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NCM_101 | Health Assessment > Health Assessment, Health History, and Physical Examination > Flashcards

Health Assessment, Health History, and Physical Examination Flashcards

(78 cards)

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1
Q

The first and most critical phase of the nursing process

A

Health Assessment

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2
Q

On-going and continuous throughout all the phases of the nursing process

A

Health Assessment

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3
Q

The nurses analyzing the data and evaluating the client care outcomes

A

Nursing Process

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4
Q

Is circular, not linear

A

Nursing Process

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5
Q

Phases of the Nursing Process

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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6
Q

Collection of subjective data and objective data / Subjective Data / Objective Data

A

Assessment

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7
Q

Analysis of subjective data and objective data / NANDA
/ Actual, Risk, and Wellness

A

Diagnosis

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8
Q

Bound generation of solutions / ABC / High, Intermediate, and Low

A

Planning

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9
Q

Taking actions / SMART

A

Implementation

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10
Q

Assessing outcomes / Independent, Dependent, and Interdependent

A

Evaluation

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11
Q

The collection of holistic subjective and objective data

A

Focus of Health Assessment in Nursing

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12
Q

Composition of a Health Assessment

A

Health History
Physical Examination

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13
Q

Data of a Health Assessment

A

Physiological Manner
Psychological Manner
Sociocultural Manner
Developmental Manner
Spiritual Manner

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14
Q

Interdependent Factors of a Health Assessment

A

Mind
Body
Spirit

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15
Q

The organized information of each and every data

A

Framework for Health Assessment in Nursing

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16
Q

Four Sections of a Health Assessment

A

History of present health concern
Personal health history
Family health history
Lifestyle and health practices

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17
Q

The supposed knowledge of physiology

A

Using Evidence to Promote Health and Prevent Disease

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18
Q

Evidence-Based Health Promotion and Disease Prevention

A

Health People 2030
US Preventive Services Task Force / USPSTF

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19
Q

Aims to increase life span and improve quality of health for all Americans

A

Health People 2030

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20
Q

Determines risk versus benefits in screenings

A

US Preventive Services Task Force / USPSTF

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21
Q

The variation of the data collected

A

Types of Health Assessment

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22
Q

Four Basic Types of Nursing Assessment

A

Initial Comprehensive Assessment
Ongoing or Partial Assessment
Focused or
Problem-Oriented Assessment
Emergency Assessment

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23
Q

Collection of subjective data / Age, Risk Factors, Health Status, Health Promotion Practices, and Lifestyle

