HEALTH ASSESSMENT LAB Flashcards
(104 cards)
1
Q
is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
A
Nursing process
2
Q
is a systematic method of providing care to clients
A
Nursing process
3
Q
is a systematic method of planning and providing individualized nursing care
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Nursing process
4
Q
PURPOSES OF NURSING PROCESS
A
- To identify a client’s health status and actual or potential health care problems or needs.
- To establish plans to meet the identified needs.
- To deliver specific nursing interventions to meet those needs.
5
Q
CHARACTERISTICS OF NURSING PROCESS
A
- Cyclic
- Dynamic nature
- Client centeredness
- Focus on problem solving and decision making
- Interpersonal and collaborative style
- Universal applicability
- Use of critical thinking and clinical reasoning.
6
Q
- Collect data
- Organize data
- Validate data
A
ASSESSMENT
7
Q
is the systematic and continuous collection, organization, validation, and documentation of data (information).
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Assessment
8
Q
TYPES OF ASSESSMENT
A
- Initial nursing assessment
- Problem-focused assessment
- Emergency assessment
- Time-lapsed reassessment
9
Q
Performed within specified time after admission
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Initial nursing assessment
10
Q
To establish a complete database for problem identification
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Initial nursing assessment
11
Q
Eg: Nursing admission assessment
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Initial nursing assessment
12
Q
To determine the status of a specific problem
identified in an earlier assessment.
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Problem-focused assessment
13
Q
Eg: hourly checking of vital signs of fever patient
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Problem-focused assessment
14
Q
During emergency situation to identify any life
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Emergency assessment
15
Q
Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest.
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Emergency assessment
16
Q
Several months after initial assessment
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Time-lapsed reassessment
17
Q
To compare the client’s current health status with the data previously obtained.
A
Time-lapsed reassessment
18
Q
is the process of gathering information about a client’s health status
A
Data collection
19
Q
It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
A
Data collection
20
Q
also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person
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Subjective data
21
Q
Itching, pain, and feelings of worry are examples of
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Subjective data
22
Q
also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard
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Objective data
23
Q
They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination
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Objective data
24
Q
For example, a discoloration of the skin or a blood pressure reading is
A
Objective data
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It is the direct source of information
Primary
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It is the indirect source of information
Secondary
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All sources other than the client are considered
Secondary
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Observation, interview and examination are
METHODS OF DATA COLLECTION
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It is gathering data by using the senses. Vision, Smell, and Hearing are used.
Observation
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is a planned communication or a conversation with a purpose
Interview
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is highly structured and directly asks the questions. And the nurse controls the interview.
directive interview
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or rapport building interview and the nurse allows the client to control the interview.
nondirective interview
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STAGES OF AN INTERVIEW
1. The opening or introduction
2. The body or development
3. The closing
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is a systematic data collection method to detect health problems
physical examination
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uses techniques of inspection, palpation, percussion and auscultation.
physical examination
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uses a format that organizes the assessment data systematically
Organization of data
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often referred to as nursing health history or nursing assessment form
Organization of data
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The information gathered during the assessment is “double-checked" or verified to confirm that it is accurate and complete
Validation of data
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To complete the assessment phase, the nurse records client data
Documentation of data
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* Analyze data
* Identify health problems, risks, and strengths
* Formulate diagnostic statements
DIAGNOSIS
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is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems
Diagnosis
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"a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community."
The official NANDA definition of a nursing diagnosis
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is a client problem that is present at the time of the nursing assessment
actual diagnosis
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relates to clients' preparedness to improve their health condition
health promotion diagnosis
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is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given
risk nursing diagnosis
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A nursing diagnosis has three components
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
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statement of the client's health problem
Problem
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causes of the health problem
Etiology
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defining characteristics manifested by the client
Signs and symptoms
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is a statement of nursing judgment that made by nurse, by their education, experience, and expertise, are licensed to treat.
nursing diagnosis
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describe the human response to an illness or a health problem
Nursing diagnoses
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may change as the client's responses change
Nursing diagnoses
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EXAMPLES OF NURSING DIAGNOSIS
* Ineffective breathing pattern
* Activity intolerance
* Acute pain
* Disturbed body image
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diagnosis is made by a physician
Medical diagnoses
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diagnoses refer to disease processes
Medical diagnoses
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remains the same for as long
| as the disease is present.
