Nursing Process - Assessment Flashcards
(175 cards)
1
Q
It is a systematic, and client- centered method that provides a structure in the delivery of nursing care
A
Nursing Process
2
Q
It is a goal-oriented method that provides a framework for nursing practice
A
Nursing Process
3
Q
They are considered the central figure in the plan of care (Nursing Process)
A
patients
4
Q
This entails gathering and analyzing data to identify health issues / concerns
A
Nursing Process
5
Q
What are the 4 purposes of the Nursing Process?
A
1.Identify the client’s health status
2.Identify actual or potential health problems or needs
3. Establish plans to meet the identified needs
4. Deliver specific nursing interventions to meet those needs
6
Q
12 Characteristics of Nursing Process
A
- Systemic
- Cyclic and Dynamic Nature
- Client-centered
- Focused on Problem-Solving
- Focused on Decision-making
- Interpersonal and Collaborative
- Universally Applicable
- Uses Critical Thinking
- Utilizes Clinical Reasoning
- Outcome Oriented
- Proactive
- Evidence-Based
7
Q
A systematic & continuous collection, organization, validation, & documentation of data
A
Assessment
8
Q
Used to establish a complete database for problem identification, reference, and future comparison
A
Initial assessment or comprehensive assessment
9
Q
This assessment should include assessment of the physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factors, and the client’s coping patterns
A
Initial assessment or comprehensive assessment
10
Q
Example of this type of assessment is Nursing admission assessment
A
Initial assessment or comprehensive assessment
11
Q
Used to determine the status of a specific problem identified in an earlier assessment
A
Problem-focused assessment
12
Q
Examples of this type of assessment are Hourly assessment of a client’s I&O in an ICU and Assessment of the client’s ability for self-care while assisting a client to bathe
A
Problem-focused assessment
13
Q
This assessment is used to identify life-threatening problems and new or overlooked problems
A
Emergency assessment
14
Q
This assessment is used to compare client’s status to baseline data previously obtained
A
Time-lapsed reassessment
15
Q
4 Major activities done during assessment
A
Collecting data, Organizing data, Validating data, Documenting data (COVD)
16
Q
What are the 5 Database sources of Data Collection?
A
A. Nursing Health History
B. Physical Assessment / Examination (PE)
C. Primary Care Provider’s History and PE
D. Results of Lab and Diagnostic Tests
E. Materials Contributed by other Health Personnel
17
Q
Gives subjective information on how a health condition came about
A
Nursing Health History
18
Q
5 Data/Information to be collected in Nursing Health History
A
- level of wellness
- changes in life patterns
- socio-cultural role
- mental and emotional reactions to illness
- other health conditions
19
Q
The purpose of this activity is to identify:
- patterns of health and illness
- risk factors for health problems
- deviations from normal, and
- available resources for adaptation
A
Nursing Health History
20
Q
They are the sources of information in Health History Taking
A
client, family or significant others, health team members & client’s health record
21
Q
Most of the data in Health History Taking are _________?
A
Subjective
22
Q
Focus on ______ from all the client’s dimensions
A
data/information
23
Q
Record data using _____, ______, and ________ terminology
A
clear, concise, and appropriate
24
Q
What are the 8 Basic Components of Health History?
A
- Demographic Data
- Reason/s for Seeking Care or Chief Complaint
- Present Health or History of Present Illness
- Past Medical/Health History
- Family History
- Socio-Economic Data or Social History
- Psychosocial Assessment
- Functional Assessment
25
What are the data collected when taking Client's Demographic (Biographical) Data?
- Client’s name
- Sex
- Age
- Date & Place of Birth
- Marital Status
- Race / Nationality, Religion
- Address / Contact Number
- Educational Background
- Other Significant Trainings, Occupation
- Usual Source of Medical Care
- Source and Reliability of Information
26
Recorded as direct quotes from the client
Reason/s for Seeking Care or Chief Complaint
27
What does a well person describes when you collect their Present Health or History of Present Illness?
