Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Assessment - Lecture > Overview of the Nursing Process and Introduction to Health Assessment > Flashcards

Overview of the Nursing Process and Introduction to Health Assessment Flashcards

1
Q

is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families,
communities and populations”

A

Nursing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Nursing: Scope on Standards of Practice states as Standard 1 that:

A

“The registered nurse collects comprehensive data pertinent to the patient’s health or situation”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

To accomplish this pertinent and comprehensive data collection, the nurse:

A
  1. Collects data in a systematic and ongoing process
  2. Involves the patient, family, other health care providers, and environment, as appropriate, in holistic data collection
  3. Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation
  4. Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data
  5. Uses analytical models and problem-solving tools
  6. Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances
  7. Documents relevant data in a retrievable format
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Standard 2 states, “

A

“The registered nurse analyzes the assessment data to
determine the diagnoses or issues”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Standard 2 states, “The registered nurse analyzes the assessment data to determine the diagnoses or issues”
To accomplish this, the nurse:

A
  1. Derives the diagnosis or issues based on assessment data
  2. Validates the diagnoses or issues with the client, family, and other healthcare providers when possible and appropriate
  3. Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

The Nursing Process

A

Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Process of collecting, validating, and clustering data

A

Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

The first and most important step in the nursing process

A

Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Sets the tone for the rest of the process and the rest of the
process flows from it

A

Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Identifies the patient’s strengths and limitations and is performed continuously throughout the nursing process

A

Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Skills of Assessment

A
  • Cognitive Skills
  • Problem-Solving Skills
  • Psychomotor Skills
  • Affective/Interpersonal Skills
  • Ethical Skills
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Needed for critical thinking, creative thinking, and clinical decision making

A

Cognitive Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what are examples of Cognitive Skills

A
  • Critical Thinking
  • Clinical Decision Making
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Not just doing but asking “why?”

A

Critical Thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Involves inquiry, interpretation, analysis, and synthesis

A

Critical Thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Looking for cues and make inferences

A

Clinical Decision Making

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Identify patterns and recognize what differs from the norm

A

Clinical Decision Making

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Use your knowledge, experience, and what the patient says to validate the data

A

Clinical Decision Making

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what are the Problem-Solving Skills

A
  • Reflexive thinking
  • Hit-or-miss thinking
  • Critical-thinking approach
  • Intuition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Select the method that best suits your patient’s needs

A

Problem-Solving Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Automatic, without conscious deliberation, and comes with
experience

A

Reflexive thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Trial-and-error approach

A

Hit-or-miss thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Random, non systematic, and efficient

A

Hit-or-miss thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Fosters creativity and allows you to formulate new ideas

A

Hit-or-miss thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Use it for situation that don’t quite fit the picture, look beyond the obvious, and keep looking until you find the answer

A

Hit-or-miss thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q
  • Scientific method
  • Involves identifying a problem and collecting supporting data, formulating a hypothesis, planning a solution, implementing the plan, and then evaluating its effectiveness
A

Critical-thinking approach

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q
  • Develops through experience
  • How “expert” nurse solves problems
A

Intuition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

A nurse with well-established experiential base of pattern
recognition, an intuitive grasp of the situation, and the ability to zero in on problem areas

A

Intuition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q
  • Needed to perform the four techniques of physical assessment (inspection, palpation, percussion, and auscultation)
  • Mastered through experience and practice
A

Psychomotor Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

the four techniques of physical assessment

A

inspection, palpation, percussion, and auscultation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Needed to practice the “art” of nursing

A

Affective/Interpersonal Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q
  • Essential in developing caring, therapeutic nurse-patient relationship
  • Includes both verbal and nonverbal communication skills
  • Establish trust and mutual respect before beginning assessment
A

Affective/Interpersonal Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q
  • Being responsible and accountable
  • You are an advocate of your patient
  • Respect for patient’s rights and ensure patient confidentiality
A

Ethical Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Four Basic Types of Health Assessment

A
  • Initial Comprehensive Assessment
  • Ongoing or Partial Assessment
  • Focused or Problem-Oriented Assessment
  • Emergency Assessment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

