The health assessment process

Question 1

holistic assessment

Answer 1

looks at the person as a whole and as part of every nursing role. Begin assessing as soon as you see

Question 2

How does the nurse perform a holistic nursing assessment?

Answer 2

collect holistic subjective/objective data to determine the overall level of functioning to make professional clinical judgment

Question 3

What is the first step in the nursing process?

Answer 3

assessment

Question 4

What does assessment include?

Answer 4

subjective/objective data collection

Question 5

preparation for health assessment

Answer 5

review record, review health status w/ other team members, educate self on diagnosis/tests performed (ex. just b/c within normal range doesn’t mean not going up). NO ASSUMPTIONS. Reflect on own feelings, organize materials needed

Question 6

What is the focus of health assessment?

Answer 6

holistic info to determine the overall level of functioning/make a professional judgment (vs. doctors specialized)

Question 7

What are the four types of health assessment?

Answer 7

-comprehensive
-ongoing/partial
-focused
-emergency

Question 8

Comprehensive assessment

Answer 8

everything = health history/complete physical exam. usually when pt first enters a health care setting = the baseline for comparing later

Question 9

ongoing/partial assessment

Answer 9

regular intervals, monitor changes/ evaluate the effectiveness of interventions

Question 10

focused assessment

Answer 10

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

Question 11

emergency assessment

Answer 11

rapid focused assessment conducted to determine potentially fatal situations (life-threatening situation)

Question 12

Steps of a health assessment

Answer 12

collect subjective data, collect objective data, validate data, document

Question 13

subjective data

Answer 13

biographical info, history of present concern/physical symptoms of each system, personal health history, family history, health/lifestyle practices - WHAT THEY TELL YOU

Question 14

Objective data

Answer 14

physical characteristics, body functions (ex: gait), appearance, behavior, measurements, lab/diagnostic results. - WHAT YOU CAN SEE

Question 15

What do you do after collecting objective and subjective data?

Answer 15

validate (correct?), document, analyze (trends)

Question 16

Using assessment data the nurse will…

Answer 16

id abnormal data/strengths, cluster data, draw inferences/id problems, possible nursing diagnoses, check for defining characteristics, confirm/rule out diagnoses, document conclusion

Question 17

Why is the nurse’s role advancing in assessment?

Answer 17

increasing complexity of acute care, aging population w/ complex comorbidities, expanding health care needs of single parents/children/homeless, mental health, expanding health services network, health promotion/preventive services, limited primary physicians, aging baby boomers