Overview: Nurse’s Role in Health Assessment

Question 1

The promotion, & optimization of health and
abilities

Promotion of Health

Prevention of illness and injury

Alleviation of suffering

Health restoration

Answer 1

Nursing is (ANA)

Question 2

Diagnosis and treatment of human
responses

Answer 2

“EMPHASIS:

Question 3

Accurate client assessments

Effectiveness of nursing interventions

Answer 3

BASIS:

Question 4

Continuously collects data systematically

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

Prioritizes data collection activities,
immediate needs comes first

Answer 4

The Nurse:

Question 5

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

Question 6

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

Answer 6

The Nurse

Question 7

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

Answer 7

The Nurse

Question 8

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

Answer 8

Late 1800”s to early 1900”s:

Question 9

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

Answer 9

USING THE FIVE SENSES

Question 10

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

Answer 10

1930’s to 1949:

Question 11

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

Answer 11

1950’s to 1969:

Question 12

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

Answer 12

1970- 1989:

Question 13

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

Answer 13

1990’s to the Present:

Question 14

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

Answer 14

Advance nurse practitioners

Question 15

It is a systemic approach used by

the nurse to allow her to

provide the best nursing care

she could.

ADEQUATELY

EFFECTIVELY

HOLISTICALLY

Answer 15

Nursing Process

Question 16

Coined by LYDIA HALL

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

Answer 16

Nursing Process

Question 17

Series of actions
directed

toward a common goal-

OPTIMUM LEVEL OF
WELLNESS

Answer 17

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

Question 18

WHY USE THE NURSING
PROCESS?

Answer 18

Cost
Efficient

Promotes
professionalism

Provides
Framework

and
collaboration

Improves
efficiency &
timeliness of care

Question 19

Steps of Nursing Process

Answer 19

ADPIE

ASSESSSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION

Question 20

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

Answer 20

The assessment phase of the Nursing process has
four major steps

Question 21

= OBSERVATION + INTERVIEW +
PHYSICAL EXAM

Answer 21

ASSESSMENT

Question 22

Sensations or symptoms

Perceptions and feelings

Desires and preferences

Beliefs, ideas, and values

Personal information

• All that can be validated by the patient
  himself

Answer 22

SUBJECTIVE DATA

Question 23

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

Answer 23

OBJECTIVE DATA

Question 24

planned,
purposeful
conversation

Answer 24

Interview-

Question 25

Use of the five senses Physical Examinations Interpretation of laboratory results

Answer 25

Observation

Question 26

PRIMARY SOURCE:

Answer 26

PATIENT

Question 27

SECONDARY SOURCE:

Answer 27

FAMLY MEMBERS PATIENTS CHART/ RECORDS HEALTHCARE TEAM RELATED LITERATURES

Question 28

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

Answer 28

VALIDATING

Question 29

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.

Answer 29

DOCUMENTATION

Question 30

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

Answer 30

Nursing diagnosis

Question 31

Establish priorities according to importance and time. Highest priority is given to life threatening situations or issues.

Answer 31

PLANNING

Question 32

Determining beforehand the strategies or course of actions to be taken before implementing nursing care. To be effective, involve the patient and his family.

Answer 32

PLANNING

Question 33

Instruct client on technique to splint painful site during activity. Administer analgesics 30 minutes before exercise as ordered by the physician

Answer 33

DEVELOP INTERVENTIONS

Question 34

To identify and communicate actions to be delivered.

Answer 34

CREATE A CAREPLAN

Question 35

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?

Answer 35

OBJECTIVE SETTING

Question 36

CARE PLAN physical care Counselling Observing for adverse reactions among other things performed with the client.

Answer 36

DIRECT CARE

Question 37

-Advocacy - Supervising Delegating - Evaluating

Answer 37

INDIRECT CARE

Question 38

PROCESS: Evaluate the interventions Identify if client goals/ outcomes were achieved Document findings / judgment Terminate, continue or revise the care plan.

Answer 38

EVALUATION

Question 39

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

Answer 39

HEALTH ASSESSMENT

Question 40

Initial Comprehensive On-going or Partial Focused or Problem Oriented Emergency Assessment

Answer 40

FOUR BASIC TYPES

Question 41

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

Answer 41

Initial Comprehensive Assessment

Question 42

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

Answer 42

Ongoing or Partial Assessment

Question 43

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.

Answer 43

Focused or Problem Oriented Assessment

Question 44

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

Answer 44

Emergency Assessment

Question 45

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

Answer 45

Review the clients medical records (when available)

Question 46

Do not assume that the information you have collected are valid Find time to validate with the client Prepare to collect additional information

Answer 46

Avoid premature judgments

Question 47

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

Answer 47

Educate yourself

Question 48

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

Answer 48

Be objective as possible

Question 49

FACTORS AFFECTING HEALTH ASSESSEMNT

Answer 49

1.CULTURE 2. FAMILY 3. COMMUNITY

Question 50

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.

Answer 50

Empathy

Question 51

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

Answer 51

Caring

Question 52

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

Answer 52

COMMUNICATION

Question 53

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.

Answer 53

TEACHING

Question 54

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.

Answer 54

CRITICAL THINKING

Question 55

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

Answer 55

PSYCHOMOTOR SKILLS

Question 56

A nurse applies therapeutic modalities like pharmacologic and nutritional interventions.

Answer 56

APPLIED THERAPEUTICS

Question 57

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

Answer 57

ETHICAL AND LEGAL CONSIDERATION

Question 58

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

Answer 58

PROFESSIONALISM