General State of Health
28
What does an ill person describes when you collect their Present Health or History of Present Illness?
History of Present Illness (HPI)
29
What are the critical characterstics or qualifiers included in the information of HPI?
- Timing (onset, duration and frequency of symptoms)
- Location
- Quality (character)
- Quantity (severity)
- Setting in which symptoms occur
- Associated phenomena / manifestations
- Aggravating / alleviating factors
- Meaning and impact of CC to the patient
30
It includes
- Review of previous illness
- Injuries & hospitalizations
- Obstetric history (female)
- Surgeries / operations
- Allergies
- Immunizations
- Use of medications
Past Medical / Health History
31
It Includes the health status of the immediate family members and other blood relations.
Family History
32
It helps the nurse assess the client’s risk of developing certain diseases / illnesses
Family History
33
Family History can be presented with what?
Genogram or Family Tree
34
This includes
- Alcohol, drug and/or tobacco use
- Sexual practices
- Travel history
- Work environment
- Home environment
- Hobbies and leisure activities
- Stressors
- Education
- Economic status
- Religion
- Ethnic background
- Roles and relationships
- Characteristic patterns of daily living
- Functional health assessment
Socio-Economic Data or Social History
35
This is used to detect endemic illnesses
Travel History
36
Specific for the current developmental stage of the client
Psychosocial Assessment
37
What Theory is used for Psychosocial Assessment?
Erik Erikson’s Psychosocial Development Theory
38
Includes a person’s ability to perform instrumental activities of daily living and physical self-maintenance activities
Functional Assessment
39
It is made up of patterns, each of which is a sequence of related behaviors that assist the nurse in collecting, organizing, and categorizing
data.
Functional Assessment
40
What is used to assess patients' Health Patterns?
Gordon’s 11 Functional Health Patterns
41
(Part of Gordon’s 11 Functional Health Patterns)
It includes person’s description of his current health
Health Perception – Health Management Pattern
42
(Part of Gordon’s 11 Functional Health Patterns)
Includes activities that the person does to improve or maintain his health
Health Perception – Health Management Pattern
43
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s knowledge about links between lifestyle choices and health
Health Perception – Health Management Pattern
44
(Part of Gordon’s 11 Functional Health Patterns)
Includes extent of a person’s problem on financing health care, if any
Health Perception – Health Management Pattern
45
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s knowledge of the names of current medications / purpose
Health Perception – Health Management Pattern
46
(Part of Gordon’s 11 Functional Health Patterns)
Includes activities that the person does to prevent problems related to allergies
Health Perception – Health Management Pattern
47
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s knowledge about medical problems in the family
Health Perception – Health Management Pattern
48
(Part of Gordon’s 11 Functional Health Patterns)
Includes any important illnesses or injuries in this person’s life
Health Perception – Health Management Pattern
49
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s nourishment
Nutritional – Metabolic Pattern
50
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s food choices in comparison with recommended food intake
Nutritional – Metabolic Pattern
51
(Part of Gordon’s 11 Functional Health Patterns)
Includes any disease that affects nutritional-metabolic function
Nutritional – Metabolic Pattern
52
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s excretory pattern
Elimination Pattern
53
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s any disease of the digestive system, urinary system, or skin
Elimination Pattern
54
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s description of his weekly pattern of activities, leisure, exercise, and recreation
Activity – Exercise Pattern
55
(Part of Gordon’s 11 Functional Health Patterns)
Includes any disease that affects his cardio-respiratory and/or musculoskeletal systems
Activity – Exercise Pattern
56
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s description of the person’s sleep-wake cycle
Sleep – Rest Pattern
57
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s physical appearance (rested and relaxed?)
