chap. 12 assessing

Flashcard maker : Daphne Armenta
Assessing
the process of collecting, organizing, validating, and recording data (information) about a client’s health status
Cue
significant information that is helpful in making decisions
data
Information
database
all the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented
emergency assessment
rapid focused assessment conducted to determine potentially fatal situations
focused assessment
assessment conducted to assess a specific problem; focuses on pertinent history and body regions
inference
the judgement reached about a cue
initial assessment
comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient’s health status, ability to manage his or her own healthcare, and need for nursing and to plan individualized, holistic healthcare for the patient
interviews
face to face data collection
minimum data set
a standard established by healthcare institutions that specifies the information that must be collected from every patient
nursing history
assessment of the patient by interview to identify the patient’s health status, strengths, health problems, health risks, and need for nursing care
objective data
information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled
observation
Involves using one or more of the five senses to gather information
physical assessment
systematic examination of the patient for objective data to better define the patient’s condition and to help the nurse in planning care; usually performed in a head-to-toe format
review of systems
Systematic method for collecting data from all body systems
subjective data
Data relating to a client’s health problem that are given in the client’s own words.
time-lapsed assessment
an assessment that is scheduled to compare a patient’s current status to baseline data obtained earlier
validation
act of confirming or verifying
four types of nursing assessments
Focused
Initial
Time-lapsed
Emergency
initial assessment
is performed shortly after the patient is admitted to the healthcare agency or service. the purpose is to establish a complete database for problem
identification and care planning
focuses assessment
conducted to assess a specific problem. Ex: abdominal pain, nurse asks about bladder and bowel habits. what when did symptoms start , what makes it worst?
Emergency assessment
Time Period: During any physiologic or psychologic crisis of the client; Purpose: To identify life-threatening problems. To identify new or overlooked problems; Example: Rapid assessment of a person’s airway, breathing status, and circulation during a cardiac arrest. Assessment of suicidal tendencies or potential for violence.
Time-lapsed assessment
an assessment that is scheduled to compare a patient’s current status to baseline data obtained earlier homecare with visiting nurses.
relationship between nursing assessments and medical assessment?
when nurses make a assessment they do not duplicate medical assessments .
Medical assessments target the pathological conditions, whereas Nursing assessments focus on the patients responses to health problems , the unique focus of nursing assessment is on the patients responses to actual or potential health problems.
objective data vs subjective data?
objective data is collected by the person doing the interview using sense what you see , smell , hear,feel.
subjective data – is given in the patients own words what they tell you
Five sources of patient data useful to the nurse?
1. Patient
2. Family and significant others
3.Patient records
4.Other healthcare professionals
5.Nursing and other healthcare literature
purpose of nursing observation,interview,and physical assessment?
the purpose for which the assessment is being performed offers the best guideline about what type and how much data to collect . Assessment priorities are based on the patients health orientation,developmental stage , culture, and need for nursing- patient health problems dicate assessment priority
obtain a nursing history using effective interviewing techniques?
The nursing history should clearly identify the patients strengths and weaknesses; health risk, such as hereditary and environmental factors; and potential and existing health problems. The nursing history focuses on getting to know the person.
Patient interview:
-preparatory phase: the nurse should insure the environment that the interview is being conducted is private and relaxed.
-introductory phase: starts off \”good afternoon Ms. Smith my name is Skippy and I’m going to be your nursing student for today.\”
-working phase: during this phase nurse gathers information to form the subjective data base. the accuracy and completeness is important
-termination: the successful interview is concluded carefully. Highlight the keys points making sure the patient agrees with you. Always ask \” is there anything else you would like us to know that will help us plan your care?\”
Nursing physical assessment?
the examination of the patient is for objective data. it identifies pathological conditions and their causes, the nursing physical assessment focuses on the patient’s functional abilities, if a deficit is present like a CVA a nurse will check for a patients reasoning and sensor motor ability. Nurse uses their senses.
Nursing process is presented in a orderly progression of 5 steps in which there is overlapping and interaction among the steps this is an example of what characteristic?
dynamic
While administering a medication to alleviate a patients pain you wonder if there are some nonpharmacologic interventions that would enhance relief by complementing the pain medication you discuss this question with the instructor, which of the following responses would you most likely hear?
Let’s talk about this we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap.
when a patient you are admitting to the unit asks you \”why you are doing a history and exam since the Dr. just did one,\” which of the following statements is your best reply?
\”In addition to providing us with valuable information about your health status it will allow us to plan and deliver individualized holistic nursing care that draws on your strengths.
When you receive the shift report you learn your patient has no special skin care needs, you are surprised you observe redness areas over bony prominences what action is appropriate?
Perform and document a focused assessment on skin integrity.
Fearful of attempting your first nursing history you ask your instructor how anyone ever learns everything you have to ask to get good baseline data. you are most likely to hear which reply from the instructor?
You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.
A patient complains about feeling nauseated after lunch. this is an example of what type of data?
Subjective Data
When you enter the patient’s room to begin your nursing history, the patient’s wife is there what should you do?
Introduce yourself and ask the patient if he would like the wife to stay.
The patient is Vietnamese and does not speak English, her son is with her and does speak English, how should you respond?
Explain to the patient and her son that you will obtain the services of a hospital approved translator.
You are surprised to detect an elevated temperature of 102 in a patient schedule for surgery. The patient has been afebrile (no fever) and shows no other signs of being febrile what is the first thing you do?
Validate your findings
Tell your instructor that your patient is fine and has no complaints you are likely to hear?
You made an inference that she is fine because she made no complaints, how do you validate this?
legal alert data reporting and recording
Appropriate communication involves correct timming and proper documentation.
Documentation of data when subjective
NURSE SHOULD TRY AND USE THE PATIENTS OWN WORDS OF HOW THEY FEEL YOU SHOULD USE \” \” MARKS or para phrased : avoid using adaquate,good average,normal,poor,small, large
Nurse Ruth gives a hypertension med after assessing the B/P at 160/98 and hours later
Nurse Ruth reassesses the B/P at 140/80 this is Not considered evaluating –Collection of pt data is considered assessment regardless of when it occurs.

Get instant access to
all materials

Become a Member