The Nurse’s Role in Health Assessment Flashcards
the first and most critical phase of the nursing process.
Assessment
Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ??? and ??? throughout all phases of the nursing process
ongoing and continuous
The nursing process should be thought of as ???, not linear
circular
Phases of the Nursing Process
assessment
diagnosis
planning
implementation
evaluation
[ADPIE] The arrow between ??? and ??? goes in both directions because these are ongoing processes as well as separate phases.
Assessment and Evaluation
Analyzing subjective and objective data to make and prioritize professional clinical judgments (client concerns, collaborative problems, or referral)
Diagnosis
Generating solutions, developing a plan, and determining
which outcomes need to be met first
Planning
Taking action. Prioritizing and implementing the planned interventions
Implementation
Assessing whether outcomes have been met and revising the plan if the interventions did not make a difference
Evaluation
A comprehensive health assessment consists of both a
??? and ???
health history and physical examination
The purpose of a nursing health assessment is to collect ??? and ??? to determine a client’s overall level of functioning in order to make a ???
- holistic subjective and objective data
- professional clinical judgment.
are considered to be interdependent factors that affect a person’s level of health (3)
The mind, body, and spirit
ADLs
activities of daily living
The nurse, in particular, focuses on how the client’s health status affects ??? and how those affect the
client’s health.
activities of daily living (ADLs)
helps to organize information and
promotes the collection of holistic data. This, in turn, provides clues that help to determine human responses.
A nursing framework
The questions asked in each physical system’s chapter focus on that particular body system and are broken down into four sections:
History of present health concern
Personal health history
Family history
Lifestyle and health practices
the phase in which the nurse identifies and clusters the cues collected to make clinical judgments
Data analysis
The end result of this data analysis
portion of the nursing process is identification of (3)
client concerns,
collaborative problems,
and/or referrals.
The four basic types of nursing assessment are:
- Initial comprehensive assessment
- Ongoing or partial assessment
- Focused or problem-oriented assessment
- Emergency assessment
involves collection of subjective data about the client’s perception of their health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client’s overall functioning) as well as objective data gathered during a step-by-step physical examination.
initial comprehensive assessment
subjective and objective data regarding functional health and body systems
total health assessment
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.
total health assessment
An ??? of the client consists of data collection that occurs after the comprehensive database is established
ongoing or partial assessment
does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern.
focused or problem-oriented assessment
consists of a thorough assessment of a particular client problem and does not address areas not related to the problem
focused or problem-oriented assessment
a very rapid assessment performed in life-threatening situations
emergency assessment
situations where emergency assessment is done
choking, cardiac arrest, drowning
example of an emergency assessment is the evaluation of the client’s ??? when cardiac arrest is suspected.
airway, breathing, and circulation (known as the ABCs)
The assessment phase of the nursing process has four major steps:
Collection of subjective data
Collection of objective data
Validation of data
Documentation of data
Before actually meeting the client and beginning the nursing health assessment, the nurse should review the ?
client’s medical record, if available
are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
Subjective data
To elicit accurate subjective data, learn to use effective ?? skills with a variety of clients in different settings.
interviewing
subjective or objective? biographical information
subj
subjective or objective? history of present health concern
subj
subjective or objective? personal health history
subj
subjective or objective? family history
subj
subjective or objective? health & lifestyle practices
subj
subjective or objective? review of systems
subj
subjective or objective? physical characteristics (skin color, posture, etc.)
obj
subjective or objective? body functions (HR, RR, etc.)
obj
subjective or objective? appearance (dress, hygiene)
obj
subjective or objective? behavior
obj
subjective or objective? measurements
obj
subjective or objective? lab test results
obj
This type of data is obtained by general observation and by using the four physical examination techniques
objective data
four physical examination techniques:
inspection, palpation, percussion, and auscultation
data that may also be observations noted by the family or significant others about the client
Objective
a crucial part of assessment that often occurs along with collection of subjective and objective data. It serves to ensure that the assessment process is not ended before all relevant data have been collected and helps to prevent documentation of inaccurate data
Validation of assessment data
is an important step of assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team
Documentation of assessment data
is defined in this textbook as a problem of a client who may be an individual, family, group, or community.
A client concern
client concern other term
nursing problem
are defined as certain “physiological complications that nurses monitor to detect their onset or changes in status
Collaborative problems
occur because nurses assess the “whole” (physical, psychological, social, cultural, and spiritual) client, often identifying problems that require the assistance of other health care professionals.
Referrals
To identify client concerns, collaborative problems, or need for referral, you must go through the steps of ?
data analysis
This process requires diagnostic reasoning skills, often called critical thinking
data analysis
process of data analysis:
-Identify ??? cues and ??? cues.
Cluster cues.
-Draw ??? and identify and prioritize ???.
-Propose possible ??? to notify primary care provider.
-Identify need for ??? to primary care provider.
-???
- abnormal; supportive
- inferences; client concerns
- collaborative problems
- referral
- Document conclusions
