Chapter 16 Nursing Assessment

Front 1

Nursing Process

Back 1

Assessment
Diagnosis
Plan
Intervention
Evaluation

Front 2

Assessment (2 steps)

Back 2

1. collect information
2. interpretate and validate info

Front 3

Purpose of Assessment

Back 3

1. establish database
2. reveals related experiences, health practices, goals, values and expectations about health care system

Front 4

Data collection comes from:

Back 4

patient, family, significant others, other health care providers, medical health info, scientific literature

Front 5

Cue

Back 5

information obtained through the use of senses

Front 6

Inference

Back 6

judgement/interpretation of cues

Front 7

approaches to comprehensive assessment (2)

Back 7

1. structured database format - based on accepted theoretical framework or practice standard
2. problem oriented approach - focus on presenting situation and begin with problematic areas

Front 8

types of data (2)

Back 8

Subjective - patient's verbal descriptions of the health problem
Objective - observations or measurements of a patient's health status

Front 9

patient centered interview (4 steps)

Back 9

1. setting the stage (orientation)
2. set an agenda
3. collect assessment/nursing health history
4. terminating the interview

Front 10

Setting the stage

Back 10

Orientation phase
explain reason for collecting health history
introduce self and reason for interview

Front 11

set an agenda

Back 11

gathering information
ask patient for list of concerns or problems

Front 12

collect assessment or nursing health history

Back 12

ask open ended questions for patients can describe more clearly concerns and problems

Front 13

terminating the interview

Back 13

summarize discussion
check for accuracy
ask if nurse can do anything for patient at that time

Front 14

interview techniques

Back 14

open ended questions
back channeling
probing
closed ended questions

Front 15

nursing health history (5)

Back 15

biographical information
reason for seeking health care
patient expectations
present illness or health concerns

Front 16

biographical information

Back 16

factual demographic data
age, address, occupation, working status, marital status, source of health care and types of insurance

Front 17

reason for seeking health care

Back 17

patient's main complaints

Front 18

present illness or health concerns

Back 18

Precipitation factors
Quality
Radiating
Severity/symptoms
Timing/triggers

Location
Relief

Front 19

health history (5)

Back 19

family history
environmental history
psychosocial history
spiritual health
review of systems