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
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”
3
Q
To accomplish this pertinent and comprehensive data collection, the nurse:
A
- Collects data in a systematic and ongoing process
- Involves the patient, family, other health care providers, and environment, as appropriate, in holistic data collection
- Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation
- Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data
- Uses analytical models and problem-solving tools
- Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances
- Documents relevant data in a retrievable format
4
Q
Standard 2 states, “
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“The registered nurse analyzes the assessment data to
determine the diagnoses or issues”
5
Q
Standard 2 states, “The registered nurse analyzes the assessment data to determine the diagnoses or issues”
To accomplish this, the nurse:
A
- Derives the diagnosis or issues based on assessment data
- Validates the diagnoses or issues with the client, family, and other healthcare providers when possible and appropriate
- Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan
6
Q
The Nursing Process
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Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
7
Q
Process of collecting, validating, and clustering data
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Assessment
8
Q
The first and most important step in the nursing process
A
Assessment
9
Q
Sets the tone for the rest of the process and the rest of the
process flows from it
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Assessment
10
Q
Identifies the patient’s strengths and limitations and is performed continuously throughout the nursing process
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Assessment
11
Q
Skills of Assessment
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- Cognitive Skills
- Problem-Solving Skills
- Psychomotor Skills
- Affective/Interpersonal Skills
- Ethical Skills
12
Q
Needed for critical thinking, creative thinking, and clinical decision making
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Cognitive Skills
13
Q
what are examples of Cognitive Skills
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- Critical Thinking
- Clinical Decision Making
14
Q
Not just doing but asking “why?”
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Critical Thinking
15
Q
Involves inquiry, interpretation, analysis, and synthesis
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Critical Thinking
16
Q
Looking for cues and make inferences
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Clinical Decision Making
17
Q
Identify patterns and recognize what differs from the norm
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Clinical Decision Making
18
Q
Use your knowledge, experience, and what the patient says to validate the data
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Clinical Decision Making
19
Q
what are the Problem-Solving Skills
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- Reflexive thinking
- Hit-or-miss thinking
- Critical-thinking approach
- Intuition
20
Q
Select the method that best suits your patient’s needs
A
Problem-Solving Skills
21
Q
Automatic, without conscious deliberation, and comes with
experience
A
Reflexive thinking
22
Q
Trial-and-error approach
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Hit-or-miss thinking
23
Q
Random, non systematic, and efficient
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Hit-or-miss thinking
24
Q
Fosters creativity and allows you to formulate new ideas
A
Hit-or-miss thinking
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Use it for situation that don’t quite fit the picture, look beyond the obvious, and keep looking until you find the answer
Hit-or-miss thinking
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- Scientific method
- Involves identifying a problem and collecting supporting data, formulating a hypothesis, planning a solution, implementing the plan, and then evaluating its effectiveness
Critical-thinking approach
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- Develops through experience
- How “expert” nurse solves problems
Intuition
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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
Intuition
29
- Needed to perform the four techniques of physical assessment (inspection, palpation, percussion, and auscultation)
- Mastered through experience and practice
Psychomotor Skills
30
the four techniques of physical assessment
inspection, palpation, percussion, and auscultation
31
Needed to practice the “art” of nursing
Affective/Interpersonal Skills
32
- Essential in developing caring, therapeutic nurse-patient relationship
- Includes both verbal and nonverbal communication skills
- Establish trust and mutual respect before beginning assessment
Affective/Interpersonal Skills
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- Being responsible and accountable
- You are an advocate of your patient
- Respect for patient’s rights and ensure patient confidentiality
Ethical Skills
34
Four Basic Types of Health Assessment
- Initial Comprehensive Assessment
- Ongoing or Partial Assessment
- Focused or Problem-Oriented Assessment
- Emergency Assessment
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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
Initial Comprehensive Assessment
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Other members of the health care team may participate in the data collection (e.g. physician, physical therapist, dietician, nurse practitioner)
Initial Comprehensive Assessment
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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
Initial Comprehensive Assessment
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Data collection after the comprehensive database is established
Ongoing or Partial Assessment
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Consists of a mini-overview of the client’s body systems and holistic health patterns as a follow-up on health status
Ongoing or Partial Assessment
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Reassessment of initial problems detected to determine any changes
Ongoing or Partial Assessment
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Brief assessment of the client’s body systems and holistic health patterns to detect new problems
Ongoing or Partial Assessment
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Usually performed whenever the nurse or another healthcare professional has an encounter with the client
Ongoing or Partial Assessment
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A client with lung cancer requires frequent assessment of
