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115 Cards in this Set

  • Front
  • Back
3 Components Needed for a Complete Assessment
Interaction:
Observation:
Measurement:
def.
Interaction
(obj or subj?)
Relevant verbal communication w/ client, family, health care providers (subjective)
def.
Observation
(obj or subj?)
Data gathered by means of the senses (objective)
def
Measurement
(obj or subj?)
Data gathered by means of instruments that quantify information (objective)
4 Types of Assessments
Initial Comprehensive Assessment:

Ongoing or Partial Assessment: Initial problems reassessed for daily changes

Focused or Problem Oriented Assessment: Thorough evaluation of a particular problem; Does not cover systems that are unrelated to problem

Emergency Assessment: Rapid assessment obtained in life threatening situations
* Refer to forms
Initial Comprehensive Assessment:
complete Health History & PE
Ongoing or Partial Assessment:
Initial problems reassessed for daily changes
Focused or Problem Oriented Assessment
Thorough evaluation of a particular problem; Does not cover systems that are unrelated to problem
Emergency Assessment:
Rapid assessment obtained in life threatening situations
* Refer to forms
What's the purpose of Nursing Assessment?
To collect subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment.
Def.
Mind, body, and spirit are interdependent factors that affect a client’s level of health
holistic
Examples of holistic factors involved in nursing assessment
Includes: physiologic, psychological, sociocultural, developmental, spiritual
List the
4 Steps of Nursing Assessment
1. Subjective Data Collected during Health History
2. Objective Data Collected during the Health Physical
3. Validation of Assessment Data
4. Documentation of Data
What is data consist of?
1. Subjective Data Collected during Health History
Data consists of what the patient describes as his history of health and illness
Recorded thoughts, statements, feelings, perceptions of the patient
What is data consists of?
2. Objective Data Collected during the Health Physical
Health data that is directly observed by the nurse during the physical, or by other health professionals
May also be included in physical exam:
Laboratory tests
Diagnostic tests
Examples of objective data collected during health physical
Examples: physical characteristics, body functions, appearance, behavior, measurements, laboratory results
How is the objective data obtained during health physical?
Obtained by using 4 examining techniques: inspection, palpation, percussion, auscultation
3. Validation of Assessment Data
Involves what?
-Compare objective & subjective findings to uncover descrepencies
(ie. c/o HA verified by BP 180/100)
-Recheck data by repeating assessment (ie., retake temperature)
-Verify data w/ another health professional or specialist
(Utilize the healthcare team to verify and make sure your assessment is accurate)

-Validate findings w/ chart or health record
4. Documentation of Data

Why do it? Explain significance of this step of assessment
Ensures accuracy
Forms the database for the entire nursing process
Provides data for all other members of the health care team
Vital to ensure valid conclusions on which the patient will be treated
Guidelines for Documentation
-Legible
-Correct grammar & spelling
-Correct vocabulary (emphasized in this course);
-Avoid use of “normal”
-Avoid wordiness or redundancy
-Do not make personal judgments
-Record client perceptions
-Accurate objective data
It is important to remember when documenting that _______!
Accuracy of each step depends on accuracy of preceding step!
-Formulation of nursing diagnoses (wellness, risk, or actual) that require nursing care (Step II in Nursing Process)
-Identification of collaborative problems that require interdisciplinary care
-Identification of problems that require immediate referral
End Result of Nursing Assessment
Step II of Nursing Process: Nursing Diagnosis - What is the purpose?
-To affirm person’s state of wellness
-Identify strengths/problems that may be responsive to nursing care
Nursing Diagnosis is directed towards _____ and _____
Directed toward health management and health prevention
Ultimate plan of nursing diagnosis includes what aspects?
Ultimate plan includes:

health education, counseling, communication w/ MD & other disciplines, community resources
What is the difference between

Medical Diagnosis vs. Nursing Diagnosis
Medical Objectives (Physician): Use “Problem Oriented Recording” (POR)
to develop a problem list of diseases/medical diagnoses.

