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Intro To Nursing Care > Nursing Assessment > Flashcards

Nursing Assessment Flashcards

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1
Q

What are the 5 steps of the nursing process?

A

Assess
Diagnose
Plan
Implement
Evaluate

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2
Q

What occurs during the assess step of the nursing process?

A

Gather information about the patient’s condition
The collection, review, and analysis of data make up the process
Uses critical thinking

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3
Q

What happens during the diagnose step of the nursing process?

A

Identify the patient’s problems

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4
Q

What happens during the plan step of the nursing process?

A

Set goals of care and desired outcomes and identify appropriate nursing actions

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5
Q

What happens during the implement step of the nursing process?

A

Perform the nursing actions identified in planning

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6
Q

What happens during the evaluate step of the nursing process?

A

Determine if goals and expected outcomes are achieved

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7
Q

What are the two stages of assessment during the assessment process?

A

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

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8
Q

What are the types of assessments?

A

Patient-centered interview
Periodic assessments
Physical examination

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9
Q

When is the patient-centered interview conducted?

A

During a nursing history

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10
Q

When are periodic assessments conducted?

A

During ongoing contact with patients

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11
Q

Which is a physical examination conducted?

A

During a nursing history and at any time a patient presents a symptom
(Hands on. Focused or head to toe)

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12
Q

What are the two types of data?

A

Subjective
Objective

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13
Q

What is subjective data?

A

Patient’s verbal descriptions of their health problems
Includes patient’s feelings, perceptions, and self-reported symptoms

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14
Q

How should subjective data be documented?

A

Patient states… “in quotations“

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15
Q

What is objective data?

A

Findings resulting from direct observation

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16
Q

What should you keep in mind when collecting objective data?

A

When collecting, you must apply critical thinking intellectual standards so that you can correctly interpret your findings

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17
Q

Sources of assessment data

A

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)

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18
Q

Foundation for creating nurse-patient relationships

A

Effective communiation

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19
Q

How can a nurse build effective communication (and a strong nurse-patient relationship) with their patients?

A
  • Trust building (have confidence)
  • Presence (body language)
  • Rounding (making rounds - checking on and assessing patients)
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20
Q

Important elements of the patient-centered interview

A

Motivational interviewing
Interview preparation
Communication skills

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21
Q

What is motivational interviewing during the patient-centered interview?

A

Addresses a patient’s ambivalence or uncertainty and allows you to become a helper in the change process

22
Q

What is interview preparation in the patient-centered interview?

A

Read a patient’s medical record and be prepared before interviewing a patient

23
Q

What does effective communication with patients require?

A

Courtesy
Comfort
Connection
Confirmation (at the end, ask patient to summarize the discussion so there are no uncertainties)

24
Q

What are the phases of the interview?

A

Orientation and setting an agenda
Working phase - collecting data (assessment)
Termination phase

25
Q

What interview techniques should be used during the working phase of an interview?

A

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

26
Q

How should you use observation during the interview?

A

Observe a patient’s verbal and nonverbal behaviors

27
Q

Example of an open ended question to use during the working phase of an interview

A

How are you doing today?

28
Q

What are direct closed-ended questions? (Used during the interview)

A

Questions with yes or no answers

29
Q

What are leading questions?

A

“You said you have pain below the knee, tell me more about that”

30
Q

Examples of back channeling

A

“Alright”
“Go on”
“Uh huh”

31
Q

Example of probing

A

“Tell me more about that”

32
Q

What is interpreting?

A

Repeat what you have heard to confirm that patient’s meaning

33
Q

What happens during the termination phase of an interview?

A

Thank the patient and close the conversation

34
Q

What is a nursing health history?

A

A key component of a comprehensive assessment
Covers all health dimensions

35
Q

What does it mean to have cultural competence?

A

Involves self-awareness, reflective practice, and knowledge of a patient’s core cultural background

36
Q

What is cultural humility?

A

Requires you to recognize your own knowledge limitations and cultural perspective and thus be open to new perspectives

37
Q

How should you show professionalism during history taking?

A

Look at the patient and not the computer
Position the computer in a way that does not distract from your focus on the patient

38
Q

When taking the health history, how should you document present illness or health concerns?

A

Use PQRST

39
Q

What does PQRST stand for?

A

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?

40
Q

What is the psychosocial history on a patient’s health history?

A

Gains info about a patient’s mental health, support system, and how they cope with stress

41
Q

What is the review of systems in a health history?

A

Subjective info from patients about the presence or absence of health related issues in each body system

42
Q

How should data documentation be recorded?

A

Record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology

43
Q

What does data documentation provide?

A

A baseline to identify a patient’s health problems
To plan and implement care
To evaluate a patient’s response to interventions

44
Q

What are the steps of the assessment process?

A

Data collection
Interpretation
Validation

45
Q

What is the data collection part of the assessment process used for?

A

Use information about a patient’s needs to adapt your data collection

46
Q

What is the interpretation part of the assessment used for?

A

To critically interpret the assessment data to determine whether abnormal findings are present
Uses cues and inferences

47
Q

What is the validation part of the assessment process used for?

A

Comparison of data with another source to determine data accuracy
(Previous notes, vital signs, MAR to see when last meds were given, etc.)

48
Q

What is concept mapping?

A

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

49
Q

Definite concomitant symptoms

A

Symptoms occurring during the same time period. Usually refers to secondary symptoms

50
Q

Define functional health patterns

A

Method for organizing assessment data based on the level of patient function in specific areas (ex: mobility)

Intro To Nursing Care (10 decks)

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