Health assessment: nursing process, health history, collecting subjective data – Flashcards

Recognize a pattern or trend Compare with normal standards Make a reasoned conclusion

A problem that is identified during the assessment and supported by obvious signs and symptoms

A problem that the nurse, through knowledge and experience, perceives will develop when risk factors exist. There is no s/s at this time. E.g. After surgery, all patients are at risk for altered breathing patterns; risk for constipation

Situation where data are insufficient to support or refute a nursing diagnosis. E.g. Patient with a fractured hip who lives alone. May use "possible impaired home maintenance management r/t unknown etiology."

A diagnosis that is part of a cluster of nursing diagnoses; 2 accepted by the NANDA: rape-trauma syndrome and risk for disuse syndrome

Diagnosis that relates to a higher level of wellness for the patient; there is no obvious problem; nursing care would focus on helping the patient maintain and achieve higher health status. E.g. "Potential for enhancing parenting" "potential for enhanced coping"

Also sometimes called an admission assessment, is performed when the clients health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the clients health status in subsequent assessments

Collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In problem centered assessments, the nurse determines whether the problems still exist and whether the status of the problem has changed (I.e. Improved, worsened, or resolved). This assessment also includes the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units, may perform focus assessment every few minutes.

Takes place after the initial assessment to evaluate any changes in the clients functional health. Nurses perform a follow up assessment when substantial periods of time have elapsed between assessments

Takes place in life-threatening situations in which the preservation of life is the top priority.

The verbal statements provided by the patient. Statements about nausea and descriptions of pain and fatigue are examples of subjective data

Are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination.