Introduction to Nursing Assessments Flashcards
first and most critical phase of the nursing process.
Assessment
Analyzing subjective and objective data to make a professional nursing judgment
Diagnosis
Determining outcome criteria and developing a plan
Planning
Carrying out plan
Implementation
Assessing whether outcome criteria have been met and revising the plan as necessary
Evaluation
It involves collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination.
Initial Comprehensive
This consists of data collection after the comprehensive database is established. reassessment of the client’s body systems
Ongoing or Partial
consists of a thorough assessment of a particular client problem and does not address areas not related to the problem.
Focused Assessment
Rapid assessment performs in life threatening situations. Immediate assessment is needed to provide prompt treatment.
Emergency Assessment
Outpatient Clinic
Ambulatory Care
It serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data
Validating Assessment Data
important step of assessment because it forms the database for the entire nursing profession.
Documentation
Establishing rapport and trusting relationship with the client to elicit accurate and meaningful information
Focus of Interview
reviews the medical record which may reveal that clients past health history and reason for seeking health care before meeting with the client
Pre Introductory
Explain the purpose of interview
Introductory
Listening , observing cues, and using critical thinking skills to interpret and validate information received from the client
Working Phase
Validating problems and goals with the client. Identifying and discussing possible plans to resolve the problem with the client
Summary and Closing Phase
Is a communication during the interview which you will assess the appearance, demeanor, attitudes, facial expression
Non Verbal
Phases of Interview
Pre Introductory, Introductory, Working Phase, Summary and Closing Phase
Is a communication during the interview which you will done by an open or close ended questions
Verbal
A special consideration during interview wherein: Age affects and commonly slows the body to varying degrees. When interviewing an older client, you must first assess hearing acuity
Gerontologic Variations
A special consideration during interview wherein: ethnic/ cultural variations in communication and self-disclosure styles may significantly affect the information obtained
Cultural Variation
A special consideration during interview wherein: Clients emotions for a number of reasons. They may be scared or anxious about their health
Emotional Variation
What is the meaning of COLD SPA
Character, Onset, Location, Duration Severity, Pattern, Associated Factors