lung sounds. Skin assessment would only focus on the ______________________________________________ to determine the level of oxygenation
color and temperature of the extremities
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Performed when comprehensive database exists for a
client who comes to the health care agency with a specific
health concern
Focused or Problem-Oriented Assessment
45
Consists of a thorough assessment of a particular client
problem and does not cover areas not related to the
problem
Focused or Problem-Oriented Assessment
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A patient came to the hospital and tells you he has headache. Your questions would be focused more on the
character, location, onset of the pain, relieving and aggravating factors, and associated symptoms
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Very rapid assessment performed in life-threatening situations like choking, cardiac arrest, drowning
Emergency Assessment
48
An immediate assessment is needed to provide prompt treatment
Emergency Assessment
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Evaluate ____________________________________________ when cardiac arrest is suspected
airway, breathing, and circulation
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Major and only concern of Emergency Assessment:
determine the status of client’s life-sustaining physical functions
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Diagnose and treat human responses to actual or potential health problems
Nursing Assessment
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Focuses not only on the physiological and psychological responses but also on the psychosocial, cultural, and developmental, and spiritual dimensions
Nursing Assessment
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Diagnose and treat disease
Medical Assessment
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Focuses on the physiological and psychological responses
Medical Assessment
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Types of Data
- Subjective Data
- Objective Data
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Symptoms
Subjective Data
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What the patient feels
Subjective Data
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Pain, nausea, weakness
Subjective Data
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Signs
Objective Data
60
What you observe using your senses
Objective Data
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Vital signs, pupillary reaction, jaundice
Objective Data
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Data Sources
- Primary Data
- Secondary Data
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Anything from the patient
Primary Data
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Anyone or anything other than the patient (relatives, guardians, friends, medical records)
Secondary Data
65
Methods of Data Collection
- Interviews
- Observation
- Physical Assessment
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- 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
Interviews
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- Entails deliberate use of senses
- Look at both your patient and his or her environment to detect anything out of the ordinary
Observation
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- 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
Physical Assessment
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Documentation Methods
- SOAPIE Method
- DAR Method
- PIE Method
- Narrative Method
70
SOAPIE Method
Subjective Data, Objective Data, Assessment, Plan, Interventions, Evaluation
71
DAR Method
Data, Action, Response
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PIE Method
Problem, Interventions, Evaluation
73
A 25 year-old male came into the emergency room
complaining of abdominal pain. How will you perform
your assessment?
What to ask:
- 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
A 25 year-old male came into the emergency room
complaining of abdominal pain. How will you perform
your assessment?
What to examine:
* 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
If with vomiting, ask about
frequency, volume, color, projectile
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If with diarrhea, ask about
frequency, volume, color, consistency
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Identifying and prioritizing actual or potential health
problems or responses
NURSING DIAGNOSIS
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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.
NURSING DIAGNOSIS
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Nursing diagnoses can be:
Actual, Potential, Possible, Collaborative, Wellness
80
occurring health problem for the patient
Actual
81
high-risk health problem that most likely will occur unless preventive measures are taken
Potential
82
one that needs further data to support it
Possible
83
potential medical complication that warrants both medical
and nursing intervention
Collaborative
84
focus on promoting or enhancing a patient’s level of wellness
Wellness
85
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 – airway
B – breathing
C – circulation
D – disability
E – exposure
86
Involves setting goals and outcomes
Planning
87
First, establish your goals and determine measurable
outcomes
Planning
88
Next, identify nursing interventions needed to meet
the goals and outcomes
Planning
89
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
Planning
90
Remember, your goals and outcomes must be
SMART
S – specific
M – measurable
A – attainable
R – relevant
T – time-bound
91
Implementation is also called as
intervention
92
Involves carrying out your plan to achieve goals and outcomes
Implementation
93
Implementation is the “______________” of the nursing process in which you actually implement the nursing interventions in the plan
doing phase
94
The “doing phase” of the nursing process in which you actually implement the nursing interventions in the plan
Implementation
95
- 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
Evaluation
96
the four techniques of physical assessment (abdomen)
intersection, auscultation, percussion, palpation
97
COLDSPA
Character
Onset
Location
Duration
Symptoms
Pattern
Aggravating Factors
98
after assessment, what will you do?
- you establish your baseline
- identify nursing diagnoses
- develop a plan
99
Critical Thinking involves
inquiry, interpretation, analysis, and synthesis
100
Includes both verbal and nonverbal communication skills
Affective/Interpersonal Skills
101
Establish trust and mutual respect before beginning assessemnt
Affective/Interpersonal Skills
