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Assesment

Exam 2 Review

TermDefinition
Four Types of Nursing Assessments Initial, Problem-Focused, Emergency, Time-Lapsed Reassessment
Assessment Activity: Step 1 Collecting Data: gathering information about the client's health status
Assessment Activity: Step 2 Organizing Data: writing data into an organized format
Assessment Activity: Step 3 Validating Data: verifying that data is complete and accurate
Assessment Activity: Step 4 Documenting Data: recording data in a factual manner
When collecting data you should... Form a database including: physical assessment primary health care providers history and physical results of labs and diagnostics healthcare teams documentation
Components of a nursing health history biographic data, chief complaint/reason for visit, history of present illness, past history, family history of illness, lifestyle, social data, psychological data, patterns of health care
Subjective Data Symptoms Described, verified by the person affected which includes sensations, feelings, values, beliefs, attitudes and perceptions
Objective Data Signs Can be observed, measured, and tested Obtained by observation or physical examination
Sources of Data Client Support People Client Records Health Care Professionals Literature
3 Data Collecting Methods Observing Interviewing Examining
What do you do when you observe patient Gather data using your five senses Skill developed over time, Observe mainly through sight,
Interviewing Planned communication or conversation with a purpose
Directive Interview Structure and obtains specific information
Non-directive Interview/ Rapport Builds a relationship understanding between the patient and nurse
Restrictive "yes" or "no" answers Closed Question
Short Factual Answers Closed Question
Allow clients to explore and talk about feelings Open-ended questions
Client may answer without influence of the nurse Neutral Questions
Closed ended that directs the client's answer Leading Questions
What to consider when setting up an interview with client time, place, seating arrangement, distance, language
What do you do in the opening of your interview? Establish rapport with the patient and orientation
What do you do in the body of your interview? Client responds to the nurse's questions
What is examinining A systematic process of gathering data through using observation to detect health problems
Four ways of examining Inspection, Auscultation, Palpation, Percussion,
Maslow's Hierarchy of Needs (pyramid) physiological, safety, love/belonging, esteem, self-actualization
To validate information you should... "Double check" data to confirm accurate Ensure that assessment info is complete obj. and subk. data agree differ between cues and inferences avoid jumping to conclusions
To document data you should.... Record in a factual manner include all data collected about client's health status Subjective data recorded in client's own words
Four things assessment involves Collecting, Organizing, Validating, and Recording Data
What is the Nursing Process? A systematic, rational method of planning and providing nursing care. Orderly, logical approach to providing nursing care and ensuring that the patients needs are met.
Five Steps of Nursing Process Assessment, Diagnosis, Planning, Implementing, Evaluating
Two Components of Health Status Healthy History and Physical Examination
Purpose of Physical Examination Obtain baseline data To validate data obtained in the nursing history To aid in establishing nursing diagnoses and the plan of care for patients
Purpose of Physical Examinations Evaluate the physiological outcomes of healthcare and the patients progression Make clinical judgments Identify areas for health promotion and disease prevention
What should you do when preparing the client? Explain what you are going to do
What should you do when preparing the environment? Prepare your equipment good lighting, warm room temp provide privacy
Health Exam Equipment Stethoscope Pen light Blood pressure cuff Thermometer Otoscope Nasal speculum Lubricant Tongue blades Reflex hammer Tuning fork Cotton applicators Gloves
Dorsal Recumbrant Back-lying position with knees flexed and hips externally rotated; small pillow under head; side of feet on the surface
Supine Back lying position with legs extended; with or without pillow under the head. Laying on their back.
Lithotomy Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table
Sims Side-lying position with lowermost arm behind the body, uppermost leg is flexed at hip and knee, upper arm flexed at shoulder and elbow.
prone lies on stomach. Lies on abdomen with head turned to the side with or without pillow supporting head.
Visual Inspection Moisture, color, texture of body surfaces Shape, position, size, symmetry Can also use olfactory and auditory senses
During Palpation you should determine... Texture, Temperature, Vibration, Position, size, and mobility of organs, Distention, Pulsation, Tenderness or pain
What does percussion determine? Determines shape and size of internal organs by establishing their borders. Indicates whether tissue is filled with air, fluid or is solid Five types of sound: Flatness, dullness, resonance, hyperresonance, tympany
Two types of percussion Direct-strike area with pads of fingers Indirect- strike an object (finger) held against the body
Two types of auscultation Direct- use of unaided ear Indirect- use of stethescope
Auscultated sounds are described according to.. Pitch: frequency of vibrations Intensity: loudness or softness Duration: length of sound Quality: description of sound
Involves observation of client's general appearance. Assessed while taking client's health history. General Survey
Created by: Alexio