Nursing Process: Assessment Flashcards
It is a systematic client care-centered with 5 processes
Nursing Process
Nursing Process (ADPIE)
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Gather information about the client’s condition.
What do you under this nursing process?
ASSESSMENT:
o Collect
o Organize
o Validates
o Document
Set goals of care and designed outcomes and identify appropriate nursing actions
What do you under this nursing process?
PLAN:
o Prioritize Problems
o Formulate Goals
o Select Interventions
o Write Interventions
Identify the client’s problems.
What do you under this nursing process?
DIAGNOSIS:
o Analyze
o Identify Problem
o Formulate Nursing Diagnosis
Determines if goals are met and
outcomes achieved.
What do you under this nursing process?
EVALUATION:
o Collect Data
o Compare
o Relate To Goals
o Conclude
o Continue/ Modify
o Terminate
Perform the nursing actions identified in planning.
What do you under this nursing process?
IMPLEMENTATION:
o Reassess
o Implement
o Supervise
o Assist
o Document
Process Involved in Nursing Process
o Critical Thinking
o Problem-solving
o Decision Making
Specific to the nursing profession
Nursing Process
Nursing Process is a framework for
Critical Thinking
“Diagnose and treat human responses to _____ or _____ health problems“
Actual or Potential
Purpose of Nursing Process
o Organized framework guide practice
o Problem solving method
o Systematic
o Goal oriented
o Dynamic-always changing, flexible
o Utilizes critical thinking processes
o Universally applicable
o Client-centered
o Interpersonal and collaborative
ADVANTAGES OF NURSING PROCESS
o Provides individualized care.
o Client is an active participant.
o Promotes continuity of care.
o Provides more effective communication among nurses and health care professionals.
o Develops clear and efficient plan of care.
o Provides personal satisfaction as you see client achieve goals.
o Professional growth as you evaluate effectiveness of your interventions.
Provide direction for planning interventions
Goals of Care
Actions taken by the nurse to
achieve patient goals and get
desired outcomes
Intervention
Critical thinking statements
that explain why a particular
intervention is necessary for
the patient’s care plan.
Rationale
To ensure the desired
outcome has been met
Evaluation
First Step of the Nursing Process
ASSESSMENT
TRUE OR FALSE?
ASSESSMENT - gathering information/collecting data
TRUE
Primary sources of an assessment
Client/Family
Secondary sources of an assessment
Physical Exam, Nursing
History, Team Members, Lab Reports, Diagnostic Tests.
TRUE OR FALSE?
ASSESSMENT - systematic, deliberate process
TRUE
To establish data base about the
client’s response to health concerns or illness and the ability to manage health care needs.
A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION
A. ASSESSMENT
Collecting, organizing and communicating/recording
client data.
A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION
A. ASSESSMENT
Assessment is finding all the “_________ ______ ______” to get a picture of your patient’s health status.
necessary puzzle pieces
Analyzes data about the patient, clients human responses, health status, strengths and concerns.
A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION
A. ASSESSMENT
TRUE OR FALSE?
Assessment is a not continuous data collection.
FALSE
Assessment is a continuous data collection.
TYPES OF DATA
Objective Data and Subjective Data
From the client
Subjective Data
Observable data
Objective Data
Other term for Objective Data
Sign
Other term for Subjective Data
Symptom
TYPE OF ASSESSMENT
Initial Assessment
Problem-focused Assessment
Emergency Assessment
Time-lapsed Assessment
Type of assessment that is performed after admission
A. Initial Assessment
B. Problem-focused Assessment
C. Emergency Assessment
D. Time-lapsed Assessment
A. Initial Assessment
Type of assessment that is an ongoing process integrated
with nursing care period of confinement.
A. Initial Assessment
B. Problem-focused Assessment
C. Emergency Assessment
D. Time-lapsed Assessment
B. Problem-focused Assessment
During any physiological or psychological crisis of the client.
A. Initial Assessment
B. Problem-focused Assessment
C. Emergency Assessment
D. Time-lapsed Assessment
C. Emergency Assessment
Several months after initial
assessment.