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 and health practices, as well as objective data gathered during a step-by-step physical examination

A

Initial Comprehensive Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Other members of the health care team may participate in the data collection (e.g. physician, physical therapist, dietician, nurse practitioner)

A

Initial Comprehensive Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Regardless of who collects the data, a total health assessment is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared

A

Initial Comprehensive Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Data collection after the comprehensive database is established

A

Ongoing or Partial Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Consists of a mini-overview of the client’s body systems and holistic health patterns as a follow-up on health status

A

Ongoing or Partial Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Reassessment of initial problems detected to determine any changes

A

Ongoing or Partial Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Brief assessment of the client’s body systems and holistic health patterns to detect new problems

A

Ongoing or Partial Assessment

42
Q

Usually performed whenever the nurse or another healthcare professional has an encounter with the client

A

Ongoing or Partial Assessment

43
Q

A client with lung cancer requires frequent assessment of
lung sounds. Skin assessment would only focus on the ______________________________________________ to determine the level of oxygenation

A

color and temperature of the extremities

44
Q

Performed when comprehensive database exists for a
client who comes to the health care agency with a specific
health concern

A

Focused or Problem-Oriented Assessment

45
Q

Consists of a thorough assessment of a particular client
problem and does not cover areas not related to the
problem

A

Focused or Problem-Oriented Assessment

46
Q

A patient came to the hospital and tells you he has headache. Your questions would be focused more on the

A

character, location, onset of the pain, relieving and aggravating factors, and associated symptoms

47
Q

Very rapid assessment performed in life-threatening situations like choking, cardiac arrest, drowning

A

Emergency Assessment

48
Q

An immediate assessment is needed to provide prompt treatment

A

Emergency Assessment

49
Q

Evaluate ____________________________________________ when cardiac arrest is suspected

A

airway, breathing, and circulation

50
Q

Major and only concern of Emergency Assessment:

A

determine the status of client’s life-sustaining physical functions

51
Q

Diagnose and treat human responses to actual or potential health problems

A

Nursing Assessment

52
Q

Focuses not only on the physiological and psychological responses but also on the psychosocial, cultural, and developmental, and spiritual dimensions

A

Nursing Assessment

53
Q

Diagnose and treat disease

A

Medical Assessment

54
Q

Focuses on the physiological and psychological responses

A

Medical Assessment

55
Q

Types of Data

A
  • Subjective Data
  • Objective Data
56
Q

Symptoms

A

Subjective Data

57
Q

What the patient feels

A

Subjective Data

58
Q

Pain, nausea, weakness

A

Subjective Data

59
Q

Signs

A

Objective Data

60
Q

What you observe using your senses

A

Objective Data

61
Q

Vital signs, pupillary reaction, jaundice

A

Objective Data

62
Q

Data Sources

A
  • Primary Data
  • Secondary Data
63
Q

Anything from the patient

A

Primary Data

64
Q

Anyone or anything other than the patient (relatives, guardians, friends, medical records)

A

Secondary Data

65
Q

Methods of Data Collection

A
  • Interviews
  • Observation
  • Physical Assessment
66
Q
  • Structured communication intended to obtain subjective data
  • Needs good interpersonal communication skills
  • Be empathetic
  • Maintain a neutral, non-judgmental position and demonstrate acceptance of your patient’s verbal and nonverbal communication
A

Interviews

67
Q
  • Entails deliberate use of senses
  • Look at both your patient and his or her environment to detect anything out of the ordinary
A

Observation

68
Q
  • Provides the objective database
  • Helps assess the patient’s health status and identify actual or potential problems
  • Use techniques of inspection, palpation, percussion, and auscultation
A

Physical Assessment

69
Q

Documentation Methods

A
  • SOAPIE Method
  • DAR Method
  • PIE Method
  • Narrative Method
70
Q

SOAPIE Method

A

Subjective Data, Objective Data, Assessment, Plan, Interventions, Evaluation

71
Q

DAR Method

A

Data, Action, Response

72
Q

PIE Method

A

Problem, Interventions, Evaluation

73
Q

A 25 year-old male came into the emergency room
complaining of abdominal pain. How will you perform
your assessment?
What to ask:

