Ncm 103 Rle

Front 1

It's an essential nursing function which provides the foundation for quality nursing care and intervention.

Back 1

Health Assessment

Front 2

It helps to identify the strengths of the client's in promoting health.

Back 2

Health Assessment

Front 3

It helps identify client's needs, clinical problems.

Back 3

Health Assessment

Front 4

To evaluate responses of the person to health problems and intervention.

Back 4

Health Assessment

Front 5

What is the first step to determine health status?

Back 5

Assessment

Front 6

What is the gathering of information to have all the "necessary puzzle pieces" to make a clear picture of the person's health?

Back 6

Assessment

Front 7

Who said that Assessment is the deliberate and systematic collection of data to determine client's current and past health status, functional status and to determine client's present and coping pattern?

Back 7

Carpenito

Front 8

"Assessment is a part of each activity the nurse does for and with the patient."

Back 8

Atkinson & Muray, 1991

Front 9

"Nursing assessment should include client's perceived needs, health problems related experience, health practices values and life styles."

Back 9

Bandman and Bandman, 1995

Front 10

What is the sequence of the Nursing Process?

Back 10

Assessment > Nursing Diagnosis > Planning > Implementation > Evaluation

Front 11

What are the 4 types of Assessment?

Back 11

1. Initial Assessment

2. Focus or Ongoing Assessment

3. Time Lapsed Assessment

4. Emergency Assessment

Front 12

What assessment is done within specified time after admission to Hospital?

Back 12

Initial Assessment

Front 13

What assessment has the purpose to establish a complete data base for problem identification, refe rence and future comparison?Eg: Admission assessment

Back 13

Initial Assessment

Front 14

What assessment has the purpose to problem identified in the earlier assessment & to identify new or overlooked problem?

Eg: Hourly fluid intake output assessment

Back 14

Initial Assessment

Front 15

What assessment has during any physiologic and psychologic crisis of the patient?

Back 15

Emergency Assessment

Front 16

What assessment is to identify life threatening problems?

Eg: ABC assessment in Cardiac arrest. Assessment of suicidal attempt on violence

Back 16

Emergency Assessment

Front 17

What assessment is in several months after the initial assessment?

Back 17

Time Lapsed Assessment

Front 18

What assessment has the purpose to compare current status to baseline data previously obtained?Eg: Reassessment of clients functional health patterns in home care

Back 18

Time Lapsed Assessment

Front 19

What assessment is an ongoing-systematic monitoring of specific problems?Eg: Pain Assessment (Pain score).

Back 19

Ongoing Assessment

Front 20

What are the 3 primary methods of assessment?

Back 20

1. Observing

2. Interviewing

3. Examining

Front 21

"The most practical lesson that can be given to a nurse to teach them what to observe."

Back 21

- Florence Nightingale ( 1859)

Front 22

"For it may be said, not that the habit of ready and correct observation will by itself make us useful nurses. But that without it we shall be useless with all our devotion."

Back 22

(Nursing- what it is and what it not F.Nightingale Page 160. (1860)

Front 23

What is a conscious deliberate skill developed only through and with an organized approach?Eg: Data observed with 4 senses-vision, hearing, smell and touch.

Back 23

Observing

Front 24

What is a planned communication or a conversation with a purpose?Eg: History taking

Back 24

Interviewing

Front 25

What are the 2 approaches of interviewing?

Back 25

Directive and Non-directive

Front 26

What is a systematic data collection method—Observational skills to detect health problems?

Back 26

Physical Assessment

Front 27

What are the 4 techniques of physical assessment?

Back 27

Inspection, Palpation, Percussion, Auscultation

Front 28

It is to assess underlying structures of location, size, density of underlying tissues.

Back 28

Percussion

Front 29

What is listening to sounds produced by the body?

• Stethoscope

• Doppler

• Feto-scope

Nursing Tip: Use the bell of the stethoscope to hear low-pitched sounds; the diaphragm to hear high-pitched sounds.

Back 29

Auscultation

Front 30

What are the 2 sources of data?