A. Initial Assessment
B. Problem-focused Assessment
C. Emergency Assessment
D. Time-lapsed Assessment
D. Time-lapsed Assessment
Type of assessment that its purpose is to compare the client’s current
status to baseline data previously obtained.
Time-lapsed Assessment
Type of assessment that its purpose is to identify life-threatening problems to identify new
or overloaded problems
Emergency Assessment
Type of assessment that its purpose is to determine status of a
specific problem identified in an earlier assessment
Problem-focused Assessment
Type of assessment that its purpose is to establish complete data base
Initial Assessment
Rapid assessment of individual’s
airway, breathing and circulation
during a cardiac arrest assessment of suicidal tendencies
Emergency Assessment
Reassessment of a client’s functional health patterns in a home care or outpatient settings
Time-lapsed Assessment
Nursing admission assessment
Initial Assessment
Hourly assessment of client’s intake
and output, or vital signs
Problem-focused Assessment
CHARACTERISTICS OF AN ASSESSMENT THAT PROMOTES CRITICAL THINKING
Purposeful
Focused & Relevant
Systematic
Must be focused to gain relevant
information, depending on purpose and context.
Focused & Relevant
Helps pay attention to what’s important, learn how to prioritize, be comprehensive and avoid omission errors.
Systematic
2 MAIN TYPES OF DATABASE
Data Base Assessment
Focus Assessment
“Start of care” Assessment.
Data Base Assessment
___________ - is a comprehensive information gathered on ______ contact with the person to assess all aspects of health status.
Data Base Assessment; initial
Data gathered to determine the status of a specific condition.
Focus Assessment
ASSESSMENT ACTIVITY
1.Collecting Data
2.Identifying Cues and Making Inferences
3.Validating/Verifying Data
4.Organizing/Clustering Data
5.Identifying Patterns/Testing First Impression.
6.Reporting and Recording Data
“The most up-to-date information comes from your ______ __________ __ ___ _______. “
direct assessment of the patient
ASSESSMENT – COLLECTING DATA
- Nursing Interview (history)
- Health Assessment – Review of systems
- Physical Examination
- Make sure information is complete and accurate
- Validate prn
- Interpret and analyze data
- Compare to “standard norms “
- Organize and cluster data
Noting pieces of information or cues through the use of senses (sight, touch, hearing, smell and taste).
Observation
KEY POINTS FOR AN INTERVIEW
o Ability to establish rapport.
o Ability to asks questions.
o Ability to listen is essential to successful interviews.
o Ability to observe.
PHYSICAL EXAMINATION INCLUDES
o Inspection
o Palpation
o Percussion
o Auscultation
TYPES OF INTERVIEW
Direct Interview
Indirect Interview
The nurse allows the client to control the purpose, subject matter and pacing.
Indirect Interview
Highly structured and elicit specific information by asking closed ended questions
Direct Interview
TYPES OF QUESTIONS
Close ended questions
Open-ended questions
Lead or invite clients to explore their thoughts or feelings.
Open-ended questions
Restrictive and generally require only short answers giving specific information; other begin with when, where, who, what, do, does, did.
Close ended questions
THINGS TO CONSIDER WHEN PLANNING AN INTERVIEW AND
SETTING
Time
Place
Seating Arrangement
Need to be scheduled when the client is comfortable and free of pain
Time
Must have adequate privacy to promote communication
Place
Most people feel comfortable _ to _ ft. apart during an interview
3 to 4
Most people feel comfortable 3 to 4 ft. apart during an interview
Seating arrangement — Distance
STAGES OF AN INTERVIEW
o Opening
o Body
o Closing
Important in facilitating future
interactions.
Closing
Client communicates what he or she
thinks, feels, knows and perceives in
response to questions from the nurse.
Body
Sets the tone of the remainder of the
interview.
Opening
Two parts of an Opening Interview
ESTABLISH RAPPORT
ORIENTATION
Process of creating good will and trust.
ESTABLISH RAPPORT
Explaining the purpose
and nature of the interview.
ORIENTATION
Your aim is to gain all information
needed to ensure that your patients have “Individualized Care”
Purposeful
