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138 Cards in this Set
- Front
- Back
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Purpose of nursing assessment
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collect subjective and objective data to be able to form a nursing diagnosis
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Holistic approach
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assessing the mind, body, and spirit interdependently
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What makes nursing assessment unique?
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Broad, holistic
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Subjective data
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can only be elicited and verified by client such as pain emo. perceptions
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Objective data
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facts such as height and weight
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4 domains for collection
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physiological, psychological, spiritual, developmental
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End result of a nursing assessment
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nursing diagnosis
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Wellness diagnosis
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readiness for enhancement
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risk diagnosis
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client has increased vulnerability
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actual
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validated by defining characteristics of a diagnostic category
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Collaborative problems
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problems that require collaboration with other healthcare providers
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what are the 4 types of assessment
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initial comprehensive, ongoing partial, focused, emergency
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Inital comprehensive assessment
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collection of subjective data by taking client perceptions and objective data via head to toe assessment
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ongoing or partial
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occurs after client has an established comprehensive review with mini-overview of systems
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emergency
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occurs in life or death situations
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what is the most important step of nursing process
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assessment
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5 steps of nursing process
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assessment diagnosis planning implementation evaluation
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steps of assessment
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prepare client, collect subj. data, collect obj data, validate data, document data
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3 phases of interviewing
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intro, work, sum
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intro
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introduce self, explain purpose of interview
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working
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take history etc.
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summary
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sum, discuss planning
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appearance
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prodessional
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demeanor
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poised
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facial expression
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neutral but not expressionless
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attitude
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nonjudgemental
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silence allows/
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client and nurse to collect thoughts
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listening
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eye contact, wellplaced phrases, appropriate expressions
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avoid
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bad eye contact, mental/physical distancing, standing
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Open ended questions
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to elicit clients perceptions and feelings
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Closed-ended questions
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keep client on topic, when asking for specific facts
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laundry list
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help avoid client from providing a perceived "correct" answer
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Rephrasing is used to
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verify data
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well placed phrases- ex and what used for
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"mm hmm" and "i see" used to show client interest and that you are listening
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inferring is used to
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elicit more data or verify data- don't assume to often
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providing information why?
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keeps client informed and encourages client to participate in their health careq
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Biased questions
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aka leading, don't do it
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Rush the interview
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no, don't do it
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Reading questions verbatim
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is a no no
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For gerontologic clients when interviewing
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1st assess hearing acuity
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if old client has poor hearing do ____ do not ---_
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speak slow and face client, do not yell
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Older clients may be fearful. If tehy do
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don't talk down, establish trust and a relationship
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the anxious client
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ask simple organized questions, explain self,
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depressed client
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no peppy, express interest and understanding.
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angry client
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calm, in control, do not argue, allow client to vent
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manipulative client
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get objective opinion, set limits
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seductive
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encourage more appropriate methods of copign
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sensitive issues
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no judging, be aware of self's feelings, allow client to vent
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Biographic data
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name, address, ssn, etc
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Reason for seeking health care
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sometimes known as "CC" by dr's. "What is your major health care concern at this time?"
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History of present concern-
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COLDSPA
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Past history
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any past health issues ?
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family history
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genetic prediposition and family's impact on client, can identify risk factors
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review of body systems in the interview should include what type(s) of data?
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subjective only
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Lifestyle and health practices
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indicate client's human responses
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description of typical day
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typical activities
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nutrition
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is client recieving proper nutrition? overweight? underweight?
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activity/exercise
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excercise is for stress releif and strengthening body
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sleep
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can bring up probles such as anxiety
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medication and substance abuse
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provides info about self-care abilities
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self concept
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assess client's self perception
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zsocial activities
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outlets for support and relaxation
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relationships
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assess support system
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values
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strengths and weaknesses
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eduacation and work
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areas of stress and satisfaction
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stress and coping
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cope positively or negatively?
