Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
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 Collectedduring 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 |