Data Collection Chapter 1
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| The Standard of practice identified by the American Nurses Association (ANA) (204 is based on the nursing process: What is the nursing process? | Assessment
Diagnosis
outcomes identification
planning
Implementation
Evaluation
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| The first and foundation step of the nursing process is assessment. Define Assessment? | Assessment: is the collection of "comprehensive data pertinent to the patient
s health or the situation"
**Assessment and subsequent analysis of data are performed by nurses in all setting
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| What are the components of Health Assessments? | Conducting a health history
Physical Examination
Documenting finding
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| Define Subjective Data? | Subjective Data--What the patient/client tells you
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| Define Objective Data? | Objective Data---What you observe
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| What does Health History of a patient consists of? | Consists of the subjective data that the nurse collects when interviewing the client/patient
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| What kind of information is collected during a health history interview between the nurse and the patient? | It includes information about the patients state of health, medications, previous illness, surgeries, their family histories and review of systems
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| A health Assessment refers to? | A health Assessment refers to a systematic method of collecting data.
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| When collecting information for a health assessment the nurse needs to take in account what from the client? | The nurse collects health data from the client and compares this to ideal state of health, taking accounts the clients age, gender, culture, ethnicity, and physical psychologic and socieconmic status
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| Define Symptom? | Is a report of what the client experiences associated with a problem, and is considered subjective data
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| If the information about a client/patient is obtained from another individual than the patient it's refereed to as? | Secondary source of data
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| A physical Examination involves what | Physical Examination involves objective Data collected by the nurse
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| Objective data are also referred to as what? | Objective Data are also referred to as "signs"
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| During a physical examination, the nurse obtains objective data using the techniques of inspection--What are the techniques of inspection? | During a physical examination, the nurse to obtains objective data using the techniques of inspection--palpation,percussion, and auscultations.
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| Other than palpation,percussion, and auscultations what else does the nurse measures ? | The nurse also measures the client
s height, weight, blood pressure, temperature, and respiratory rate (The extent of the examinations depends on the setting, context of care, client needs and the nurse's experience)
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| What must you do when the information collected in a health assessment? | Data collected from health assessment must be documented so that other health care providers can use the information.
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| The written Data collected from a health assessment serves as what to the patient, and the health team? | The data collection serves as legal document and permanent record of the client
s health status at the time of the nurse-client interaction as well serves as a baseline for evaluation or subsequent changes and decisions related to care
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| What are the types of health assessment? | Comprehensive assessment, problem-bases/focused assessment, Episodic/follow-up assessment
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| What does Comprehensive Assessment Involve? | Comprehensive Assessment involves a detailed history and physical examination performed at the onset of care in a primary setting or upon admission to a facility
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| What does the context of care refers to? | The context of care refers to the circumstances or situation related to the health care delivery. Which maybe related to the setting, environment, physical, psychological or socioeconomic circumstances involving the client or expertise of the nurse.
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| A comprehensive assessment involves encompasses of health problems experiences by the client, as well as? | Health promotion, disease prevention, assessment for problems, associated with risk factors, or assessment of for age/gender specific health problems
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| What does problem-based/Focused Assessment involve? | Involves a history and examination that is limited to a specific problem or complaint,commonly used in walk-in clinics or ER, client's underlying health status also must be considered
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| Where is problem-based/focused assessment commonly used? | Commonly used in walk-in-clinics or ER
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| What does Episodic/Follow-up Assessment involve or done? | Usually done when a client is following up with a health care provider for a previously identified problem.
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| What is a shift assessment? | Shift assessment is performed by nurses in acute care facilities.
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| What is the purpose of a shift assessment? | The purpose of the shift assessment is to identify changes in condition from baseline; thus the focus of the assessment is largely based on the condition or problem the client is experiencing
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| Define screening assessment? | It is an assessment that is short and usually inexpensive examination focused on disease detection
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| What does a screening assessment include? | Includes blood pressure screening, glucose screening, cholesterol screening and colorectal screening
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| What is the outcome of a health assessment? | The outcome of a health assessment is a picture of the client's physical status,strengths & weaknesses,abilities, support systems, health beliefs, & activities to maintain health as well his or her problems and lack or resources for maintaining health.
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| What is the role of the LPN when Collecting Data? | Gather data, report data, record/document data
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| Who does the LPN report data to? | Report data to RN, nurse supervisor
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