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NCM136/RLE106 > Unit I - Introduction to Health Assessment > Flashcards

Unit I - Introduction to Health Assessment Flashcards

1
Q

When was the nursing process introduced?

A

The nursing process was first introduced in 1958 and has been integrated with the nursing care plan since the early 1960s.

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2
Q

What is health?

A

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, according to WHO.

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3
Q

WHO Definition of health:

A

Health is a quality of life, involving social, emotional, mental, spiritual, and biological fitness on the part of the individual which results from adaptations to the environment.

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4
Q

___ refers to the achievement of the highest level of health in each of several key dimensions

A

Wellness

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5
Q

___ is to gather information about the patient’s condition

A

Assess

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6
Q

___ is to identify the patient’s problem

A

Diagnose

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7
Q

___ is to set goals of care and desired outcomes and identify appropriate nursing actions

A

Plan

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8
Q

___ is to perform the nursing actions identified in the planning

A

Implement

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9
Q

___ is to determine if goals and expected outcomes are achieved

A

Evaluate

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10
Q

it is the Deliberate & systematic collection of data to determine clients’ current/past health status, and present & coping patterns.

A

Nursing Assessment

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11
Q

What is happening?

A

(actual problem),

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12
Q

What could happen?

A

(potential problem)

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13
Q

Importance of nursing health assessment:

A

Establish a database (medical information) for the client’s normal abilities, risk factors, and any alterations.

Plan strategies to encourage the continuation of healthy patterns, prevent potential health problems, and alleviate or manage existing health problems.

Provide a holistic view of the client.

Provide an essential foundation for the care of the client.

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14
Q

1 day to 28 days

A

Neonates

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15
Q

Cuddling facilitates the development of trust and bonding with the parents, especially the mother.

A

Neonates

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16
Q

Protect the ___ from stressors such as lights and excessive handling.

A

neonates

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17
Q

developmental stage for neonates

A

Trust vs. Mistrust

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18
Q

Recognize that the neonate’s behavior is largely ___ in nature.

A

reflexive

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19
Q

29 days to 2 years

A

Infant

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20
Q

stressors for this age group are: strangers, loud noises, bright lights, and sudden environmental changes.

A

Infant

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21
Q

1 year to 3 years

A

Toddler

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22
Q

Expect exaggerated responses to pain, frustration, and changes in the environment.

A

Toddler

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23
Q

___ are ritualistic (exact time to follow in performing hygiene, putting off lights, waking up on their chosen side of the bed, etc).

A

Toddlers

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24
Q

This age group also are impulsive and their moods change quickly.

As a result, they often do things like take unnecessary risks, blurt things out, don’t wait their turn, and interrupt conversations.

A

Toddlers

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25
Q

Parents and nurses should use the firm, direct approach. ___ test limits and may have temper tantrums.

Use play to prepare for and explain procedures.

A

Toddlers

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26
Q

developmental stage for toddlers

A

Autonomy vs. Shame and Doubt

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27
Q

3 years to 5 years

A

Preschool Age

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28
Q

___ engage in magical thinking and may become fearful based upon imagined threats.

A

Preschoolers

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29
Q

Support them when fearful. Fear of the unknown, the dark, mutilation, bodily injury, and being left alone are common.

A

Preschoolers

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30
Q

developmental stage for preschoolers

A

Initiative vs. Guilt

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31
Q

6 years to 12 years

A

School-Aged Child

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32
Q

Allow to participate in his care cause they resent forced dependence.

A

School-Aged Child

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33
Q

developmental stage for School-Aged Child

A

Industry vs. Inferiority

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34
Q

13 years to 18 years

A

Adolescent

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35
Q

subgroup of adolescents aged 13 years to 15 years

A

Young adolescents

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36
Q

subgroup of adolescents aged 16 years to 18 years

A

Older adolescents

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37
Q

Encourage peer visitation if possible. Peers are important to ___.

A

adolescents

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38
Q

developmental stage for adolescents

A

Identity vs. Confusion

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39
Q

Provide support & information related to threats to body image.

A

adolescents

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40
Q

19 years and older

A

Adult

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41
Q

subgroup of adults aged 20 years to 40 years

A

Young adults

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42
Q

subgroup of adults aged 40 years to 65 years

A

Older adults

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43
Q

Assess physical and cognitive ability to work and communicate with co-workers, family, and friends.

A

Adult

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44
Q

Assess the impact of hospitalization on family, work, and body image.

