Taylor - Fundamentals Of Nursing - Adn 1 Exam #3 Chapter 12-The Nursing Process - Assessment

Front 1

Assessing is: .

Back 1

the systematic and continuous collection, validation, analysis, and communication of patient data,or information. These data reflect how health functioning is enhanced by health promotion or compromised by illness and injury.

Front 2

A database includes:

Back 2

all the pertinent patient information collected by the nurse and other healthcare professionals.The database enables a comprehensive and effective plan of care to be designed and implemented for the patient.

Front 3

The initial comprehensive nursing assessment results in:

Back 3

baseline data that enable the nurse to:
•Make a judgment about a patient’s health status, the ability to manage his or her own healthcare, and the need for nursing
•Refer the patient to a physician or other healthcare professional, if indicated
•Plan and deliver individualized, holistic nursing care that draws on the patient’s strengths

Front 4

In addition to an initial assessment of the patient, the nurse makes ONGOING ASSESSMENTS. These assessments alert the nurse to:

Back 4

changes in the patient’s responses to health and illness,and suggest necessary changes in the plan of nursing care or care offered by other healthcare professionals.

Front 5

The nursing history identifies the patient’s:

Back 5

health status, strengths, health problems, health risks, and need for nursing care. The nurse may also perform a nursing physical examination to collect data.

Front 6

Types of Nursing Assessments:

Back 6

Nursing assessments include the comprehensive initial assessment,
the focused assessment,
the emergency assessment, and
the time-lapsed assessment.

Front 7

Types of Nursing Assessments:
Initial

Back 7

The initial assessment is performed shortly after the patient is admitted to a healthcare agency or service. The purpose of this assessment is to establish a complete database or problem identification and care planning. The nurse collects data concerning all aspects of the patient’s health,establishing priorities for ongoing focused assessments and creating a reference for future comparison.

Front 8

Types of Nursing Assessments:
Focused.

Back 8

In a focused assessment,the nurse gathers data about a specific problem that has already been identified.
Helpfulquestions include:
•What are your symptoms?
•When did they start?
•Were you doing anything different than usual when they started?•
What makes your symptoms better? Worse?
•Are you taking any remedies (medical or natural) for your symptoms?A focused assessment may be done during the initial assessment if patient health problems surface, but it is routinely part of ongoing data collection. Another purpose of the focused assessment is to identify new or overlooked problems.

Front 9

Types of Nursing Assessments:
Emergency.

Back 9

When a physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life-threatening problems.

Front 10

Types of Nursing Assessments:
Time-lapsed.

Back 10

The time-lapsed assessment is scheduled to compare a patient’s current status to baseline data obtained earlier.Periodic time-lapsed assessments are done to reassess health status and to make necessary revisions in the plan of care.

Front 11

Assessment priorities are influenced by:

Back 11

the patient’s health
orientation,
developmental stage,
culture, and
need for nursing.
After the comprehensive nursing assessment has been completed, patient health problems dictate assessment priorities for future nurse–patient interactions.

Front 12

Structuring the Assessment:
Holistic.
Human Needs Model-Maslow.

Back 12

Maslow uses a hierarchy of five sets of human needs:
Physiological-Survival needs,
Safety and security,
love and belonging,
Self-esteem, and
self-actualization needs.

Front 13

Structuring the Assessment:
Holistic.
Functional Health Patterns-Gordan.

Back 13

health perception,
nutritional/metabolic,
elimination,
activity,
cognitive,
sleep/rest,
self perception,
role/relationship,
sexuality/reproductive,
coping/stress tolerance and
value/beliefs

Front 14

Structuring the Assessment:
Medical.
Body System Model.

Back 14

Neurologic,
Cardiovascular,
Respiratory,
Gastrointestinal,
Musculoskeletal,
Genitourinary, and
Psychosocial.

Front 15

There are two types of data: subjective and objective.
Subjective(symptoms or covert data)

Back 15

Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous,nauseated, or chilly and experiencing pain. Subjective data also are called symptoms or covert data.

Front 16

There are two types of data: subjective and objective.
Objective(signs or overt data)

Back 16

Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient.Examples of objective data are an elevated temperature reading (e.g., 101 F), skin that is moist, and refusal to look at or eat food.