Sleep – Rest Pattern
58
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s any sensory deficit and if corrected
Cognitive – Perceptual Pattern
59
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s ability to express himself clearly and logically
Cognitive – Perceptual Pattern
60
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s education
Cognitive – Perceptual Pattern
61
(Part of Gordon’s 11 Functional Health Patterns)
Includes any disease that affects mental or sensory function
Cognitive – Perceptual Pattern
62
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s pain description and causes, if any
Cognitive – Perceptual Pattern
63
(Part of Gordon’s 11 Functional Health Patterns)
Includes anything unusual about the person’s appearance
Self-Perception / Self-Concept Pattern
64
(Part of Gordon’s 11 Functional Health Patterns)
Includes if person is comfortable with his appearance
Self-Perception / Self-Concept Pattern
65
(Part of Gordon’s 11 Functional Health Patterns)
Includes description of the person’s feeling state
Self-Perception / Self-Concept Pattern
66
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s description of his various roles in life
Role-Relationship Pattern
67
(Part of Gordon’s 11 Functional Health Patterns)
Includes positive role models of his roles, if any
Role-Relationship Pattern
68
(Part of Gordon’s 11 Functional Health Patterns)
Includes important relationships at present
Role-Relationship Pattern
69
(Part of Gordon’s 11 Functional Health Patterns)
Includes any big changes in role or relationship
Role-Relationship Pattern
70
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s satisfaction with his situation related to sexuality
Sexuality-Reproductive Pattern
71
(Part of Gordon’s 11 Functional Health Patterns)
Includes How have the person’s plans and experiences matched regarding having children?
Sexuality-Reproductive Pattern
72
(Part of Gordon’s 11 Functional Health Patterns)
Includes any disease/dysfunction of the reproductive system
Sexuality-Reproductive Pattern
73
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s means/actions of coping with problems
Coping-Stress Tolerance Pattern
74
(Part of Gordon’s 11 Functional Health Patterns)
Includes if coping actions help or make things worse
Coping-Stress Tolerance Pattern
75
(Part of Gordon’s 11 Functional Health Patterns)
Includes any treatment for emotional distress
Coping-Stress Tolerance Pattern
76
(Part of Gordon’s 11 Functional Health Patterns)
Includes principals that the person learn as a child which are still important to him
Value-Belief Pattern
77
(Part of Gordon’s 11 Functional Health Patterns)
Includes person’s identification with any cultural, ethnic, religious, regional, or other groups
Value-Belief Pattern
78
(Part of Gordon’s 11 Functional Health Patterns)
Includes support systems that the person has
Value-Belief Pattern
79
The patient’s subjective response to a series of body system-related questions
Review of Systems (ROS)
80
Covers a broad base of clinical states
Review of Systems (ROS)
81
ROS follows what type of approach?
head-to-toe approach
82
What are the 2 types of questions included in Review of Systems (ROS)?
sign or symptom related and disease-related
83
What are the 20 data included in ROS?
A.General / Overall State of Health
B. Integumentary
C. Head
D.Eyes
E. Ears
F. Nose and Sinuses
G.Mouth and Throat
H.Neck
I. Breast and Axilla
J. Respiratory
K. Cardiac
L. Gastrointestinal
M.Urinary
N.Genitalia / Reproductive
O.Peripheral - Vascular
P. Musculoskeletal
Q.Neurologic / Nervous
R. Hematologic
S. Endocrine
T. Psychiatric
84
Also referred to as symptoms or covert data
SUBJECTIVE DATA
85
Can be described or verified only by the
individual
SUBJECTIVE DATA
86
Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation
SUBJECTIVE DATA
87
Also referred to as signs or overt data
OBJECTIVE DATA
88
Can be measured or tested against an accepted standard
OBJECTIVE DATA
89
Can be seen, heard, felt, or smelled
OBJECTIVE DATA
90
Obtained by observation or physical examination (PE)
