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nursing assessment
| Question | Answer |
|---|---|
| open-ended questions | beyond yes or no |
| close-ended question | one word answer |
| leading questions | leading them to the answer |
| back channeling | nodding, agreeing, etc |
| probing | anything else? to get more info |
| review of systems | systemic collection of subjective info from patients about presence or absence of health-related issues in each body system |
| 5 components of nursing process | ADPIE (assess for cues, diagnose hypothesis, plan solutions, implement action, evaluate outcome) |
| purpose of nursing assessment | A thorough and comprehensive assessment allows you to sort the data (cues), recognize patterns, and make judgments that allow you to identify the type of health problems your patient is experiencing |
| what are the 2 types of nursing assessments used in practice | patient centered interview and periodic assessments |
| what is patient-centered interview | detailed assessment of patient's physical, psychosocial, cultural, spiritual and life style needs (FOLLOW STRUCTURED DATABASE BASED ON PRACTICE STANDARD) |
| periodic assessment def | conducted during ongoing contact with patient, use ABCDE for rapid bedside assessment |
| what is ABCDE's | airway, breathing, circulation, disability, exposure |
| why is scientific data and theory important in assessment (critical thinking) | helps to become more aware of patient's behavior and body systems to assess and increases awareness for treatments (only most up to date) |
| what is subjective data | verbal descriptions of health problems, patient's feelings and perceptions and self-reported symptoms |
| what is objective data | what we observe |
| how does family caregivers help with critical thinking in nursing assessment | helps confirm findings or identify health patterns, influence the way we deliver care (hygiene, eating) |
| healthcare team help with critical thinking in assessment> | hand off reports to improve accuracy and types of interventions that were provided |
| medical records assessment critical thinking | patient's medical history, summaries of ongoing assessments and care activities, lab and diagnostic treatment plan, consultation notes |
| diagnostic data critical assessment | results such as serum blood testing, procedures, radiological exams helps confirm observational findings |
| what are the phases of assessment of patient-centered interview | orientation: setting agenda working phase collecting data termination phase: end of nurse patient relationship |
| what is orientation phase (DEF) | explaining why youre collecting data |
| working phase DEF | gathering accurate and relevant info about patient's condition and what reasons are for seeking healthcare (patient) |
| termination phase DEF | summarizing discussion with patient and double checking, let patient know interview is coming to end ( 2more q's,,...) |
| what is the importance of building therapeutic nurse-patient relationship during assessment | enables patients to tell stories and nurses to understand patients and experiences they express |
| what is central to achieving effetive patient-centered relationships | trust, ensures you are able to learn info needed to care for a patient |
| what is PQRST for nursing history | provokes (what is the cause), quality (what does it feel like ex: lightheaded), radiate (where is pain, other places?), severity (0-10 pain), time (when did symptom first occur, how long) |
| what are 4 skills for physical examination | inspection, palpation, percussion, auscultation |
| what is inspection | observation of patient's body, behaviors, and movement, check for color, turgor |
| palpation def | Use touch to assess temp, moisture, texture, tenderness and size or location |
| percussion def | Tapping on skin to vibrate underlying tissues to determine structures are air-filled, fluid-filled or solid |
| auscultation def | Listening to sounds produced by body (heart, lungs, bowels) using stethoscope |
| what are the 4 communication techniques when conducting patient interview | courtesy, comfort, connection, confirmation |
| what is data validation | act of confirming, verifying or corroborating accuracy of assessment data or appropriateness of care plan |
| why is data validation important before interpretation | helps avoid making incorrect inferences (continually analyze to make concise accurate and meaningful interpretations) |
Created by:
shinykwon