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FUNDA > Nursing Process - Assessment > Flashcards

Nursing Process - Assessment Flashcards

1
Q

It is a systematic, and client- centered method that provides a structure in the delivery of nursing care

A

Nursing Process

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2
Q

It is a goal-oriented method that provides a framework for nursing practice

A

Nursing Process

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3
Q

They are considered the central figure in the plan of care (Nursing Process)

A

patients

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4
Q

This entails gathering and analyzing data to identify health issues / concerns

A

Nursing Process

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5
Q

What are the 4 purposes of the Nursing Process?

A

1.Identify the client’s health status
2.Identify actual or potential health problems or needs
3. Establish plans to meet the identified needs
4. Deliver specific nursing interventions to meet those needs

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6
Q

12 Characteristics of Nursing Process

A
  1. Systemic
  2. Cyclic and Dynamic Nature
  3. Client-centered
  4. Focused on Problem-Solving
  5. Focused on Decision-making
  6. Interpersonal and Collaborative
  7. Universally Applicable
  8. Uses Critical Thinking
  9. Utilizes Clinical Reasoning
  10. Outcome Oriented
  11. Proactive
  12. Evidence-Based
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7
Q

A systematic & continuous collection, organization, validation, & documentation of data

A

Assessment

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8
Q

Used to establish a complete database for problem identification, reference, and future comparison

A

Initial assessment or comprehensive assessment

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9
Q

This assessment should include assessment of the physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factors, and the client’s coping patterns

A

Initial assessment or comprehensive assessment

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10
Q

Example of this type of assessment is Nursing admission assessment

A

Initial assessment or comprehensive assessment

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11
Q

Used to determine the status of a specific problem identified in an earlier assessment

A

Problem-focused assessment

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12
Q

Examples of this type of assessment are Hourly assessment of a client’s I&O in an ICU and Assessment of the client’s ability for self-care while assisting a client to bathe

A

Problem-focused assessment

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13
Q

This assessment is used to identify life-threatening problems and new or overlooked problems

A

Emergency assessment

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14
Q

This assessment is used to compare client’s status to baseline data previously obtained

A

Time-lapsed reassessment

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15
Q

4 Major activities done during assessment

A

Collecting data, Organizing data, Validating data, Documenting data (COVD)

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16
Q

What are the 5 Database sources of Data Collection?

A

A. Nursing Health History
B. Physical Assessment / Examination (PE)
C. Primary Care Provider’s History and PE
D. Results of Lab and Diagnostic Tests
E. Materials Contributed by other Health Personnel

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17
Q

Gives subjective information on how a health condition came about

A

Nursing Health History

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18
Q

5 Data/Information to be collected in Nursing Health History

A
  1. level of wellness
  2. changes in life patterns
  3. socio-cultural role
  4. mental and emotional reactions to illness
  5. other health conditions
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19
Q

The purpose of this activity is to identify:
- patterns of health and illness
- risk factors for health problems
- deviations from normal, and
- available resources for adaptation

A

Nursing Health History

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20
Q

They are the sources of information in Health History Taking

A

client, family or significant others, health team members & client’s health record

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21
Q

Most of the data in Health History Taking are _________?

A

Subjective

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22
Q

Focus on ______ from all the client’s dimensions

A

data/information

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23
Q

Record data using _____, ______, and ________ terminology

A

clear, concise, and appropriate

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24
Q

What are the 8 Basic Components of Health History?

A
  1. Demographic Data
  2. Reason/s for Seeking Care or Chief Complaint
  3. Present Health or History of Present Illness
  4. Past Medical/Health History
  5. Family History
  6. Socio-Economic Data or Social History
  7. Psychosocial Assessment
  8. Functional Assessment
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25
Q

What are the data collected when taking Client’s Demographic (Biographical) Data?