A

Adult

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45
Q

developmental stage for young adults

A

Intimacy vs. Isolation

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46
Q

developmental stage for middle-aged adults

A

Generativity vs. Stagnation

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47
Q

developmental stage for older adults

A

Integrity vs. Despair

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48
Q

A Complete Health Assessment consists of:

A

Physical
Emotional
Mental
Social
Spiritual

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49
Q

Approach to Identifying Priorities

A

Immediate priorities

Second-level Priorities

Third-level priorities

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50
Q

The ABCs of immediate priorities

A

Airway
Breathing
Circulation
Vital Signs

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51
Q

Second-level Priorities

A

Mental status change
Acute pain
Urinary elimination problem
Untreated medical problem (diabetic without insulin)
Abnormal lab values
Risk of infection, safety, security

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52
Q

Third-level priorities

A

Lack of sleep
Activity, rest, sleep

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53
Q

Types of Assessment

A

Initial nursing assessment
Focus or Ongoing assessment
Emergency assessment
Time-Lapsed assessment

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54
Q

It is performed within a specified time after admission to a health care agency.

A

Initial nursing assessment

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55
Q

Purpose of Initial Nursing Assessment

A

To establish a complete database for problem identification, reference, and future comparison.

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56
Q

Ongoing process integrated with nursing care.

A

Focus or Ongoing assessment

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57
Q

Purpose of the focus or ongoing assessment:

A

To determine the status of a specific problem identified in an earlier assessment and to identify a new or overlooked problem.

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58
Q

During any psychologic or physiologic crisis of the client

A

Emergency assessment

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59
Q

Purpose of the emergency assessment:

A

To identify life-threatening problems.

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60
Q

Several months after the initial assessment.

A

Time-Lapsed assessment

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61
Q

Purpose of the time-lapsed assessment:

A

To compare the client’s current status to baseline data previously obtained

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62
Q

Approaches/skills in Assessment

A
  1. Cognitive skills
  2. Problem–solving skills
  3. Psychomotor skills
  4. Affective and interpersonal skills
  5. Ethical skills
63
Q

the skill where the Assessment is a “thinking” process.

The why, how, and what in the nurse assessment findings. Clinical decision making. The use of knowledge plus experience.

A

Cognitive skills

64
Q

a skill that is performed with experience and scientific methods.

A

Problem–solving skills

65
Q

the skill where the Assessment is “doing”.

A

Psychomotor skills

66
Q

the skill where the Assessment is “feeling” trust and mutual respect.

A

Affective and interpersonal skills

67
Q

the skill where the Assessment is “being responsible and accountable “

A

Ethical skills

68
Q

The assessment process means:

A

collecting data
organizing data
validating data
documenting data
reporting data.

69
Q

Types of Data

A

Subjective data
Objective data

70
Q

also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person.

A

Subjective data

71
Q

also referred to as signs or overt data, they are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.

A

Objective data

72
Q

Sources of Data

A

Primary source
Secondary source

73
Q

what type of source is the patient?

A

Primary source

74
Q

what type of source is data collection, family members, health professionals, diagnostic results, records, and reports

A

Secondary source

75
Q

Methods of Data Collection

A
  1. Observation
  2. Interview
  3. Examination
76
Q

It gathers data by using the senses of sight, smell, and hearing.

A

Observation

77
Q

This is a planned communication or a conversation with the purpose of identifying more cues about the patient’s problems.

A

Interview

78
Q

Forms/Types of Interview

A

directive interview
non-directive interview

79
Q

The ___ interview is highly structured and directly asks questions. The nurse controls the interview.

A

directive

80
Q

A ___ interview, or rapport-building interview, allows the client to control the interview.

A

non-directive

81
Q

Nurses can ease clients’ apprehensions by being prepared for client’s clarifications about their health.

A

Facilitating interventions

82
Q

Occurs when a reward is given to strengthen a desired behavior.

A

Reinforcement

83
Q

Using the patient’s words, the nurse indicates that he/she heard the client.

A

Reflection

84
Q

This is to clarify things or modify the client’s level of understanding.

Ending the summary by “Does that sound okay for you?’

A

Summarizing

85
Q

Acknowledge what clients say.

can be done by saying “Yes, I understand”

A

Accepting

86
Q

Acknowledge the patient’s behavior.

“I noticed you took all your meds”

A

Giving recognition

87
Q

A comment to remove fears and doubts but false ___ should never be given

A

reassurance

88
Q

This shows that the nurse values the client and is willing to give the latter time.

Offering to stay for lunch
Watch TV with client
Sitting with the client

A

Offering self

89
Q

Allowing the client to direct the conversation and allow him to talk on the topic.

“What’s on your mind today?”
“What would you like to talk about?”