A

Initial Comprehensive Assessment

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24
Q

Composition upon comprehensive database / Acuity

A

Ongoing or Partial Assessment

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25
Specific health concerns
Focused or Problem-Oriented Assessment
26
Rapid life-threatening issues
Emergency Assessment
27
The client’s assessment phase of the nursing process
Steps of Health Assessment
28
Four Major Steps of Nursing Assessment
Collection of Subjective Data Collection of Objective Data Validation of Data Documentation of Data
29
Functioned data / Biographical Information, History of Present Health Concern, Personal Health History, Family History, Health and Lifestyle Practices, and Review of Systems
Collection of Subjective Data
30
Physiological data / Physical Characteristics, Body Functions, Appearance, Behavior, Measurements, and Results of Laboratory Testing
Collection of Objective Data
31
Checked data
Validation of Data
32
Documented Data
Documentation of Data
33
The flow of the nurse meeting the client
Preparing for the Assessment
34
Nurse reviews the client’s medical record
Before
35
Nurse educates self about client’s diagnoses or tests performed / Nurse reflects on personal feelings about client’s encounter / Nurse obtains needed materials for client’s assessment
During
36
Nurse reviews the client’s status with others
After
37
The nurse using clinical judgement on the client
Analyzing Cues to Identify Client Concerns
38
Physiological complications
Collaborative Concern / Collaborative Problem
39
Client problems
Client Concern / Nursing Problem
40
Whole being alongside other healthcare professionals
Medicine or Discipline Concern / Referrals
41
Process of Data Analysis
Identify abnormal cues and supportive cues Cluster cues Draw inferences and identify and prioritize client concerns Propose possible collaborative problems to notify primary care provider Identify need for referral to primary care provider Document conclusions
42
Collection of Data
Holistic Nursing Assessment Medical Nursing Assessment
43
The content of the data to be verified / Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information
Subjective Data
44
The communication process of the nurse and client for subjective data / Establishment of rapport and gathered information.
Interviewing
45
Phases of the Interview
Preintroductory Phase Introductory Phase Working Phase Summary and Closing Phase
46
Nurse reviews the client’s medical record / Interview
Preintroductory Phase
47
Nurse explains to the client
Introductory Phase
48
Nurse listens, observes cues, and uses critical thinking towards the client
Working Phase
49
Nurse summarizes the client’s supposed needs / Interventions
Summary and Closing Phase
50
Communication During the Interview
Nonverbal Communication Verbal Communication
51
How the nurse is perceived by the client / Appearance, Demeanor, Facial Expression, Attitude, Silence, and Listening
Nonverbal Communication
52
How the client is probed by the nurse / Open-Ended Questions, Closed-Ended Questions, Laundry List, Rephrasing, Well-Placed Phrases, Inferring, and Providing Information
Verbal Communication
53
The variations of communication to be used
Special Considerations During the Interview
54
Geriatric Care
Gerontologic Variations in Communication
55
Culture Care
Cultural Variations in Communications
56
Emotional Care
Emotional Variations in Communication
57
The foundation of all clinical judgement
Complete Health History
58
Seven Sections of Health History
Biographical Data Reasons for Seeking Health Care History of Present Health Concern Personal Health History Family Health History Review of Systems for Current Health Problems Lifestyle and Health Practices Profile
59
Primary Source and all other Secondary Source
Biographical Data
60
What and How Question and Answers
Reasons for Seeking Health Care
61
Concern Description
History of Present Health Concern
62
Earliest Beginnings
Personal Health History
63
Genetics
Family Health History
64
Highlighted Issues
Review of Systems for Current Health Problems
65
Typical Day, Nutrition and Weight Management, Activity Level and Exercise, Sleep and Rest, Substance Use, Self-Concept and Self-Care Responsibilities, Social Activities, Relationships, Values and Beliefs System, Education and Work, Stress Levels and Coping Styles, and Environment
Lifestyle and Health Practices Profile
66
COLDSPA
Character Onset Location Duration Severity Palliative Associated Factors
67
The content of the data to be validated / Types and operation of equipment needed for the particular examination, preparation of the setting, oneself, and the client for the physical assessment, and the performance of the four examination techniques
Objective Data
68
The essential embodiment of clinical judgements / Assessing own feelings and anxieties, preventing transmission of infectious agents.
Preparing Oneself
69
General Principles of a Physical Assessment
Wash your hands Always wear gloves Discard pins Wear your mask and protective eye googles
70
The establishment of a nurse-client relationship
Approaching and Preparing the Client
71
Respecting Client Desires and Requests
Present family or friend Simple non-exposure of a certain body part
72
The nurse’s thorough and complete assessment of the client
Physical Examination Techniques
73
Four Basic Examination Techniques
Inspection Palpation Percussion Auscultation
74
Comfortable temperature / Good lighting / Look and observe before touching / Completely expose the body part you are inspecting / Color, patterns, size, location, consistency, symmetry, movement, behavior, odor, or sounds / Appearance of symmetric body parts or both sides of any individual body part
Inspection
75
Texture / Temperature / Moisture / Mobility / Consistency / Strength of pulses / Size / Shape / Degree of tenderness / Light Palpation, Moderate Palpation, Deep Palpation, and Bimanual Palpation
Palpation
76
Determining location, size, and shape / Determining density / Determining abnormal masses / Eliciting reflexes / Direct, Blunt, Indirect
Percussion
77
Intensity / Pitch / Duration / Quality / Sound
Auscultation
78
Documentation
Communication Legal Evidence of Care Education Financial Billing Evaluation of Quality Care Rendered Research and Statistical Information

NCM_101 | Health Assessment (11 decks)

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