Back 30

Primary and Secondary Source

Front 31

Who is the primary source?

Back 31

The Patient

Front 32

Who is the secondary source?

Back 32

The family

Front 33

What is the process of gathering information?

Back 33

Collecting Data

Front 34

What data is the verbal statement by the patient (e.g. nausea, pain, fatigue itching.)?

Back 34

Subjective (symptoms)

Front 35

What data detected by an observer- can be measured over an accepted standard? Can be seen, felt, heard, smelt — information by observation and examination?

• E.g. discoloration of the skin.

Back 35

OBJECTIVE (signs) (overt) data

Front 36

What is the OPQRST Method of PAIN Assessment?

Back 36

O = Onset

P = Provokes

Q = Quality

R = Radiates

S = Severity

T = Time

Front 37

OPQRST:

What you were doing when the pain started ?What was the onset sudden or gradual ?

Back 37

Onset

Front 38

OPQRST:

What causes pain?What makes it better?What makes it worse?

Back 38

Provokes

Front 39

OPQRST:

What does it feel like?Is it sharp? Dull?Stabbing? Burning? Crushing?(Try to let patient describe the pain)

Back 39

Quality

Front 40

OPQRST:

Where does the pain radiate?Is it in one placerDoes it go anywhere else?Did it start elsewhere and now localized to one spot?

Back 40

Radiates

Front 41

OPQRST:

How severe is the pain on a scale of 1-10.(This is a difficult one as the rating will differ from patient to patient)

Back 41

Severity

Front 42

OPQRST:

Time pain started?How long did it last?

Back 42

Time

Front 43

While collecting data:

Be open , honest and sincere with the patient.

Back 43

Genuineness

Front 44

While collecting data:

Be non-judgemental, let him feel accepted as a unique individual.

Back 44

Respect

Front 45

While collecting data:

Is knowing what patient means and acknowledge and understanding how he /she feels.

Back 45

Empathy

Front 46

WHAT DATA:

Cluster the data into groups of information? (Identify the pattern of illness) (Data base)

Back 46

Organizing Data

Front 47

WHAT DATA:

• Double checking or verifying the data whether it is factual or accurate.• The assessment information must be accurate, factual and complete.• Nursing diagnos is and interventions based on this.

Back 47

Validating Data

Front 48

WHAT DATA:

• Accurate documentation is essential which include all data collected about client's health status.

• Record in a FACTUAL manner, NOT interpretation.

• E.g. Recording the breakfast intake as—Ate 2 pieces of Bread toast, 1 egg and a cup of coffee. Instead of "Good appetite."

Back 48

Documenting Data

Front 49

In reporting, when you will Report?

Back 49

• Depending on each Patient.

• Disease conditions—potential problems.

• Family interests.

• Psychological upset—may lead to suicidal attempt.

Front 50

What are the 5 skills required for health assessment?

Back 50

1. Cognitive skills

2. Problem-solving skills

3. Psychaomotor skills

4. Affective/Interpersonal skills

5. Ethical skills

Front 51

What skill shows assessment is a "thinking" process?

Back 51

Cognitive Skills

Front 52

What skill shows with a scientific methods experience-"intuition" (with experience)?

Back 52

Problem-Solving Skills

Front 53

What skill, shows assessment is "doing"?

Back 53

Psychaomotor Skills

Front 54

What skill shows assessment is "feeling" trust and mutual respect?

Back 54

Affective/Interpersonal Skills

Front 55

What skill shows assessment is "being responsible & accountable" for your practice?

Back 55

Ethical Skills

Front 56

What assessment focuses on diagnosis and treatment?

Back 56

Medical Assessment

Front 57

What assessment focuses on patient as a person and reach to the optimal level of wellness, an Holistic Approach?

Back 57

Nursing Assessment

Front 58

What is a planned communication or a conversation with a purpose, for example to get or give information, identify problems of mutual concem, evaluate change, teach, provide support?

Back 58

Interviewing

Front 59

What are the 2 types of interview?

