Nursing Data, Documentation, Holistic Assessment Flashcards
The purpose of a nursing health assessment is to…
collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment
Phases of the nursing assessment
Assessment
Diagnosis
Planning
Implementation
Evaluation
____________________ is the first and most critical phase of the nursing process.
Assessment
In a hospital setting, the ___________________ usually performs a total physical examination when the client is admitted.
physician
A(n) _____________________ assessment is a very rapid assessment performed in life-threatening situations.
emergency
T/F An initial comprehensive assessment of the client consists of data collection that occurs after a comprehensive database is established
False
Is it important for the nurse to maintain a focus on each client’s context of their culture, family, and community when providing care.
yes
T/F Family history is subjective data
true
You percuss a client’s lungs, and hear a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?
Resonance
An pt is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform?
Emergency
Assessment phase of nursing process
Collecting objective and subjective data
Diagnosis phase of nursing process
Analyzing subjective and objective data to make and prioritize professional clinical judgments (client concerns, collaborative problems, or referral)
Assessment phase of nursing process
Generating solutions, developing a plan, and determining which outcomes need to be met first
Implementation phase of nursing process
Taking action. Prioritizing and implementing the planned interventions
Evaluation phase of nursing process
Assessing whether outcomes have been met and revising the plan if the interventions did not make a difference
Healthy People 2030 was developed by
U.S. Department of Health and Human Services (DHHS)
Healthy People 2030 aims to
increase the life span and improve the quality of health for all Americans. The progress toward this goal is evaluated every 10 years, resulting in the development of new goals and objectives
USPSTF
determines risk versus benefit in screenings
Type of assessment that collects subjective and objective data gathered during a step-by-step physical examination. Establishes baseline data against which future health status changes can be measured and compared
Initial comprehensive assessment
Data collection that occurs after the comprehensive database is established. Mini overview of the client’s body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes from the baseline data.
Ongoing or partial assessment
A thorough assessment of a particular client issue and does not address areas not related to the problem. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern.
Focused or problem-oriented assessment
Very rapid assessment performed in life-threatening situations. The major and only concern during this type of assessment is to determine the status of the client’s life-sustaining physical functions.
Emergency assessment
What are the 4 Steps of Health Assessment?
Collection of subjective data
Collection of objective data
Validation of data
Documentation of data
Is the review of systems part of objective or subjective data?
Subjective
During this phase, the nurse identifies and clusters the cues collected to make clinical judgments. The end result of this is identification of client concerns, collaborative problems, and/or referrals.
Data analysis phase of the nursing process
Preintroductory Phase of interviewing
The nurse reviews the medical record before meeting with the client.
Introductory Phase of interviewing
After introducing self to the client, nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential
Working Phase of interviewing
The nurse elicits the client’s comments observed from the chart. The nurse listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client.
The nurse and client collaborate to identify the client’s problems and goals.
Working phase
Closing / Summary Phase
The nurse summarizes information obtained during the working phase and validates problems and goals with the client