Medical diagnoses
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EXAMPLES OF MEDICAL DIAGNOSIS
* Asthma
* Cerebrovascular accident
* Appendicitis
* Amputation
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* Prioritize problems/diagnoses
* Formulate goals/desired outcomes
* Select nursing interventions
* Write nursing interventions
PLANNING
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involves decision making and problem solving
Planning
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It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems
Planning
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Planning which is done after the initial assessment
Initial Planning
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It is a continuous planning
Ongoing Planning
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Planning for needs after discharge
Discharge Planning
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Planning includes;
* Establishing client goals/desired outcomes
* Selecting nursing interventions and activities
* Writing individualized nursing interventions on care plans
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food, water, warmth, rest
Physiological needs
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security, safety
Safety needs
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intimate relationships, friends
Belongingness and love needs
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prestige and feeling of accomplishment
Esteem needs
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achieving one's full potential, including creative activities
Self-actualization
70
is any treatment, that a nurse performs to improve patient's health.
NURSING INTERVENTIONS
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are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
Independent interventions
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are activities carried out under the orders or supervision of a
licensed physician.
Dependent interventions
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are actions the nurse carries out in collaboration with other
health team members
Collaborative interventions
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is a written or computerized information about the client's care
Nursing care plan
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consists of doing and documenting the activities
Implementation
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The process of implementation includes;
* Implementing the nursing interventions
| * Documenting nursing activities
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is a planned, ongoing, purposeful activity in which the nurse determines:
(a) the client's progress toward achievement of goals/outcomes and
(b) the effectiveness of the nursing care plan.
Evaluation
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The evaluation includes;
* Comparing the data with desired outcomes
| * Continuing, modifying, or terminating the nursing care plan.
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Communication is a series of experience of
* Hearing
* Smell
* Seeing
* Taste
* Touch
80
is the ability to use language (receptive) and express (expressive) information.
Communication skills
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are a critical element in your career and personal lives
Effective communication skills
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COMMUNICATION GOALS
* To change behavior
* To get action
* To ensure understanding
* To persuade
* To get and give information
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MOST COMMON WAYS TO COMMUNICATE
* Speaking
* Writing
* Visual Image
* Body Language
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-On The Basis Of Organization Relationship:
* Formal
| * Informal
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-On the basis of Flow:
* Vertical
* Crosswise/Diagonal
* Horizontal
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-On the basis of Expression:
* Oral
* Written
* Gesture
87
```
> Symbols with different meaning
> Badly expressed message
> Faulty translation
> Unclarified assumption
> Specialist's language
```
Semantic Barriers
88
```
> Premature evolution
> Inattention
> Loss of transmission & poor retention
> Undue reliance on the written word
> Distrust of communication
> Failure to communicate
```
Emotional Or Psychological Barriers
89
> Organizational policy
> Organization rules & regulation
> Status relation
> Complexity in organization
Organizational Barriers
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* Attitude of Superior
* Fear of challenge of authority
* Lack of time
* Lack of awareness
Barriers in Superior
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* Unwillingness to communicate
| * Lack of proper incentive
Barriers in Subordinates
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the process of sending and receiving information among people
Communication
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COMMUNICATION CODE SCHEME
1. Codifying
2. Sending the message
3. Decodifying
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the words we choose
Verbal Messages
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how we say the words
Paraverbal Messages
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our body language
Nonverbal Messages
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EFFECTIVE VERBAL MESSAGES ARE
> Are brief, succinct, and organized
> Are free of jargon
> Do not create resistance in the listener
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are the primary way that we communicate emotions
NONVERBAL MESSAGES
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refers to the messages that we transmit through the tone, pitch, and pacing of our voices.
PARAVERBAL MESSAGES
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Giving full physical attention to the speaker
Nonverbal
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Paying attention to the words and feelings that are being expressed
Verbal
102
WHAT MAKES A GOOD COMMUNICATOR?
* Clarity
* Adequacy
* Timing
* Integrity
103
TIPS TO GOOD COMMUNICATION SKILLS
```
> Maintain eye contact with the audience
> Body awareness
> Gestures and expressions
> Convey one's thoughts
> Practice effective communication skills
```
104
EFFECTIVE COMMUNICATION IS
* It is two way.
* It involves active listening.
* It reflects the accountability of speaker and listener.
* It utilizes feedback.
* It is free of stress.
* It is clear.