A
  • Client’s name
  • Sex
  • Age
  • Date & Place of Birth
  • Marital Status
  • Race / Nationality, Religion
  • Address / Contact Number
  • Educational Background
  • Other Significant Trainings, Occupation
  • Usual Source of Medical Care
  • Source and Reliability of Information
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26
Q

Recorded as direct quotes from the client

A

Reason/s for Seeking Care or Chief Complaint

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27
Q

What does a well person describes when you collect their Present Health or History of Present Illness?

A

General State of Health

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28
Q

What does an ill person describes when you collect their Present Health or History of Present Illness?

A

History of Present Illness (HPI)

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29
Q

What are the critical characterstics or qualifiers included in the information of HPI?

A
  • Timing (onset, duration and frequency of symptoms)
  • Location
  • Quality (character)
  • Quantity (severity)
  • Setting in which symptoms occur
  • Associated phenomena / manifestations
  • Aggravating / alleviating factors
  • Meaning and impact of CC to the patient
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30
Q

It includes
- Review of previous illness
- Injuries & hospitalizations
- Obstetric history (female)
- Surgeries / operations
- Allergies
- Immunizations
- Use of medications

A

Past Medical / Health History

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31
Q

It Includes the health status of the immediate family members and other blood relations.

A

Family History

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32
Q

It helps the nurse assess the client’s risk of developing certain diseases / illnesses

A

Family History

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33
Q

Family History can be presented with what?

A

Genogram or Family Tree

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34
Q

This includes

  • Alcohol, drug and/or tobacco use
  • Sexual practices
  • Travel history
  • Work environment
  • Home environment
  • Hobbies and leisure activities
  • Stressors
  • Education
  • Economic status
  • Religion
  • Ethnic background
  • Roles and relationships
  • Characteristic patterns of daily living
  • Functional health assessment
A

Socio-Economic Data or Social History

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35
Q

This is used to detect endemic illnesses

A

Travel History

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36
Q

Specific for the current developmental stage of the client

A

Psychosocial Assessment

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37
Q

What Theory is used for Psychosocial Assessment?

A

Erik Erikson’s Psychosocial Development Theory

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38
Q

Includes a person’s ability to perform instrumental activities of daily living and physical self-maintenance activities

A

Functional Assessment

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39
Q

It is made up of patterns, each of which is a sequence of related behaviors that assist the nurse in collecting, organizing, and categorizing
data.

A

Functional Assessment

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40
Q

What is used to assess patients’ Health Patterns?

A

Gordon’s 11 Functional Health Patterns

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41
Q

(Part of Gordon’s 11 Functional Health Patterns)

It includes person’s description of his current health

A

Health Perception – Health Management Pattern

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42
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes activities that the person does to improve or maintain his health

A

Health Perception – Health Management Pattern

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43
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s knowledge about links between lifestyle choices and health

A

Health Perception – Health Management Pattern

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44
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes extent of a person’s problem on financing health care, if any

A

Health Perception – Health Management Pattern

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45
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s knowledge of the names of current medications / purpose

A

Health Perception – Health Management Pattern

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46
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes activities that the person does to prevent problems related to allergies

A

Health Perception – Health Management Pattern

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47
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s knowledge about medical problems in the family

A

Health Perception – Health Management Pattern

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48
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any important illnesses or injuries in this person’s life

A

Health Perception – Health Management Pattern

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49
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s nourishment

A

Nutritional – Metabolic Pattern

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50
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s food choices in comparison with recommended food intake

A

Nutritional – Metabolic Pattern

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51
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any disease that affects nutritional-metabolic function

A

Nutritional – Metabolic Pattern

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52
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s excretory pattern

A

Elimination Pattern

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53
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s any disease of the digestive system, urinary system, or skin

A

Elimination Pattern

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54
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s description of his weekly pattern of activities, leisure, exercise, and recreation

A

Activity – Exercise Pattern

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55
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any disease that affects his cardio-respiratory and/or musculoskeletal systems

A

Activity – Exercise Pattern

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56
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s description of the person’s sleep-wake cycle

A

Sleep – Rest Pattern

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57
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s physical appearance (rested and relaxed?)