A

Giving broad opening

90
Q

Observe the client’s appearance, demeanor or behavior

The nurse observes the client’s eyebags, fatigue or not eating.

A

Making observations

91
Q

Patients do not always have a specific topic or question relevant to their illness.

The nurse can open or pick out topics or possible questions for the client to initiate the conversation.

A

Focusing

92
Q

Being attentive to what the client is saying by facing the client, eye contact, and attentiveness.

A

Active listening

93
Q

To check whether the client is able to understand what the nurse is conveying.

A

Seeking clarification

94
Q

As the patient manifests s/s, these areas may have other related symptoms and should be explored.

A

Associations

95
Q

Very helpful if the interviewer smiles, laughs, or even when appropriate, adds another punchline.

Sharing of ___ can decrease tension and anxiety and reinforce the interviewer’s genuineness.

A

Use of humor

96
Q

Often, encouraging the patient to continue their story can be facilitated by asking who, what, where, when questions.

“Why” questions are generally not helpful early in an interview.

A

Leading

97
Q

Gently encouraging the patient to talk more about the issue may be quite productive.

Tell me more. How did that affect you?

A

Probing

98
Q

___ can be used when the patient changes topics too quickly or persists in offering information about non-productive or already crossed areas.

A

Redirection

99
Q

Interrupting the patient finishes off what they are saying.

A

Premature Interpretation

100
Q

If introduced in an unclear manner, unconnected to content, or poorly timed, they may be experienced as unresponsive to the patient’s concerns or feelings.

A

Obstructive interventions

101
Q
  • Even though it may be accurate, it may be counter-productive, as the patient may respond defensively and feel misunderstood.
A

Premature advice

102
Q

___ gives an opportunity to think through and process what comes next in the conversation.

It may give patients the time and space they need to broach a new topic.

A

Using silence

103
Q

Three Stages of Interviewing

A

Introduction
Body
Close

104
Q
  • Generally a professional non-confrontational tone
  • Greet interviewee and state reason for interview
  • Sets the tone for all interview types
  • Establish rapport with interviewee
  • Assess witness’ spirit of cooperation
  • Provides the beginnings of the baseline for assessment of misdirection and deceit
A

Introduction

105
Q
  • Facts and evidence of the case are reviewed withinterviewee
  • Generally open-ended questions
  • Allow interviewee to completely answer question
  • Completely understand answers before moving on
  • Demonstrate patience and don’t interrupt interviewee
  • Focus on listening, gathering information, and watching for misdirection and deceit
  • Issues with checklists and pre-written questionnaires
A

Body

106
Q
  • Review and summarize important aspects of the interview
  • Clarify any questions regarding the interviewee’s responses
  • Attempt to end the interview on a positive note
  • Interviewer should leave the door open for future discussion
A

Close

107
Q

The physical ___ is a systemic data collection method to detect health problems.

A

examination

108
Q

Four primary techniques used in the physical assessment

A

Inspection
Palpation
Percussion
Ausculatation

109
Q

type of inspection that relies on sight and smell.

A

Direct inspection

110
Q

type of inspection that uses of equipment to expose internal tissues or to enhance view of a specific body area

A

Indirect inspection

111
Q

___ is the examination of the body using the sense of touch. The pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination.

A

Palpation

112
Q

these sense vibrations

A

Metacarpophalangeal joints

113
Q

these assess Fine tactile discrimination, Moisture, Texture, Masses, Pulsations, Edema, Crepitation, Organ size, shape, position, mobility, and consistency

A

Finger pads

114
Q

this is the secondary part of the hand that senses vibration

A

Ball of hand

115
Q

The ___ is used to assess surface temperature.

A

dorsum, or back of the hand,

116
Q
  • It is used to feel the abnormalities that are on the surface.
  • Use the front of your fingers, and gently press down into the area of the body about 1-2 cm.
  • Then lift your fingers off the body and move to the next nearby area.
  • It helps to identify the texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
  • All areas must be palpated systemically.
  • Use nine quadrants as a guide
A

Light palpation

117
Q

light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm). Use it to check muscle tone and to assess for tenderness.

A

Light palpation

118
Q
  • is used to feel internal organs and masses.
  • Use the front of your fingers to firmly press down into the area of the body about 4-5 cm, then lift your fingers off the body and move to the next area nearby.
  • It helps to identify the size, shape, tenderness, symmetry, and motility.
  • can be painful and uncomfortable for patients while examining the abdomen.
  • Another way to palpate is to put one hand on top of another when pressing down it is called the bimanual technique.
A

Deep palpation

119
Q

___ is used with caution because pressure can damage internal organs. The skin and underlying structures about 1 inch (2 cm) are depressed.

