Nurs 200, Ch 16

Front 1

Assessment

Back 1

deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns. 1. collection of data (database) 2. analysis of data. Assessment moves from general to specific.

Front 2

On Data Collection . ..

Back 2

Cue - information that you obtain through use of the senses
Inference- your judgment or interpretation of those cues. Reviewing nursing, medical, etc literature completes nurses assessment database.

Front 3

2 approaches to a comprehensive assessment

Back 3

1. use of a structured database format, based upon an accepted theoretical framework or practice standard.

Front 4

2 approaches to a comprehensive assessment (part 3)

Back 4

ex. Gordon's 11 functional health patterns (holistic framework for assessment of any health problem - biopsychosocial integration, dysfunctional patterns -nursing diagnoses) (Box 16-1), Pender's health promotion model, and the Agency for Healthcare Research and Quality's standards for acute pain assessment. The theory or practice standard provides categories of info for me to assess.

Front 5

2 approaches to a comprehensive assessment (part 3)

Back 5

2. Problem Oriented approach (focus on client's presenting situation and begin w/ problematic areas, such as back pain. Ask follow up questions to clarify and expand

Front 6

Subjective Data
Objective Data

Back 6

Client's verbal description of their health problems (only clients provide subjective)
observations or measurements of a client's health status (could be BP measurement, a description of an observed behavior)

Front 7

Methods of data collection

Back 7

client interview, nursing health history, physical examination, and results of laboratory and diagnostic tests to establish a client's assessment database. 90% can be known from interview!

Front 8

HIPPA

Back 8

requires signature from client BEFORE you collect personal health data. Occurs in admitting and screening before client meets nurse

Front 9

Nursing Interview 3 phases

Back 9

Orientation Phase - begin relationship with client, collect demographic info
Working Phaise - nursing health history, more specific about client's health status, expectation of care, review of bodily systems, sociocultural history, spiritual health, etc
Termination Phase- "two more questions", summarize points

Front 10

back channelling
Client's explanatory model

Back 10

includes active listening, "uh-huh", encourages the client to give more details.
Ask client what might be causing his problem, the meaning the problem is having for the client, after client's story of their problem, use FOCUSED assessment w/ closed-ended questions and problem seeking interview

Front 11

Cultural Competence
(under Cultural Considerations in Assessment)

Back 11

involves a conscientious understanding of your client's culture so that you can offer better care w/in differing value systems and act w/ respect and understanding w/out imposition of your own attitudes and beliefs. Do not make assumptions about the client's cultural beliefs and behaviors w/out validation fr. the client.

Front 12

Eye Contact

Back 12

Spanish and French firm eye contact. May be rude to Asian and Middle Eastern. Americans let eyes wander.

Front 13

Validation
(under "interpreting Assessment Data and Making Nursing Judgments", data validation)

Back 13

___of assessment data is the comparison of data w/ another source to determine data accuracy. Clarifies vague or unclear data.