A

Sleep – Rest Pattern

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58
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s any sensory deficit and if corrected

A

Cognitive – Perceptual Pattern

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59
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s ability to express himself clearly and logically

A

Cognitive – Perceptual Pattern

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60
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s education

A

Cognitive – Perceptual Pattern

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61
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any disease that affects mental or sensory function

A

Cognitive – Perceptual Pattern

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62
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s pain description and causes, if any

A

Cognitive – Perceptual Pattern

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63
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes anything unusual about the person’s appearance

A

Self-Perception / Self-Concept Pattern

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64
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes if person is comfortable with his appearance

A

Self-Perception / Self-Concept Pattern

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65
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes description of the person’s feeling state

A

Self-Perception / Self-Concept Pattern

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66
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s description of his various roles in life

A

Role-Relationship Pattern

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67
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes positive role models of his roles, if any

A

Role-Relationship Pattern

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68
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes important relationships at present

A

Role-Relationship Pattern

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69
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any big changes in role or relationship

A

Role-Relationship Pattern

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70
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s satisfaction with his situation related to sexuality

A

Sexuality-Reproductive Pattern

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71
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes How have the person’s plans and experiences matched regarding having children?

A

Sexuality-Reproductive Pattern

72
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any disease/dysfunction of the reproductive system

A

Sexuality-Reproductive Pattern

73
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s means/actions of coping with problems

A

Coping-Stress Tolerance Pattern

74
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes if coping actions help or make things worse

A

Coping-Stress Tolerance Pattern

75
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes any treatment for emotional distress

A

Coping-Stress Tolerance Pattern

76
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes principals that the person learn as a child which are still important to him

A

Value-Belief Pattern

77
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes person’s identification with any cultural, ethnic, religious, regional, or other groups

A

Value-Belief Pattern

78
Q

(Part of Gordon’s 11 Functional Health Patterns)

Includes support systems that the person has

A

Value-Belief Pattern

79
Q

The patient’s subjective response to a series of body system-related questions

A

Review of Systems (ROS)

80
Q

Covers a broad base of clinical states

A

Review of Systems (ROS)

81
Q

ROS follows what type of approach?

A

head-to-toe approach

82
Q

What are the 2 types of questions included in Review of Systems (ROS)?

A

sign or symptom related and disease-related

83
Q

What are the 20 data included in ROS?

A

A.General / Overall State of Health
B. Integumentary
C. Head
D.Eyes
E. Ears
F. Nose and Sinuses
G.Mouth and Throat
H.Neck
I. Breast and Axilla
J. Respiratory
K. Cardiac
L. Gastrointestinal
M.Urinary
N.Genitalia / Reproductive
O.Peripheral - Vascular
P. Musculoskeletal
Q.Neurologic / Nervous
R. Hematologic
S. Endocrine
T. Psychiatric

84
Q

Also referred to as symptoms or covert data

A

SUBJECTIVE DATA

85
Q

Can be described or verified only by the
individual

A

SUBJECTIVE DATA

86
Q

Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation

A

SUBJECTIVE DATA

87
Q

Also referred to as signs or overt data

A

OBJECTIVE DATA

88
Q

Can be measured or tested against an accepted standard

A

OBJECTIVE DATA

89
Q

Can be seen, heard, felt, or smelled

A

OBJECTIVE DATA

90
Q

Obtained by observation or physical examination (PE)

A

OBJECTIVE DATA

91
Q

During PE, the nurse obtains ________ _____ to validate the subjective data

A

OBJECTIVE DATA

92
Q

2 Sources of Data?

A

Primary and Secondary

93
Q

The client serves as the best source of data

A

PRIMARY SOURCES

94
Q

Includes statements made by the client and objective data directly obtained from the client

A

PRIMARY SOURCES

95
Q

Refers to all sources other than the client

A

SECONDARY SOURCES

96
Q

4 Data Collection Methods?

A
  1. Observing
  2. Interviewing
  3. Examining
  4. Using Laboratory Results
97
Q

A conscious and deliberate skill in gathering data using the senses

98
Q

Involves noticing data then selecting, organizing, and interpreting data

99
Q

Planned communication or a purposeful conversation

A

INTERVIEWING

100
Q

2 Approaches to Interviewing?

A

Directive and Nondirective

101
Q

Type of Interview Approach that is highly structured?

