Nursing Assessment (CBA 1) Flashcards
clinical inference
An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength
probing
an open ended question technique used in interviewing. asked after data are gathered to seek more in-depth information
-ex: “Tell me what makes your headaches begin”
cue
information gathered through your senses
reflection
an internal process of thinking back about a situation
value belief pattern
leads a patient to describe patterns of values, beliefs, and life goals
cognitive perceptual pattern
questions that focus on the patient’s language adequacy, memory, and decision-making ability
health perception health management pattern
a patient’s self-report of how he or she manages his or her health and his or her knowledge of preventive health practices
assessment
- Recognition that further observations are needed to clarify information
- collection of data from secondary sources such as the patient’s family
- Comparison of data with another source to determine data accuracy
different types of assessment
patient centered interview, physical assessment, periodic assessments
nursing health history
includes a description of a patient’s habits and lifestyle patterns
nursing health history
includes a description of a patient’s habits and lifestyle patterns
gordons functional health patterns
structured database-type assessment technique that includes 11 patterns to assess.
- health perception and health management
- nutritional-metabolic
- elimination
- activity and exercise
- sleep and rest
- cognition and perception
- self-perception and self-concept
- roles and relationships
- sexuality and reproduction
- coping and stress tolerance
- values and beliefs
validation
involves comparing data with other sources for accuracy
PQRST assessment
- what causes the pain? P= provokes
- what does the pain feel like? Q= quality
- where is the pain located? R= radiate
- what is the rating on a scale of 0-10? S=severity
- does it come and go? T= time