Front 17

Characteristics of Data:

Back 17

When collecting and recording patient data, nurses should be purposeful, complete, accurate, factual, and relevant.

Front 18

Sources of Assessment Data:

Back 18

Patient report,
family and significant others,
patient record,
Other Healthcare professionals, and
nursing and healthcare literature.

Front 19

Nursing History:
Components of a Nursing History

Back 19

•Profile: name, age, sex, race/ethnicity, marital status,religion, occupation, education
•Reason for seeking healthcare
•Normal health habits and patterns and related needs for nursing assistance
•Cultural considerations in relation to diet, decision making, and activities
Current state of health, functioning of body systems,degree of pain, and past medical and surgical history
•Current medications, allergies, and record of immunizations and exposure to communicable diseases
•Perception of health status and the meaning the patient attributes to health and illness, as well as characteristic response or coping patterns
•Developmental history, family history, environmental history, and psychosocial history
•Patient’s and family’s expectations of nursing and of the healthcare team
•Patient’s and family’s educational needs and ability and willingness to learn
•Patient’s and family’s ability and willingness to participate in the plan of care
•Whether or not an advance directive exists, or if the patient wants help to prepare an advance directive
•Patient’s personal resources (strengths) and deficits
•Patient’s potential for injury

Front 20

Nursing History:
Patient interview.

Back 20

a planned communication that can be
understood in terms of its four phases, which include the:
preparatory phase,
introduction,
working phase, and
termination.

Front 21

Nursing History:
Patient interview.
Preparatory phase.

Back 21

it is best to communicate with patients at eye level.
Both the seating arrangement and the distance between nurse and patient are important .
Chairs placed atright angles to each other and about 3 to 4 feet
. If the patientis in bed, placing a chair at a 45-degree angle to the bed is helpful.

Front 22

Nursing History:
Patient interview.
Introductory phase.

Back 22

The nurse initiates the interview by stating his or her name and status, identifying the purpose of the interview, and clarifying the roles of nurse and patient. A typical introduction might run like this: “Good afternoon, Miss LeBon. My name is Nick Maraldo and I’ll be your student nurse. Right now I’d like to ask you a few questions about yourself so that we can plan your nursing care together. Feel free to respond only to those questions you feel comfortable answering, and know that your responses will be treated confidentially by the staff.This will take about 20 minutes. Is this time convenient for you? Do you need anything before we start?”
At the end of this phase of the interview, the patient should know the name of the primary nurse and what he or she can expect of nursing care, and should know what is expected of him or her in terms of developing the plan of care and participating in its execution.

Front 23

Nursing History:
Patient interview.
Working phase.

Back 23

here the nurse gathers the subjective information to form a database.
Closed questions elicit specific information.
Open-ended questions allow the patient to verbalize freely.
Reflective questions encourage the patient to elaborate on thoughts and feelings.
Direct questions can validate information, clarify information, or place events into a meaningful sequence.
•Avoid comments and questions that impede communication such as clichés, questions that require a “yes” or“no” answer only, intimidating “why” or “how” questions,
probing questions,
giving advice,
using judgmental comments, changing the subject, and
giving false assurance.
•Use silence and touch appropriately.

Front 24

Nursing History:
Patient interview.
Termination.

Back 24

Data is collected,
patient should know what to expect and when contact will be re-established.
ask if there is anything more patient would like to add and if there are any more questions.

Front 25

Nursing Physical Assessment:
ROS

Back 25

this phase collect objective data.
this involves the examination of all body systems, Rreview of Systems (ROS),in a systematic manner, commonly using a head-to-toe format.
Four methods are used to collect data during a physical assessment:
inspection,
palpation,
percussion,
and auscultation.

Front 26

Validation is:

Back 26

the act of confirming or verifying data.
When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy.

Front 27

Cues and Inferences are used to describe the process of validation.

Back 27

The subjective and objective data you identify (patient does not respond when I speak to him on his left side) is a CUE that something may be wrong.The judgment you reach about the cue (the patient’s hearing may be impaired on his left side) is an INFERENCE.