A

Directive Interview

102
Q

Interview Approach used to gather or give information when time is limited

A

Directive Interview

103
Q

Type of Interview Approach where nurse establishes the purpose and controls the interview

A

Directive Interview

104
Q

a rapport-building interview

A

Nondirective Interview

105
Q

Type of Interview Approach where the client controls the purpose, subject matter, and pacing

A

Nondirective Interview

106
Q

4 Types of Interview Questions

A

Closed, Open-ended, Neutral, Leading

107
Q

Questions used during direct interviews

A

Closed Questions

108
Q

Questions generally restrictive; requires a yes, no, or short factual responses

A

Closed Questions

109
Q

Questions often used when information is needed quickly

A

Closed Questions

110
Q

Questions associated with non-directive interviews

A

Open-ended Questions

111
Q

Questions that invites longer responses from the clients

A

Open-ended Questions

112
Q

Questions that provides the client with freedom to share information

A

Open-ended Questions

113
Q

Questions that are open-ended, used in non-directive interviews

A

Neutral Questions

114
Q

Questions that can be answered by the client without direction or pressure

A

Neutral Questions

115
Q

Questions that are closed questions and are used in directive interviews

A

Leading Questions

116
Q

Questions that directs the client’s answers

A

Leading Questions

117
Q

Questions that gives the client less opportunity to decide if responses are true or not

A

Leading Questions

118
Q

What type of interview question is used when asking

“How old are you?”

119
Q

What type of interview question is used when asking

”What do you think led to the operation?”

A

OPEN-ENDED

120
Q

What type of interview question is used when asking

“Are you having pain now?”

121
Q

What type of interview question is used when asking

“When did you fall?”

122
Q

What type of interview question is used when asking

“What would you like to talk about today?”

A

OPEN-ENDED, NEUTRAL

123
Q

What type of interview question is used when asking

“What brought you to the hospital?”

A

OPEN-ENDED, NEUTRAL

124
Q

What type of interview question is used when asking

“You will take the medicine, won’t you?”

A

CLOSED, LEADING

125
Q

What type of interview question is used when asking

”What do you think led to the operation?”

A

OPEN-ENDED, NEUTRAL

126
Q

What type of interview question is used when asking

“How do you feel about that?”

A

OPEN-ENDED, NEUTRAL

127
Q

What type of interview question is used when asking

“You’re stressed about the surgery, aren’t you?

A

CLOSED, LEADING

128
Q

It is a complete health assessment

129
Q

Examining is _____ and ______

A

orderly and systematic

130
Q

4 basic skills in examining

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
131
Q

2 Approaches used in Examining

A
  • Cephalocaudal
  • Body systems approach
132
Q

Upon Admission what should you do in Examining?

A
  • Perform complete PE
  • Alternative: screening exam or ROS
133
Q

During Ongoing Assessment what should you do in Examining?

A

Examine specific body areas, systems, or functions

134
Q

4 objectives of Examining

A
  • obtain baseline data
  • supplement, confirm, or refute health history data
  • obtain data to help establish the plan of care
  • evaluate physiologic outcomes or progress
135
Q

Principles / Guidlines of Examining

Make client _______ and ________

A

relaxed and comfortable

136
Q

Principles / Guidlines of Examining

Provide ______ and avoid unnecessary exposure

137
Q

Principles / Guidlines of Examining

Have an ______ for examination

138
Q

Principles / Guidlines of Examining

Follow a ____ of _____ for PE techniques

A

plan of order

139
Q

Principles / Guidlines of Examining

Maintain a __________ room

A

well-lighted

140
Q

Principles / Guidlines of Examining

_______ explain every step to be undertaken

141
Q

Principles / Guidlines of Examining

Compare _______ from one side of the body to the other

142
Q

Principles / Guidlines of Examining

Consider the ______ _______ of the body

A

underlying structures

143
Q

Principles / Guidlines of Examining

Use all ______ during the exam

144
Q

What are the 6 Positioning in Examining?

