will be kept confidential
  5. tell the patient how long the interview
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18
Q

Watch what you say means to:

A
  1. assess the patient to see if language barriers exist
  2. speak slowly and clearly
  3. address the patient by a formal name
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19
Q

Realize that you and the patient communicate nonverbally as well as verbally. Being aware of these two forms of communication will aid you in the interview process.

A

Communicate Effectively

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20
Q

2 communication strategies

A

a. Nonverbal communication strategies
b. Verbal communication strategies

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21
Q

5 Nonverbal communication strategies

A

➢Listen attentively and make eye contact frequently
➢Use reassuring gestures (nodding)
➢Watch for nonverbal cues that indicate the patient is uncomfortable
➢Be aware of your nonverbal behaviors
➢Observe the patient closely to see if he understands each question

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22
Q

It range from alternating between open-ended and closed-ended questions to employing such techniques

A

Verbal communication strategies

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23
Q

it is a way of encouraging the patient to continue talking, and also gives you a chance to assess his ability to organize thoughts.

A

silence

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24
Q

using such phrases as “please continue”, “go on”, and even “uh-huh” encourages the patient to continue with his story.

A

Facilitation

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25
Q

it helps ensure that you and the patient are on the same track. For example, you might say, “If I understand you correctly, you said..”

A

Confirmation

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26
Q

it is repeating something that the patient has just said to help you obtain more specific information

A

Reflection

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27
Q

when information is vague and confusing, use this technique. For example, if your patient says, “I can’t stand this”, you might respond, “what can’t you stand?”

A

Clarification

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28
Q

this technique ensures that the data you’ve collected are accurate and complete. It signals that the interview is about to end.

A

summary

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29
Q

this gives the patient the opportunity to gather his thoughts and make any pertinent final statements. You can do this by saying, “I think I have all the information I need now. Is there anything you would like to add?”

A

Conclusion

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30
Q

A complete health history requires information from each of the following categories

A

Reviewing General Health

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31
Q

this includes the name, address, telephone number, birth date, age, marital status, religion and nationality.

A

Biographic data

32
Q

try to pinpoint why the patient is seeking health care.

A

Chief complaint

33
Q

ask the patient about past and current medical problems, such as hypertension, diabetes and back pain.

A

Medical history

34
Q

questioning the patient about his family’s health is a good way to uncover his risk of having certain diseases.

A

Family history

35
Q

find out how the patient feels about himself, his place in society, and his relationships with others. Ask about his education, economic status, and responsibilities.

A

Psychosocial history

36
Q

find out what’s normal for the patient by asking him to describe his typical day. Ask about his diet and elimination, exercise and sleep, work and leisure, use of alcohol, tobacco and other drugs, religious observances.

A

Activities of daily living

37
Q

Factors for Assessment

A

P- Palliative factors
Provocative factors
Q- Quality
R- Radiation
S- Severity
T- Temporal factors

38
Q

‘What makes it better?’ refers to what factor of assessment ?

A

Palliative factors

39
Q

“What makes it worse?’ refers to what factor of assessment ?

A

Provocative factors

40
Q

‘What exactly is it like?” refers to what factor of assessment ?

A

Quality

41
Q

‘Does it spread anywhere?’ refers to what factor of assessment ?

A

Radiation

42
Q

‘How severe is it?’ / ‘How much does it affect your life?’ refers to what factor of assessment ?

A

Severity

43
Q

‘Is it there all the time or does it come and go?’ refers to what factor of assessment ?

A

Temporal factors

44
Q

is a clinical judgment about individual, family or community responses to actual and potential health problems/life processes.

A

Nursing Diagnosis

45
Q

Types of nursing diagnosis:

A

1- An actual diagnosis
2- A risk nursing diagnosis

46
Q

is a client problem that is present at the time of nursing assessment, and is based on the presence of associated signs and symptoms.

A

Actual Diagnosis

47
Q

is a clinical judgment that a problem does not exit, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervention.

A

Risk Nursing Diagnosis

48
Q

impaired mobility is an example of _____

A

actual diagnosis

49
Q

risk for infection is an example of _____

A

Risk Nursing Diagnosis

50
Q

There are words that have been added to some NANDA label to give additional meaning

A

Problem: ( diagnostic label )

51
Q

identifies one or more probable causes of the health problem.

A

Etiology (related factor and risk factor)

52
Q

Are cluster of sign and symptoms that indicate the presence of a particular diagnostic label.

A

Defining characteristics

53
Q

3 Nursing Diagnosis process:

A

1- Analyzing data.
2- Identifying health problem, risks and strengths.
3- Formulating diagnostic statement.

54
Q

Ineffective breathing pattern R/T decreased lung expansion AEB dyspnea is an example of:

A

Nursing Diagnosis

55
Q

Disturbed body image R/T amputation AEB patient’s verbalization “nahuya ko makita sang tawo nga utod tiil ko” id an example of:

A

Nursing Diagnosis

56
Q

Risk for electrolyte imbalance R/T purging is an example of:

A

Nursing Diagnosis

57
Q

words that have been added to some NANDA label to give additional meaning are:

A

altered , impaired , decrease, ineffective, acute , chronic, Knowledge deficit. Ineffective breathing pattern

58
Q

is a deliberative, systematic phase of nursing process that involve decision making and problem solving

A

Planning

59
Q

Types of planning:

A

1- Initial planning
2- Ongoing planning
3- Discharge planning

60
Q

The process of anticipating and planning for needs after discharge.

A

Discharge planning

61
Q

Is done by all nurses who work with the client.

A

Ongoing planning

62
Q

It is the beginning of shift as the nurse plans the care to be given that day.

A

Ongoing Planning

63
Q

the nurse who performs the admission assessment usually develops the initial comprehensive plan of care.

A

Initial Planning

64
Q

4 Planning Process:

A

1- Setting priorities.
2- Establishing client goals/desired out comes.
3- Selecting nursing strategies.
4- Writing nursing orders.

65
Q

Selecting nursing intervention and activities are actions that nurse performs to a achieve client goals.

A

Implementing

66
Q

The specific strategies chosen should focus on eliminating or reducing the etiology.

A

Implementing/Intervention

67
Q

Types of Nursing Intervention:

A

1- Independent intervention
2- Dependent intervention
3- Collaborative intervention

68
Q

are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.

A

Independent intervention

69
Q

are activities carried out under the physician orders.

A

Dependent intervention

70
Q

are actions the nurse carries out in collaboration with other health team member.

A

Collaborative intervention

71
Q

Is the phase in which the nurse puts the nursing care plan into action.

A

Implementing

72
Q

Process of implementing:

A

1- Reassessing the client.
2- Determining the nurse need for assistance.
3- Implementing the nursing orders (strategies).
4- Delegating and Supervising.
5- Communicating the nursing actions.

73
Q

Is to judge or to appraise.

A

Evaluating

74
Q

______ is a planned, ongoing, purposeful activity in which clients and health care professionals determine:
- The clients progress toward goals an achievement.
- The effectiveness of the nursing care plan.

A

Evaluating

75
Q

Process of evaluating client responses:

A

1- Identify the desired out comes.
2- Collecting data related to desired out comes.
3- Compare the data with desired out comes
4- Relate nursing actions to client goals/desired outcomes.
5- Draw conclusions about problem status.
6- Continue to modify or terminate the clients care plan.

HEALTH ASSESSMENT LEC (DOC CONDES) (10 decks)

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