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Assesment
Exam 2 Review
| Term | Definition |
|---|---|
| Four Types of Nursing Assessments | Initial, Problem-Focused, Emergency, Time-Lapsed Reassessment |
| Assessment Activity: Step 1 | Collecting Data: gathering information about the client's health status |
| Assessment Activity: Step 2 | Organizing Data: writing data into an organized format |
| Assessment Activity: Step 3 | Validating Data: verifying that data is complete and accurate |
| Assessment Activity: Step 4 | Documenting Data: recording data in a factual manner |
| When collecting data you should... | Form a database including: physical assessment primary health care providers history and physical results of labs and diagnostics healthcare teams documentation |
| Components of a nursing health history | biographic data, chief complaint/reason for visit, history of present illness, past history, family history of illness, lifestyle, social data, psychological data, patterns of health care |
| Subjective Data | Symptoms Described, verified by the person affected which includes sensations, feelings, values, beliefs, attitudes and perceptions |
| Objective Data | Signs Can be observed, measured, and tested Obtained by observation or physical examination |
| Sources of Data | Client Support People Client Records Health Care Professionals Literature |
| 3 Data Collecting Methods | Observing Interviewing Examining |
| What do you do when you observe patient | Gather data using your five senses Skill developed over time, Observe mainly through sight, |
| Interviewing | Planned communication or conversation with a purpose |
| Directive Interview | Structure and obtains specific information |
| Non-directive Interview/ Rapport | Builds a relationship understanding between the patient and nurse |
| Restrictive "yes" or "no" answers | Closed Question |
| Short Factual Answers | Closed Question |
| Allow clients to explore and talk about feelings | Open-ended questions |
| Client may answer without influence of the nurse | Neutral Questions |
| Closed ended that directs the client's answer | Leading Questions |
| What to consider when setting up an interview with client | time, place, seating arrangement, distance, language |
| What do you do in the opening of your interview? | Establish rapport with the patient and orientation |
| What do you do in the body of your interview? | Client responds to the nurse's questions |
| What is examinining | A systematic process of gathering data through using observation to detect health problems |
| Four ways of examining | Inspection, Auscultation, Palpation, Percussion, |
| Maslow's Hierarchy of Needs (pyramid) | physiological, safety, love/belonging, esteem, self-actualization |
| To validate information you should... | "Double check" data to confirm accurate Ensure that assessment info is complete obj. and subk. data agree differ between cues and inferences avoid jumping to conclusions |
| To document data you should.... | Record in a factual manner include all data collected about client's health status Subjective data recorded in client's own words |
| Four things assessment involves | Collecting, Organizing, Validating, and Recording Data |
| What is the Nursing Process? | A systematic, rational method of planning and providing nursing care. Orderly, logical approach to providing nursing care and ensuring that the patients needs are met. |
| Five Steps of Nursing Process | Assessment, Diagnosis, Planning, Implementing, Evaluating |
| Two Components of Health Status | Healthy History and Physical Examination |
| Purpose of Physical Examination | Obtain baseline data To validate data obtained in the nursing history To aid in establishing nursing diagnoses and the plan of care for patients |
| Purpose of Physical Examinations | Evaluate the physiological outcomes of healthcare and the patients progression Make clinical judgments Identify areas for health promotion and disease prevention |
| What should you do when preparing the client? | Explain what you are going to do |
| What should you do when preparing the environment? | Prepare your equipment good lighting, warm room temp provide privacy |
| Health Exam Equipment | Stethoscope Pen light Blood pressure cuff Thermometer Otoscope Nasal speculum Lubricant Tongue blades Reflex hammer Tuning fork Cotton applicators Gloves |
| Dorsal Recumbrant | Back-lying position with knees flexed and hips externally rotated; small pillow under head; side of feet on the surface |
| Supine | Back lying position with legs extended; with or without pillow under the head. Laying on their back. |
| Lithotomy | Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table |
| Sims | Side-lying position with lowermost arm behind the body, uppermost leg is flexed at hip and knee, upper arm flexed at shoulder and elbow. |
| prone | lies on stomach. Lies on abdomen with head turned to the side with or without pillow supporting head. |
| Visual Inspection | Moisture, color, texture of body surfaces Shape, position, size, symmetry Can also use olfactory and auditory senses |
| During Palpation you should determine... | Texture, Temperature, Vibration, Position, size, and mobility of organs, Distention, Pulsation, Tenderness or pain |
| What does percussion determine? | Determines shape and size of internal organs by establishing their borders. Indicates whether tissue is filled with air, fluid or is solid Five types of sound: Flatness, dullness, resonance, hyperresonance, tympany |
| Two types of percussion | Direct-strike area with pads of fingers Indirect- strike an object (finger) held against the body |
| Two types of auscultation | Direct- use of unaided ear Indirect- use of stethescope |
| Auscultated sounds are described according to.. | Pitch: frequency of vibrations Intensity: loudness or softness Duration: length of sound Quality: description of sound |
| Involves observation of client's general appearance. Assessed while taking client's health history. | General Survey |
Created by:
Alexio
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