Final assessment and plan includes medical, nursing, related disciplines (i.e., PT, OT, SS, mental health etc.)
Who is the Client or Patient?
Individual
Family
community
List the ethical considerations
-Nonmaleficence
-Beneficience
-Autonomy
-Confidentiality
-Justice
Ethical considerations:
def.
Beneficence:
Be motivated by what is in the best interest of the patient
Ethical considerations:
def.
Autonomy:
Patient has a right to refuse services or treatments; also has a right not to answer questions
Ethical considerations:
def.
Confidentiality:
Giving people information without patient’s permission
Ethical considerations:
def.
Justice:
Each patient, regardless of race, color, diagnosis, is equally important & has a right to equal attention
Ethical considerations:
def.
Nonmaleficence
“First do no harm”
giving inaccurate information;
Avoiding relevant topics
Who is of greatest priority in ethical considerations?
The pt. is your first priority!!
What is the main role of the nurse?
Nurse is the Patient’s Advocate
What does the nurse do as pt. advocate?
-Nurse works intimately w/ patient; He/she is most aware of patient’s needs, problems, family, community
-Nurse functions as patient advocate as well as health coordinator
-Represents patient to the physician and other health disciplines
-Nurse case manager may also function in this position
What type of data does the Health History collect
Subjective Data
AIMS OF PROFESSIONAL NURSING
 To promote health
 To prevent illness
 To restore health
 To facilitate coping with disability or death
Primary care v. primary healthcare:
def.
Primary Care
= the delievery of healthcare services, including the initial contact & ongoing care
Primary care v. primary healthcare:
def.
Primary Healthcare
= essential healthcare based on practical, scientifically sound, & socially acceptable methods & technology, made universally accessible to individuals & families in the community through their full participation & at a cost the community can afford. It bring healthcare as close as possible to where people live & work.
Prof. Nursing Orgs:

(ANA)
American Nurses Association
Prof. Nursing Orgs:
(AACN)
American Association of Colleges of Nursing
Prof. Nursing Orgs:
(NLN)
National League for Nursing
Prof. Nursing Orgs:
(ICN)
International Council of Nursing
Prof. Nursing Orgs:
(NSNA)
National Student Nurses Association
Prof. Nursing Orgs. (Specialties)
AACN, ONS
Specialty Nursing Organizations:

American Association of Critical-Care Nurses

Oncology Nursing Society
What should be the end goal/result of completing an effective Health History?
-90% of time, effective & thorough health history, using effective interviewing techniques, leads to a diagnosis before PE is initiated.
-Physical Exam becomes a confirmation of the truth and/or assumptions of the diagnosis(es), that are derived from taking a health history
Initial (complete) health history, taken on admission to hospital or clinic
Initial Comprehensive Assessment
Explores a single problem or patient complaint, by using OLDCART, & by examining only those systems that are related, or connected to that problem, in some way.
Focused or Problem Oriented Assessment
This type of data refers only to the client’s perception of his/her health, symptoms, past history, family history , lifestyle and health practices, psychosocial history, nutritional status, review of all body systems
subjective (found in HHx)
Information in the Health History is not…
-Observations made by the nurse
(skin color, obesity, posture, gait)
-What the nurse perceives to be true
-What the doctor says or observes
-What the social worker, or other members of the interdisciplinary team, observe
subjective or objective?

Nausea
S
subjective or objective?
Cyanosis
O
subjective or objective?
Edema
O
subjective or objective?
Numbness
S
subjective or objective?
Diaphoresis
O
subjective or objective?
Pallor
O
subjective or objective?
Chest pain
S or if pt. is bending over holding his fist in chest = O)
subjective or objective?
Dizziness
S
subjective or objective?
Stridor
O
subjective or objective?