Back 59

Directive and Non-directive Interview

Front 60

What interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview. The client responds to questions but may have limited opportunitiesbto ask questions or discuss concerns?

Back 60

Directive Interview

Front 61

What interview by contrast the nurse allows the client to control the purpose, subject matter, and pacing?

Back 61

Non-directive Interview or Rapport-building Interview

Front 62

What interview is the first step in the examination process and establish a relationship with the patient?

Back 62

Patient Interview

Front 63

What is a subjective statement by patient describing the most significant symptoms or signs of illness?

Back 63

Cheif Complaint

Front 64

What are the 8 steps to a successful interview?

Back 64

1. Do research before the interview

2. Plan the interview

3. Make the patient feel at ease

4. Ask the patient for an interview

5. Ensure privacy/ No interruptions

6. Be respectful with sensitive topics

7. Do not diagnose or give an opinion

8. Formulate a general picture

Front 65

WHAT STEP:

—Review patient records.—Be sure test and lab results are on the chart.

Back 65

1. Do research before the interview

Front 66

WHAT STEP:

—Be organized before starting the interview.—Follow office policy.

Back 66

2. Plan the interview

Front 67

WHAT STEP:— Icebreakers— Appear relaxed— Eye contact

Back 67

3. Make the patient feel at ease

Front 68

WHAT STEP:— Makes the patient feel more comfortable.— Emphasizes the importance of the process.

Back 68

4. Ask the patient for an interview

Front 69

WHAT STEP:— Close door.— Do not use "pet" names.

Back 69

5. Ensure privacy/ No interruptions

Front 70

WHAT STEP:— Watch for noverbal cues.— Watch your own norverbal cues.

Back 70

6. Be respectful with sensitive topics

Front 71

WHAT STEP:— Refer questions to physician.— Do not go beyond your scope of practice.

Back 71

7. Do not diagnose or give an opinion

Front 72

WHAT STEP:— Summariae key points.— Ask if patient has questions or needs to add additional information.

Back 72

8. Formulate a general picture

Front 73

What part of the Interview:

• Aways state the reason for the interview and how it will be conducted.

• Put the interviewee at ease.

• Ask the interviewee if they agree to you taking notes.

Back 73

Introduction

Front 74

What part of the Interview:

• Listen to the answers and request clarification if necessary.

• Avoid making criticisms or taking sides.

• Keep control of the interview: refocus the interviewee they are rambing or carity if they misundersood the question.

• Stay focused and follow your interview guide.

• Allow the interviewee to ask questions.

Back 74

Body

Front 75

What part of the Interview:

• Thank the interiewee.• Advise them what the next steps are and the timeframe.

Back 75

Wrap-up

Front 76

Your interview needs to balance the building of rapport and collecting of required information.

Back 76

Build Rapport

Front 77

What is honing in on a particular area of interest and drilling down to obtain more detail. It includes asking for more information to clarify a vague phrase or statement made by the inerviewee such as "quite high" or "often late"?

Back 77

Probe Questioning

Front 78

What needs to be balanced with open and closed questioning to avoid the interview seeming like an interrogation?

Examples:

"How did that happen?"

Back 78

Probe Questioning

Front 79

What is a technique used to confim or clarify something the interviewee has said or implied?

Back 79

Paraphrasing

Front 80

What is a standard interview note format is useful in orienting intervews to results?

Back 80

Interview Review

Front 81

What are the 3 types of interviewees?

Back 81

1. The Nervous Interviewee

2. The Non-talker

3. The Angry/Hostile Interviewee

Front 82

What interviewee can be very explicit in setting the scene, tell why you are there and what they can expect: Establish rapport and make sure you are and confident?

Back 82

The Nervous Interviewee

Front 83

What interviewee can make you a special effort to build rapport and find common language and experience. Avoid closed questions, use open questions to draw them out?

Back 83

The Non-talker Interviewee

Front 84

What interviewee that has a threatening behaviour and is directed towards you or others?

Back 84

The Angry/Hostile Interviewee