Assessment and Promotion of HLN

Question 0

Definition

Answer 0

data-information
database-ALL info about client
baseline-initial data collected
sign-objective data
symptom-subjective data

Sources

• client’s words
• observations
• chart
• family

Question 1

Nursing Process

Answer 1

• method of problem-solving
• systematic approach
• used to organize and deliver care
  
  • promotes individualized care
• assessment
• diagnosis
• planning
• implementation
• evaluation

Question 2

Objective Data

Answer 2

• observable
• can be tested against accepted standard
• seen, felt, heard, smelled

Question 3

Subjective Data

Answer 3

• non-observable
• client’s perceptions, beliefs, feelings, values, attitudes
• aka symptoms

Question 4

Methods of Collection

Answer 4

1) Observation
- be organized so nothing is missed

2) Interview/Health History
- planned and purposeful questions
- subjective (Health history)

3) Physical Exam
- objective data
- systematic (head-to-toe)

4) Diagnostic Tests
- compare to established norms
- not any abnormal

Question 5

Physical Assessment Skills-Inspection

Answer 5

• observation without touching (no steth)
• general to specific
• objective and detailed
• systematic (head to toe)

Question 6

Physical Assessment Skills-Palpation

Answer 6

• sense of touch
• tender areas last
• light (1-1/2cm) or deep (2-4cm) (nurses don’t do deep)

Question 7

Physical Assessment Skills-Percussion

Answer 7

• tapping body with short, sharp strokes to elicit sounds and assess underlying structures
• character of sound depends on density of underlying tissue

Question 8

Physical Assessment Skill-Auscultation

Answer 8

• listening with stethoscope, place on skin
• diaphragm for high-pitched (lungs, bowel)
• bell for low-pitched (heart)
• for frequency, loudness, quality, duration

Question 9

Documentation

Answer 9

• assists to develop nursing diagnosis
• assists in identifying health problem
• provides continuity
• makes everyone accountable