A
  • What did the patient eat for the past 24 hours?
  • What other symptoms did the patient have? (e.g. nausea,
    vomiting, diarrhea, dizziness)
  • If with vomiting, ask about frequency, volume, color,
    projectile
  • If with diarrhea, ask about frequency, volume, color,
    consistency
  • Pain scale
74
Q

A 25 year-old male came into the emergency room
complaining of abdominal pain. How will you perform
your assessment?
What to examine:

A
  • Assess the general appearance of the patient. Awake?
    Conscious? Lethargic?
  • Assess vital signs
  • Perform inspection, auscultation, percussion, and palpation of the abdomen. Listen for bowel
    sounds, note for the location of pain and other unusualities
  • Note for signs of dehydration. Check skin turgor, note for
    sunken eyeballs, dry skin and mouth
75
Q

If with vomiting, ask about

A

frequency, volume, color, projectile

76
Q

If with diarrhea, ask about

A

frequency, volume, color, consistency

77
Q

Identifying and prioritizing actual or potential health
problems or responses

A

NURSING DIAGNOSIS

78
Q

Once data is collected, they need to be analyzed and actual and potential health problems or responses to life
processes should be identified and stated as nursing diagnoses.

A

NURSING DIAGNOSIS

79
Q

Nursing diagnoses can be:

A

Actual, Potential, Possible, Collaborative, Wellness

80
Q

occurring health problem for the patient

A

Actual

81
Q

high-risk health problem that most likely will occur unless preventive measures are taken

A

Potential

82
Q

one that needs further data to support it

A

Possible

83
Q

potential medical complication that warrants both medical
and nursing intervention

A

Collaborative

84
Q

focus on promoting or enhancing a patient’s level of wellness

A

Wellness

85
Q

After identifying the diagnoses, you need to prioritize them in order to develop a plan of care.

In prioritizing your nursing diagnosis, remember ABCDE

A

A – airway
B – breathing
C – circulation
D – disability
E – exposure

86
Q

Involves setting goals and outcomes

A

Planning

87
Q

First, establish your goals and determine measurable
outcomes

A

Planning

88
Q

Next, identify nursing interventions needed to meet
the goals and outcomes

A

Planning

89
Q

Then, communicate your plan to both the patient and all
members involved in the plan of care to maintain continuity of care and ensure success

A

Planning

90
Q

Remember, your goals and outcomes must be

A

SMART
S – specific
M – measurable
A – attainable
R – relevant
T – time-bound

91
Q

Implementation is also called as

A

intervention

92
Q

Involves carrying out your plan to achieve goals and outcomes

A

Implementation

93
Q

Implementation is the “______________” of the nursing process in which you actually implement the nursing interventions in the plan

A

doing phase

94
Q

The “doing phase” of the nursing process in which you actually implement the nursing interventions in the plan

A

Implementation

95
Q
  • Involves determining the effectiveness of your plan
  • Did you meet your goals and outcomes?
  • Assess your patient’s response based on the criteria you set for the outcome
  • If goals and outcomes have been met, you’ll need to rethink the plan and work through the process again to develop a more effective plan of care for your patient
A

Evaluation

96
Q

the four techniques of physical assessment (abdomen)

A

intersection, auscultation, percussion, palpation

97
Q

COLDSPA

A

Character
Onset
Location
Duration
Symptoms
Pattern
Aggravating Factors

98
Q

after assessment, what will you do?

A
  • you establish your baseline
  • identify nursing diagnoses
  • develop a plan
99
Q

Critical Thinking involves

A

inquiry, interpretation, analysis, and synthesis

100
Q

Includes both verbal and nonverbal communication skills

A

Affective/Interpersonal Skills

101
Q

Establish trust and mutual respect before beginning assessemnt

A

Affective/Interpersonal Skills

Health Assessment - Lecture (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions