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HEALTH ASSESSTMENT > Overview: Nurse’s Role in Health Assessment > Flashcards

Overview: Nurse’s Role in Health Assessment Flashcards

1
Q

The promotion, & optimization of health and
abilities

Promotion of Health

Prevention of illness and injury

Alleviation of suffering

Health restoration

A

Nursing is (ANA)

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2
Q

Diagnosis and treatment of human
responses

A

“EMPHASIS:

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3
Q

Accurate client assessments

Effectiveness of nursing interventions

A

BASIS:

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4
Q

Continuously collects data systematically

Patients, their relatives, the healthcare
team is involved in providing the data.

Prioritizes data collection activities,
immediate needs comes first

A

The Nurse:

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5
Q

Makes use of instruments and assessment tools

Documents information gathered

Data gathered becomes basis for
identifying a problem or a need

Nursing interventions appropriated
according to the need of the patient

A
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6
Q

Makes use of instruments and assessment tools

Documents information gathered

Data gathered becomes basis for
identifying a problem or a need

Nursing interventions appropriated
according to the need of the patient

A

The Nurse

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7
Q

Makes use of instruments and assessment tools

Documents information gathered

Data gathered becomes basis for
identifying a problem or a need

Nursing interventions appropriated
according to the need of the patient

A

The Nurse

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8
Q

Period: Nurses relied on their senses to detect
the clients conditions like changes in
the body temperature, and other signs
visible to the eyes and felt by the
hands.

Palpation is limited to locating the
fundus of the pregnant mother or
taking the pulse rate

A

Late 1800”s to early 1900”s:

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9
Q

Eyes: discoloration of the skin, mucous
membrane of the eyes, signs of cuts and bruises,
redness and swelling , urine output amount and
character etc.

Hands: body temperature

Nose: body odor, urine odor

Ears: hear the beat of the heart , air in the
lungs

A

USING THE FIVE SENSES

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10
Q

Period: Nursing practice was significant for
case finding and prevention of
communicable diseases

A

1930’s to 1949:

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11
Q

Period: nurses were hired and work in offices
and do pre-employment health
assessment and physical examinations

A

1950’s to 1969:

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12
Q

Period: Nurses have been actively involved in PHC
services and actively do health assessment &
physical exams plus psychosocial examinations

A

1970- 1989:

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13
Q

Period: Nurses role evolved from being on the side of
the doctors to apparently at the same levels as
doctors.

Nurse practitioners became common

Advance nurse practitioners were on the rise

A

1990’s to the Present:

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14
Q

Birth of Forensic Nursing, Nurse
Anesthetist, Nurse therapist, Nurse
Informatics . Rescue Nurses, Ambulance
Nurses , Nurse in the Academe..etc..

Nurses have to do intensive assessments,
do diagnosing and referrals.

Nurses documents all assessment results
and interventions provided as they
portray more independent roles.

Roles became more advanced and crucial

A

Advance nurse practitioners

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15
Q

It is a systemic approach used by

the nurse to allow her to

provide the best nursing care

she could.

ADEQUATELY

EFFECTIVELY

HOLISTICALLY

A

Nursing Process

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16
Q

Coined by LYDIA HALL

It is an ORGANIZED ,
SYSTEMATIC manner of
providing goal –oriented &
humanistic care that is both
EFFICIENT &
EFFECTIVE

A

Nursing Process

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17
Q

Series of actions
directed

toward a common goal-

OPTIMUM LEVEL OF
WELLNESS

A

a. identifying a need

b. determining a problem

c. identify goals and plan of

actions

d. implement the plan of care

e. evaluate effectiveness of
care rendered

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18
Q

WHY USE THE NURSING
PROCESS?

A

Cost
Efficient

Promotes
professionalism

Provides
Framework

and
collaboration

Improves
efficiency &
timeliness of care

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19
Q

Steps of Nursing Process

A

ADPIE

ASSESSSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION

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20
Q
  1. Collection of Subjective data
  2. Collection of Objective data
  3. Validation of data
  4. Documentation of data
A

The assessment phase of the Nursing process has
four major steps

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21
Q

= OBSERVATION + INTERVIEW +
PHYSICAL EXAM

A

ASSESSMENT

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22
Q

Sensations or symptoms

Perceptions and feelings

Desires and preferences

Beliefs, ideas, and values

Personal information

  • All that can be validated by the patient
    himself
A

SUBJECTIVE DATA

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23
Q

Obtained by general observation

Makes use of the four physical examination techniques
(IPPA)

Medical records can also be a source of objective data
(Documentation)

Observations made by family and significant others.

Physical characteristics

  • Body functions
  • Appearance
  • Behaviors
  • Measurements
  • Laboratory results
A

OBJECTIVE DATA

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24
Q

planned,
purposeful
conversation

A

Interview-

25
Q

Use of the five senses

Physical
Examinations

Interpretation of
laboratory results

A

Observation

26
Q

PRIMARY SOURCE:

A

PATIENT

27
Q

SECONDARY SOURCE:

A

FAMLY MEMBERS

PATIENTS CHART/
RECORDS

HEALTHCARE TEAM

RELATED
LITERATURES

28
Q

ensuring that the
information collected are relevant and
validated
This will also ensure that the information are
accurate for documentation

A

VALIDATING

29
Q

is vital in assessment

It is an important step because it forms the
database of all that are involved in the
patient care.

It is important to arrive as a valid
conclusion or diagnosis.

A

DOCUMENTATION

30
Q

a specific result of
analyzing and is the problem statement that
nurses use to communicate to the healthcare
team.

A

Nursing diagnosis

31
Q

Establish priorities according to importance and
time.

Highest priority is given

to life threatening

situations or issues.

A

PLANNING

32
Q

Determining beforehand the strategies or
course of actions to be taken before
implementing nursing care.

To be effective, involve the patient and his
family.

A

PLANNING

33
Q

Instruct client on technique to splint painful site during
activity.

Administer analgesics 30 minutes before exercise as
ordered by the physician

A

DEVELOP INTERVENTIONS

34
Q

To identify and communicate actions to be delivered.

A

CREATE A CAREPLAN

35
Q

Establish SMART goals

THE CLIENT WILL STATE THAT PAIN IS
RELIEVED TO A LEVEL OF 2/10 WITHIN 30
MINUTES

Is this a good goal?

A

OBJECTIVE SETTING

36
Q

CARE PLAN

physical care

Counselling

Observing for adverse reactions among other things
performed with the client.

A

DIRECT CARE

37
Q

-Advocacy
- Supervising

Delegating
- Evaluating

A

INDIRECT CARE

38
Q

PROCESS:

Evaluate the interventions

Identify if client goals/ outcomes were
achieved

Document findings / judgment

Terminate, continue or revise the care
plan.

A

EVALUATION

39
Q

A comprehensive collection of
information from the client necessary to
provide effective nursing care

A

HEALTH ASSESSMENT

40
Q

Initial Comprehensive

On-going or Partial

Focused or Problem Oriented

Emergency Assessment

A

FOUR BASIC TYPES

41
Q

Assessment that involves collection of:

Subjective data about the client’s
perception of his or her health of all
body parts or systems , past health
history, family history and lifestyle as
well as health practices

Objective data gathered during the
step by step physical assessment

A

Initial Comprehensive Assessment

42
Q

The assessment that is done after a
comprehensive assessment is completed.

It will consist of a mini overview of the
health systems. Any abnormal findings
initiated during the comprehensive
assessment will be looked into to detect
new problems

Done frequently in every encounter with
the client or whenever the need arises

Frequency is determined by the acuity
or whenever the patient perceives a
problem

A

Ongoing or Partial Assessment

43
Q

An assessment made when a database
exist for a specific client that comes back
to the health facility with a specific
health concern.

A thorough assessment of a particular
client problem , focusing only on the
health concern itself.

A

Focused or Problem Oriented
Assessment

44
Q

A rapid assessment performed in life
threatening situations like cardiac
arrest, choking, drowning where
immediate assessment is vital to have a
prompt treatment

The only concern is to determine the
health status of the client’s life
sustaining functions

A

Emergency Assessment

45
Q

Provides biographical information of
the client ( age ,sex, religion,
educational level & occupation)

Information of chronic diseases,
medications and allergies

Impact of the illness on the client’s
ADL’s

A

Review the clients medical records (when
available)

46
Q

Do not assume that the information
you have collected are valid

Find time to validate with the client

Prepare to collect additional
information

A

Avoid premature judgments

47
Q

Review diagnosis and diagnostic / laboratory tests
done to the patient to learn the results and its
implications

A

Educate yourself

48
Q

PROCESS OF DATA ANALYSIS
- IDENTIFY ABNORMAL DATA
AND STRENGTHS
-CLUSTER THE DATA
- DRAW INFERENCES AND
IDENTIFY PROBLEMS
-PROPOSE POSSIBLE NURSING
DIGNOSIS
-CHECK FOR DEFINING
CHARACTERISTICS
-CONFIRM NURSING DIAGNOSIS
- DOCUMENT CONCLUSIONS

A

Be objective as possible

49
Q

FACTORS AFFECTING
HEALTH ASSESSEMNT

A

1.CULTURE

  1. FAMILY
  2. COMMUNITY
50
Q

is a Nurse’s ability to
understand, be aware of, be sensitive to
and vicariously experience the feelings,
thoughts, and experiences of the patients
and their families.

A

Empathy

51
Q

involves knowing and trusting the
patient, an interest in their growth and
well being, honesty, courage and humility.

A

Caring

52
Q

The exchange of thoughts, messages, or
information which is vital to the nursing
process.

A

COMMUNICATION

53
Q

The most important role of a nurse is to
assist patients and their families with
receiving information necessary for
maintaining a patient’s optimal health.

A

TEACHING

54
Q

Nurses must be able to think critically and
make decisions when problems are not
clear. A nurse must question, wonder, and
be able to explore various perspective and
possibilities in order to give patients the best
care.

A

CRITICAL THINKING

55
Q

are best learned through practice after
achieving an understanding of the basic
principles of skills as part of the nursing
education

A

PSYCHOMOTOR SKILLS

56
Q

A nurse applies therapeutic modalities like
pharmacologic and nutritional interventions.

A

APPLIED THERAPEUTICS

57
Q

The code of ethics for nurses provides the
ideal framework for safe and correct practices
and behaviour.

A

ETHICAL AND LEGAL
CONSIDERATION

58
Q

Involves the characteristics of a nurse that
reflects his or her professional status. These
characteristics involves behaviours with
regard to self, patient, others, and the public
as they reflect the values of the nursing
profession

A

PROFESSIONALISM

HEALTH ASSESSTMENT (31 decks)

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