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21 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What is the Assessment phase? |
A systematic rational method of planning and providing individualized nursing care |
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What is the purpose of the Assessment phase? |
To identify clients health status To identify actual risk potential health care needs/problems |
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What does it Mean to Assess? |
Collect data Validate data Communicate patient data |
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Activities in the Assessment Phase |
Obtain nursing health history Conduct physical assessment Review client records Review nursing literature Consult support persons Consult health professionals Update data as needed |
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What type of data is in a Nursing Health History ? |
Biographic data Present health or illness Past history Family history Psychosocial history Review of body systems for current health problems |
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What is Nursing Assessment? |
An assessment that focuses on the patients response to health problems |
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What are the Types of Assessment? |
Initial Problem -focused Emergency Time-lapsed |
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Explain Initial Assessment |
Carried out right after admission Establish complete database for problem identification
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Right away |
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Explain Problem - Focused assessment |
Ongoing assessment It is integrated with nursing care Determine status of a problem identified Eg. Hourly assessment |
Non time specific |
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Explain Emergency Assessment |
During a physiological or psychological crisis Identify life threatening, new or overlooked problems
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Immediately |
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Explain Time -lapsed Assessment |
Several months after initial Compare current status to baseline Aka shift changed assessment |
Longer period of time |
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What are Subjective (Covert) data? |
Symptoms Problems that can ONLY be identified by the patient |
Can't see |
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What is Objective (Overt) data? |
Signs Detectable by an observer, can be measured and tested |
Can see |
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What are the Types of Data? |
Constant- does not change over time (ethnicity, culture) Variable- can change quickly, frequently or rarely (age pain) |
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Characteristics of Data |
Purposeful Complete Factual and accurate Relevant |
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Sources of Data |
Primary data - data from the client Secondary data - data from the client records, family members, other health care practitioner literature |
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Assessing and Organizing Data |
Utilizes a theoretical framework to organize data. These frameworks include: Orems nursing model - arrange data according to the self care requisites of the client. Maslow non nursing model- cluster data according to a hierarchy of needs. |
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What are the Different Types of Frameworks and Models? |
1. Gordon's Functional Health Pattern framework 2. Orems Self - Care model 3. Roy's Adaption Model 4. Body Systems Model 5. Maslow's hierarchy of Needs 6. Developmental Theories |
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Assessing - Validating Data |
Scrutinize data Clarify ambiguous statements Determine completeness of data Discriminate between cues and inference Use references Look at factors that may interfere with data accuracy |
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What are Cues? |
Subjective or objective data identified Can be observed by the nurse |
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What are Inferences? |
Judgment reached about a cue |
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