Nursing Assessment Flashcards
What are the 5 steps of the nursing process?
Assess
Diagnose
Plan
Implement
Evaluate
What occurs during the assess step of the nursing process?
Gather information about the patient’s condition
The collection, review, and analysis of data make up the process
Uses critical thinking
What happens during the diagnose step of the nursing process?
Identify the patient’s problems
What happens during the plan step of the nursing process?
Set goals of care and desired outcomes and identify appropriate nursing actions
What happens during the implement step of the nursing process?
Perform the nursing actions identified in planning
What happens during the evaluate step of the nursing process?
Determine if goals and expected outcomes are achieved
What are the two stages of assessment during the assessment process?
1 - Collection of information from a primary source (a patient) and secondary sources (medical record, relatives, nurse before you, etc.)
2 - The interpretation and validation of data to determine whether more data are needed or if the database is complete
What are the types of assessments?
Patient-centered interview
Periodic assessments
Physical examination
When is the patient-centered interview conducted?
During a nursing history
When are periodic assessments conducted?
During ongoing contact with patients
Which is a physical examination conducted?
During a nursing history and at any time a patient presents a symptom
(Hands on. Focused or head to toe)
What are the two types of data?
Subjective
Objective
What is subjective data?
Patient’s verbal descriptions of their health problems
Includes patient’s feelings, perceptions, and self-reported symptoms
How should subjective data be documented?
Patient states… “in quotations“
What is objective data?
Findings resulting from direct observation
What should you keep in mind when collecting objective data?
When collecting, you must apply critical thinking intellectual standards so that you can correctly interpret your findings
Sources of assessment data
Patient
Family caregivers and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse’s experience (what you’re bringing to the table)
Foundation for creating nurse-patient relationships
Effective communiation
How can a nurse build effective communication (and a strong nurse-patient relationship) with their patients?
- Trust building (have confidence)
- Presence (body language)
- Rounding (making rounds - checking on and assessing patients)
Important elements of the patient-centered interview
Motivational interviewing
Interview preparation
Communication skills
What is motivational interviewing during the patient-centered interview?
Addresses a patient’s ambivalence or uncertainty and allows you to become a helper in the change process
What is interview preparation in the patient-centered interview?
Read a patient’s medical record and be prepared before interviewing a patient
What does effective communication with patients require?
Courtesy
Comfort
Connection
Confirmation (at the end, ask patient to summarize the discussion so there are no uncertainties)
What are the phases of the interview?
Orientation and setting an agenda
Working phase - collecting data (assessment)
Termination phase
What interview techniques should be used during the working phase of an interview?
Direct the flow of discussion so patients have the opportunity to freely describe their problems and enable you to get a detailed picture of their needs
How should you use observation during the interview?
Observe a patient’s verbal and nonverbal behaviors
Example of an open ended question to use during the working phase of an interview
How are you doing today?
What are direct closed-ended questions? (Used during the interview)
Questions with yes or no answers
What are leading questions?
“You said you have pain below the knee, tell me more about that”
Examples of back channeling
“Alright”
“Go on”
“Uh huh”
Example of probing
“Tell me more about that”
What is interpreting?
Repeat what you have heard to confirm that patient’s meaning
What happens during the termination phase of an interview?
Thank the patient and close the conversation
What is a nursing health history?
A key component of a comprehensive assessment
Covers all health dimensions
What does it mean to have cultural competence?
Involves self-awareness, reflective practice, and knowledge of a patient’s core cultural background
What is cultural humility?
Requires you to recognize your own knowledge limitations and cultural perspective and thus be open to new perspectives
How should you show professionalism during history taking?
Look at the patient and not the computer
Position the computer in a way that does not distract from your focus on the patient
When taking the health history, how should you document present illness or health concerns?
Use PQRST
What does PQRST stand for?
Provokes - precipitating and relieving factors
Quality - what does it feel like?
Radiate - where is it located and does it go anywhere else?
Severity - pain scale
Time - onset and duration of symptoms, does it come and go?
What is the psychosocial history on a patient’s health history?
Gains info about a patient’s mental health, support system, and how they cope with stress
What is the review of systems in a health history?
Subjective info from patients about the presence or absence of health related issues in each body system
How should data documentation be recorded?
Record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology
What does data documentation provide?
A baseline to identify a patient’s health problems
To plan and implement care
To evaluate a patient’s response to interventions
What are the steps of the assessment process?
Data collection
Interpretation
Validation
What is the data collection part of the assessment process used for?
Use information about a patient’s needs to adapt your data collection
What is the interpretation part of the assessment used for?
To critically interpret the assessment data to determine whether abnormal findings are present
Uses cues and inferences
What is the validation part of the assessment process used for?
Comparison of data with another source to determine data accuracy
(Previous notes, vital signs, MAR to see when last meds were given, etc.)
What is concept mapping?
Helps organize assessment data
Placing all of the cues together into clusters that form patterns and leads you to the next stem of the nursing process and nursing diagnosis
Definite concomitant symptoms
Symptoms occurring during the same time period. Usually refers to secondary symptoms
Define functional health patterns
Method for organizing assessment data based on the level of patient function in specific areas (ex: mobility)