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environmen
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assess environmental hazards to client
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stanford sleepiness scale
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low = awake high (7 max) = very sleepy (X= asleep)
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sphygmomanometer
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blood pressure
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wood's lightq
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tests for fungus
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snellen chart
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far-distance eyesight
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rosenbaum/ newspaper
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close up eyesight
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eye-covering card
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test for strabmisus
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otoscope
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view ears
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tuning fork
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test for bone and air conduction
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goniometer
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measure degree of flexion and extension of joints
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assessment- physical setting
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temp, privacy, light, table, tray
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preparing self for assessment
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assess anxieties, wash hands etc
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preparing client for assessment
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tell to put on gown, empty bladder before exam
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when assessing, begin with
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least threatening, noninvasive procedures first
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approach client from what side of bed
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right
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you can not assess the ____ in the dorsal recumbent position because _____--
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abdominals; they are contracted
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Order of physical assessment techniques
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inspect, ausculate, percuss, palpate
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light palpation used for
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pulses, tenderness, texture temp moisture
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moderate palp. used for
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size consiostency of easily palpable organs
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deep palpation used for
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feeling of deep organs or structures covered by muscle
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bimanual used for
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uterus, breasts, spleen
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fingerpads
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fine discriminations
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palmar
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vibrations, thrills, fremitus
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dorsal
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temp
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purposes of percussion
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elicit pain, density, abnormal masses, reflexes
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inderect percussion
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most common, used for determining desnity
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direct percussion
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to elicit tenderness
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blunt
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tenderness over organs
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resonance
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part air part solid
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hyperresonance
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mostly air
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tympany
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air
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dull ness
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soft tiussue
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flatnes
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dense tissue
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auscultation is classified by (4) thinsg
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intensity,pitch, duration, quality
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auscultation intensity
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loud or soft
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auscultation pitch
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high or low
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duration
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length
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quality of auscultation
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musical, crackling, raspy
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steth 2 main parts
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diaphragm and bell
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diaphragm
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should be 1.5" for adults, smaller for children, listening to nornal sounds
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bell
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used for low pitched sounds
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do's of stehtoscope
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warm before skin, explain why ur listening, answer client question
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steh don'ts
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apply too much pressure, listen through clothing
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culture
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shared system of values/beliefs and learnde patterns of behavior
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ethnicity
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person identifies with group that holds common set of unique characteristics
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race
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socially constructed meaning to larger group
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minority
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means group w less people, but can refer to group w less power or prestige
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nurse needs to have 5 things about the culture
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Awareness Skill Knowledge Encounters Desire
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awareness
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aware that culture is different than the nurse's own
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unconcious incompetence
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not aware that one lacks cultural knoweledge, unaware cultural differences exist
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concious incompetence
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aware that one lacks knowledeg, aware that differences exist but doesn't know what they are
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concious competence
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learning about culture aware of differences, can automatically provide culturally acceptable care
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unconcious competence
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automatically provides culturally congruent care using intuition
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cultural knowledge
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seeking information about client's culture
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cultural desire
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nurse must have motivation to learn and get involved with other cultures
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cultural skill
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collect relavent cultural data
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cultural encounters
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process allowing worker to engage in face to face client w member of different culture
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cultural assessment- time orientation
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past present or future
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cult. assess. space
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levels of accepted personal space
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cultural variations- eye contact
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excessive or inefficient?
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body language
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Ok symbol bad, cautious to hand gesture for height
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silence
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space between talking? overlap?
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touch
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is touch ok to their culture?
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autonomy
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don't assume that clients expect it
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diet and nutrition
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what food means to the individual
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spirituality
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practices, faith, relationship w higher being
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death ituals
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views of death, grief responses
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pregnancy and childbearing
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what is culturally accepted or taboo
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culture based treatments
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may look like abuse
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cupping
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hot jars on skin on cooling create suction, leaves marks and bruising
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coining
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rubbing ointment onto skin with coin or spoon, causes bruising and red marks
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moxibustion
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burning herbs on skin, looks like cigarette burns
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