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Flashcards in assessment Deck (26):
1

what is assessment

data collection process, continuous process, systematic, involves collecting, validating, and clustering data

2

why do an assessment

establish baseline, identify abnormal findings, identify clients strength and coping resources, pinpoint actual health problems and identify risk factors

3

how to establish health-trusting relationships

communication

4

facilitation

encourage patient to say more also called general leads, maintaining eye contact, shifting forward in seat, nodding, hand gesture

5

silence

after open ended questions, note nonverbal cues, gives patient time to organize thoughts, time to think, gives nurse time to plan next approach

6

reflection

echos patients words, repeating what patient said,

7

empathy

recognizes a feeling and puts it into words, patient feels accepted do NOT give false reassurance, does not deny feeling i.e. "now i don't do everything you are feeding yourself"

8

clarification

"tell me what you mean by..." , also used to summarize what person said, simplify the words to make them clearer, and then ask if you are on the right track

9

explination

share factual/objective info

10

nursing process

ADPIE 5 step

11

A in ADPIE stand for

A= assess,

12

D in ADPIE stand for

D= diagnosis

13

P in ADPIE stand for

P= plan

14

I in ADPIE stand for

Implement

15

E in ADPIE stand for

evaluate

16

how to make a nursing diagnosis

distinguish between relevant and irrelevant data and use clustering related clues to see relationships in data, used in critical thinking skills, validating data checks for accuracy and reliability

17

3 types of nursing diagnosis

actual, risk, wellness `

18

3 steps to prioritizing data

primary, secondary, tertiary

19

primary prioritizing

life threatening problem

20

secondary prioritizing

requires prompt attention to prevent further problems

21

tertiary

important but does not require immediate attention

22

four types of data base

complete data base, focused or problem centered, follow up, emergency

23

complete data base

full physical exam

24

focused or problem centered

mini data collection

25

follow up

re-evaluation of the problem

26

emergency

life saving, rapid assessment