A

✓ Standing position
✓ Supine position
✓ Prone position
✓ Dorsal recumbent position
✓ Sims’ position
✓ Lithotomy position

145
Q

4 Techniques used during Physical Examination

A

Inspection
Palpation
Percussion
Auscultation

146
Q

Assessment of the patient’s general appearance

A

Inspection

147
Q

Technique in Examining wherein sense of sight, hearing and smell are used

A

Inspection

148
Q

Uses the sense of touch; “therapeutic touch”

149
Q

Tools used for palpation

A

Dorsum, Palm, Fingertips, Index-Thumb

150
Q

2 Types of Palpation

A

Light and Deep

151
Q

Type of Palpation wherein the skin is depressed for about 1-2 cm using the finger pads

A

Light Palpation

152
Q

Type of Palpation used to assess texture, tenderness, temp., moisture, elasticity

A

Light Palpation

153
Q

Type of Palpation can also be used to assess pulsations and masses

A

Light Palpation

154
Q

Type of Palpation that can be done with 1 or 2 hands, skin is depressed for about 4-5 cm

A

Deep Palpation

155
Q

Type of Palpation - used when trying to feel for the internal organs

A

Deep Palpation

156
Q

Type of Palpation - used to feel mass size, shape, tenderness, symmetry, and mobility

A

Deep Palpation

157
Q

Involves the striking of a body surface, usually with a tip of the finger to elicit a sound or vibration

A

Percussion

158
Q

Types of Percussion

A

Direct and Indirect

159
Q

uses pads of 2, 3, or 4 fingers or with a pad of the middle finger

A

Direct Percussion

160
Q

commonly used when percussing adult sinuses

A

Direct Percussion

161
Q

the nurse strikes an object (another finger) held against a body area

A

Indirect Percussion

162
Q

Indirect Percussion uses _____ (finger placed on the skin), ______ (striking finger)

A

pleximeter, plexor

163
Q

Involves the process of listening to sounds produced within the body and could either be direct or indirect

A

Auscultation

164
Q

use of unaided ear

A

Direct Auscultation

165
Q

use of stethoscope

A

Indirect Auscultation

166
Q

Constitutes another source of objective data, which is important in assessing many health problems and conditions

A

USING LABORATORY RESULTS

167
Q

7 Conceptual Models/Frameworks used in Organizing Data

A
  1. Gordon’s 11 Functional Health Patterns
  2. The Review of Systems
  3. Maslow’s Hierarchy of Needs
  4. Henderson’s 14 Fundamental Needs
  5. Abdellah’s 21 ADLs
  6. Orem’s Self-Care Model
  7. Roy’s Adaptation Model
168
Q

This model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development

A

Orem’s Self-Care Model

169
Q

4 data used in Roy’s Adaptation Model

A

a. Physiologic needs
b. Self-concept (Physical and Personal Self)
c. Role function
d. Interdependence

170
Q

the act of double-checking or verifying data to confirm that it is accurate and factual

A

Validation

171
Q

Helps the nurse ensure completion of tasks

A

DATA VALIDATION

172
Q

The nurse needs to _______ ______ especially when there are discrepancies

A

validate data

173
Q

Data are recorded in a factual manner and not interpreted by the nurse

A

DOCUMENTATION

174
Q

To increase accuracy, the nurse records subjective data in
the client’s own words, using ________ _______.

A

quotation marks

175
Q

Accurate __________ is essential and should include all data collected about the client’s health status.

A

documentation

FUNDA (9 decks)

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