Palpitations
S
subjective or objective?
Irregular pulse
O
subjective or objective?
Shortness of breath
S or O
What are the 5 Simple rules of documentation
1. Health History is recorded before the PE; It is not “mixed up” w/ the PE
2. Don’t use complete sentences; use abbreviations that will be commonly understood
3. Include positive (+) findings before negative (-) findings
4. Write what is heard, felt or seen
5. Do not ever falsify information
Always sign your name, title, university
Documentation in Health History should state:
Client denies…
Client complains of…
Client states…
What are the components implicating Health History
-Bias of Interviewer
-Culture
-Age
-Religion
-Interviewing Techniques
-Other
What are the potential bias of Interviewer?
Ethnic/Racial
Social Issues
Religion
Handicaps
Political
What are the culture considerations in the HHx
Transcultural
Culture
Ethnicity
Diversity
Ethnocentricity
definition:
-Formal study & practice based on knowledge & understanding of different cultures (Leninger)
-Idea that holistic care includes understanding of how beliefs, values, & traditions of patients from diverse racial, ethnic, & cultural groups influence their responses to health & illness
Interest in health care since mid 50’s.
-One quarter of U.S. population is non-Euopean ethnic people of color; steadily increasing (US Census Bureau)
What is transcultural nursing?
definition:
Learned & shared values & beliefs, norms, & practices of a particular group that guide thinking, decisions, & actions in a patterned way
Culture
def. -
Closely associated w/ “race,” “minority groups;” to a lesser degree w/ socioeconomic status. Shared culture, biology, territory
Ethnicity
Means the “fact or quality of being different.”(Amer. Herit. Dict., 1983). Include race, ethnicity, culture, gender, sexual orientation, socioeconomic status, education, religious affiliation
Diversity
Belief that your beliefs, practices, & values are right & those of persons from different cultures are wrong
Ethnocentricity
Examples of an ethnocentric nurse's response
Common ethnocentric reactions by nurses to those who are culturally different: shock, laughter, anger.
Results of ethnocentricity
Patients react by feeling rejected, embarrassed, or experience low self-esteem; or become angry, withdrawn, retaliatory
Significant barrier to providing culturally sensitive care
ethnocentricity
Guidelines for Providing Culturally Sensitive Care
-Knowledge of the different cultures and ethnic backgrounds through reading & talking to patients & their families
-Mutual respect: Knowledge increases respect
-Negotiation betw/ patient & nurse about treatment plan
-Nurse must know herself & be aware of his/her predjudices & feelings (Chrisman (1991)
Ways to move towards removal of Stigma and Stereotyping
Move beyond categories of difference, such as those of culture, race, ethnicity, & toward accepting individuals based on their humanity
See individuals as all worthy of quality care
Age Specific Modifications:
Adolescents
-Direct questions
-Honesty
-Give them time w/ parents in room & w/o parents in room
-HEADSS (Home, Education, Activities, Drugs, Sex, Suicide)
How to ask about sexual history across the life span
-Adolescent: Are you sexually active? How many partners? Contraception
-Adult: Are you married? Are you monogamous? How many sexual partners have you had in te last 6 months? Men or women? Have you had any exposure to AIDES or STD?
-Elderly: Ask same questions

*Even innocuous looking adolescent can potentially have had multiple partners.
Considerations during elderly assessment include
-Undergo changes in hearing, vision, attention span, memory, recall, & cognitive processing
Allow more time for patient to respond
-Respond better if a relationship is established
-Patient comfort: room temperature
-Assess if information will be accurate; may need another adult present
-Decreased sense of identity or self esteem related to changes in role expectations, loss of significant others, support system
**Write down instructions on a note if the elderly will forget.
Areas of emphasis during elderly assessment include
-Functional Survey: Bathing, dressing, continence, feeding, managing money, shopping, eating, preparing food, housekeeping, transportation, taking medicine
-Mini-mental Exam
-Depression: Highest rate of suicide in this age group; May present w/ physical symptoms
When Interviewing the Elderly...
-Speak clearly & slowly
-Repeat as necessary
-Reassure
-Evaluate hearing & comprehension
-Evaluate eye sight
-Avoid pushy or impatient behavior or attitude
-Show respect
Questions to ask about end of life issues include...
Do you have an Advanced Directive?
Do you have a living will?
Do you have a durable Power of Attorney?
Do you have a DNR (Do Not Resuscitate)
If “yes” to any of above, Physician must be notified & copy posted in chart
Chart must be identified

Chart: Do they have AD? DNR? Legal docs? in their charts? BE AWARE ALWAYS BEFOREHAND, you never know what might happen.
What are the major functions of the following receptor type: beta-2
-Vasodilation
-Bronchodilation
-increased heart rate
-increased contractility
-increased lipolysis
- increased insulin release
- decrease uterine tone
List the 7 Major Components of the Health History
1. Identifying/biographical data (ID)
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Past Medical History (PMH)
5. Psychosocial History (PS)
6. Family History (FH)
7. Review of Systems (ROS)
*Refer to “Health History Guidelines”
Def.
Communication
-Process of exchanging messages between people
-Understanding meanings & responding w/ an understandable message is the essence of effective communication
Communication includes and entails for the nurse....
-Communication exists in all human systems
-Includes all possible methods for transmitting & receiving messages both verbal & nonverbal
-The nurse must understand the communication process and be able to utilize it therapeutically
Components of Communication Cycle include
Communicator: Sends a message
Message: Verbal & nonverbal symbols
Receiver: Interprets the message
Feedback: Verbal & nonverbal evidence of the message received
List the 3 Factors Influencing communication
Personal
Interpersonal & Community
Environmental
1. Personal

Aspects includes:
-Emotions: anger, anxiety, stress, excitement, grief, past experiences
-Physical: fatique, pain, deafness, speech defects
-Cognitive: IQ, language use, knowledge levels
-Spiritual: Close to God, alienated, guilt
2. Interpersonal & Community