To identify abdominal organs and abdominal masses.

A

Deep palpation

120
Q

___ palpation places the fingers of one hand on top of those of the other.

The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation.

A

Two-handed deep

121
Q

The tapping of fingers quickly and sharply against body surfaces to produce sounds, to detect tenderness, or to assess reflexes.

This helps locate organ borders, identify shape and position determine if the organ is solid or filled with fluid or gas.

A

Percussion

122
Q

Methods of percussion

A

Direct percussion
Indirect percussion

123
Q

using one hand to strike the surface of the body

Tapping the patient’s body directly with the distal end of a finger.

A

Direct percussion

124
Q

using the finger of one hand to tap the finger of the other hand.

A

Indirect percussion

125
Q

the middle finger of the nondominant hand

A

Pleximeter

126
Q

Percussion elicits five types of sound.

A

Flatness
Dullness
Resonance
Hyperresonance
Tympany

127
Q

___ is an extremely dull sound produced by very dense tissue such as muscle or bone.

A

Flatness

128
Q

___ is a thudlike sound produced by dense tissue such as the liver, spleen, or heart.

A

Dullness

129
Q

___ is a hollow sound such as that produced by lungs filled with air.

A

Resonance

130
Q

___ is not produced in the normal body. It is described as booming and can be heard over an emphysematous lung.

A

Hyperresonance

131
Q

___ is a musical or drumlike sound produced from an air-filled stomach.

A

Tympany

132
Q

It is the process of listening to sounds produced within the body using a stethoscope

A

Auscultation

133
Q

Parts of the stethoscope:

A

Eartips
Binaural
Binaural spring
Tubing
Bell
Diaphragm

134
Q

Types of Auscultation

A

Direct or immediate auscultation
Mediate/Indirect auscultation

135
Q

Application of the ear directly to the body surface where the sound is most prominent.

A

Direct or immediate auscultation

136
Q

The use of sound augmentation devices such as stethoscopes in the detection of body sounds.

A

Mediate/Indirect auscultation

137
Q

Auscultation can be performed in the following activities:

A
  • Listening to body sounds
  • Movement of air in the lungs
  • Blood flow like taking the HR and BP
  • Fluid and gas movement (bowels)
138
Q

Technique order used in the physical assessment ->

A

IPPA

139
Q

Technique order For Abdominal assessment ->

A

IAPP (percussion then palpation)

140
Q

Nursing models or framework

A

➤ Gordon’s functional health pattern
> Orem’s self-care model
> Roy’s adaptation model
➤ Wellness model

141
Q

Nonnursing models

A

➤ Body system model
➤ Maslow’s hierarchy of needs
➤ Developmental theories

142
Q

___ is the act of “double checking “or verifying the data to confirm that it is accurate and factual.

A

Validation

143
Q


Takes place when two or more people share information about client care, either face-to-face or by telephone.

A

REPORTING

144
Q

Three general types of assessment:

A

Functional assessment
Descriptive assessment
Indirect assessment

145
Q

A method used to determine the function of problem behavior.

A

Functional assessment

146
Q

type of assessment Intended to help us determine why a behavior occurs rather than how often a behavior occurs.

A

Descriptive assessment

147
Q

It is gathering information through means other than looking at actual samples of student work.

These include surveys, exit interviews, and focus groups.

A

Indirect assessment

148
Q

Types of Clients to be Assessed

A
  1. Silent Client
  2. An Overly Talkative Client
  3. The anxious frightened patient
  4. The angry client
  5. The intoxicated client
  6. Depressed client
149
Q

Short periods of silence may be normal.

Allow them time to collect their thoughts.

The patient may be frightened, or perhaps you frightened them

Are you dominating the discussion?

Have you offended the client?

Is there a physical or mental disorder? Or a lack of understanding?

A

Silent Client

150
Q

Allow the client to talk.

Don’t display your impatience

If necessary, politely interrupt and focus the discussion

A

An Overly Talkative Client

151
Q

Try to understand the pts. Feelings – “I don’t know why you are so anxious, would you like to talk about it?”

Identify the source of anxiety/fear

A

The anxious frightened patient

152
Q

Understand the source of these feelings

Be firm but let your verbal and body language show that you care

A

The angry client

153
Q

These patients may manifest being irrational, at times violent and abusive, shouting

Do not respond back with shouting

A

The intoxicated client

154
Q

Call for assistance

A

Depressed client

NCM136/RLE106 (27 decks)

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