Aspects include:
Culture/ethnicity
Accents
Socioeconomic status
3. Environmental

Aspects include:
Privacy
Noise
comfort
Distinguish btwn:
Therapeutic communication vs. social communication
Therapeutic: GOAL DIRECTED; requires an empathic listening for the purpose of assisting the client

Social: Give & take of ideas which may not be goal directed
What is the purpose of a Health History interview?
Goal directed:
-To acquire data that may be used to make judgments about a person’s health status
-To establish a trusting, helping relationship between the nurse & the client
-To accomplish a therapeutic goal; not just a conversation
What are the functions of the Assessment Interview?
-Gathering data to understand a patient’s health problems
-Developing rapport & responding to the patient’s emotions
-Patient education & motivation
Tips for setting up a milieu (interview setting)
-Quiet place w/ privacy
-Assure that client is as comfortable as possible
-Assure confidentiality
-Give client permission not to answer
Try not to be rushed
Interview preparation and Introduction involves:
-Review patient’s chart first
-Introduce yourself by name & title
-Shake hands as part of introduction
-Ask how he or she wishes to be called
-Give an overview of what you plan to do
How to personalize the interview
-After asking patient how he or she wishes to be called, use name frequently during the interview
-Address by last name unless given permission to call them by their first name
-Remember, you are not only eliciting information, you are establishing a relationship w/ the patient
-Have good eye contact; Focus on the patient & glance down only occasionally
-Shake hands & use touch when appropriate
What about Non-Verbal Communication?
Remember, non-verbal communication can be as effective as verbal communication
Non-verbal may contradict what the nurse is saying
How to Explore the Patient’s Perspective
Explore how the patient’s illness has affected his life
Adapt the interview to specific problems (poor hearing or poor eye sight)
Beginning the Interview: Use Broad Opening Statements such as...
“What brought you to the hospital today?”
“What would you like to discuss w/ me today?”
Open ended questions
-use for narrative info.
-calls for long paragraph answers that cannot be answered in y/n
-elicits feelings, opinions, ideas; patient’s perceptions
-builds & enhances rapoort
Closed, direct questions
-use for specific info.
-calls for short one- to two- word answers
-elicits cold facts
-limits rapport & leaves interaction neutral
-Questions typically begin with? “When” or Did.”
-Used to keep interview on course
-Used to clarify
Laundry List
Provides client w/ a choice of words to choose from
“Is the pain severe, dull, sharp, mild, cutting, or piercing?”
Does the pain occur once every year, day, month, or hour?”
What to ask when clients ramble on..
“Is that a problem for you now?”
“What brought you here today?”
“What would you like me to do for you today?”
Barriers to Effective Communication
-Interrupting (Don’t unless absolutely necessary)
-Chiming in w/ your own stories
-Being judgmental. “Why” questions can be judgmental
-Putting words in a client’ mouth. “You’ve never had any problems w/ your eyes have you?”
-Offering advice
-Abruptly changing subjects interrups rapport. Use smooth transitional phrases
-Acting defensive
-Minimizing feelings: “Don’t worry about it.”
-Offering false assurance or false hope; Promising quick solutions, “Everything will be ok.”
-Jumping to conclusions: “Assuming that a client that is overweight wants to lose weight
-Engaging in distancing
-using prof. jargon
-talking too much
-using authority
How to close the interview:
-Review and summarize the discussion at the close of the conversation
-Negotiate a plan (further diagnostic tests evaluation, treatment)
-Plan for follow-up
Type of data collected from a physical exam is...
objective
How to prepare for physical exam
Preparing the physical setting
Preparing the client
Preparing oneself
Standard precautions
physical exam equipment needed
Stethoscope
Sphygmomanometer
Thermometer
Opthalmoscope
Otoscope
Other
4 Physical Assessment Techniques
Inspection
Palpation
Percussion
Auscultation
General survey: Check the following
Handshake
Signs of distress
Skin
Stature and frame
Body development
Posture, gait, motor activity

Nutritional status
Dress, grooming, personal hygiene
Chronologic vs. apparent age
Sex, role, class
Odors
Facial expressions
Manner, mood, relationship
Speech
Assessment of Mental Status: Check the following
Function
Reasoning
Orientation
Memory
Arithmetic
Judgment
Emotion
Two standardized mental screening tests:
MMSE
GCS
-Mini Mental State Exam
-Glasgow Coma Scale