OBJECTIVE DATA
91
During PE, the nurse obtains ________ _____ to validate the subjective data
OBJECTIVE DATA
92
2 Sources of Data?
Primary and Secondary
93
The client serves as the best source of data
PRIMARY SOURCES
94
Includes statements made by the client and objective data directly obtained from the client
PRIMARY SOURCES
95
Refers to all sources other than the client
SECONDARY SOURCES
96
4 Data Collection Methods?
1. Observing
2. Interviewing
3. Examining
4. Using Laboratory Results
97
A conscious and deliberate skill in gathering data using the senses
OBSERVING
98
Involves noticing data then selecting, organizing, and interpreting data
OBSERVING
99
Planned communication or a purposeful conversation
INTERVIEWING
100
2 Approaches to Interviewing?
Directive and Nondirective
101
Type of Interview Approach that is highly structured?
Directive Interview
102
Interview Approach used to gather or give information when time is limited
Directive Interview
103
Type of Interview Approach where nurse establishes the purpose and controls the interview
Directive Interview
104
a rapport-building interview
Nondirective Interview
105
Type of Interview Approach where the client controls the purpose, subject matter, and pacing
Nondirective Interview
106
4 Types of Interview Questions
Closed, Open-ended, Neutral, Leading
107
Questions used during direct interviews
Closed Questions
108
Questions generally restrictive; requires a yes, no, or short factual responses
Closed Questions
109
Questions often used when information is needed quickly
Closed Questions
110
Questions associated with non-directive interviews
Open-ended Questions
111
Questions that invites longer responses from the clients
Open-ended Questions
112
Questions that provides the client with freedom to share information
Open-ended Questions
113
Questions that are open-ended, used in non-directive interviews
Neutral Questions
114
Questions that can be answered by the client without direction or pressure
Neutral Questions
115
Questions that are closed questions and are used in directive interviews
Leading Questions
116
Questions that directs the client’s answers
Leading Questions
117
Questions that gives the client less opportunity to decide if responses are true or not
Leading Questions
118
What type of interview question is used when asking
“How old are you?”
CLOSED
119
What type of interview question is used when asking
”What do you think led to the operation?”
OPEN-ENDED
120
What type of interview question is used when asking
“Are you having pain now?”
CLOSED
121
What type of interview question is used when asking
“When did you fall?”
CLOSED
122
What type of interview question is used when asking
“What would you like to talk about today?”
OPEN-ENDED, NEUTRAL
123
What type of interview question is used when asking
“What brought you to the hospital?”
OPEN-ENDED, NEUTRAL
124
What type of interview question is used when asking
“You will take the medicine, won’t you?”
CLOSED, LEADING
125
What type of interview question is used when asking
”What do you think led to the operation?”
OPEN-ENDED, NEUTRAL
126
What type of interview question is used when asking
“How do you feel about that?”
OPEN-ENDED, NEUTRAL
127
What type of interview question is used when asking
“You’re stressed about the surgery, aren’t you?
CLOSED, LEADING
128
It is a complete health assessment
EXAMINING
129
Examining is _____ and ______
orderly and systematic
130
4 basic skills in examining
- Inspection
- Palpation
- Percussion
- Auscultation
131
2 Approaches used in Examining
- Cephalocaudal
- Body systems approach
132
Upon Admission what should you do in Examining?
- Perform complete PE
- Alternative: screening exam or ROS
133
During Ongoing Assessment what should you do in Examining?
Examine specific body areas, systems, or functions
134
4 objectives of Examining
- obtain baseline data
- supplement, confirm, or refute health history data
- obtain data to help establish the plan of care
- evaluate physiologic outcomes or progress
135
Principles / Guidlines of Examining
Make client _______ and ________
relaxed and comfortable
136
Principles / Guidlines of Examining
Provide ______ and avoid unnecessary exposure
privacy
137
Principles / Guidlines of Examining
Have an ______ for examination
order
138
Principles / Guidlines of Examining
Follow a ____ of _____ for PE techniques
plan of order
139
Principles / Guidlines of Examining
Maintain a __________ room
well-lighted
140
Principles / Guidlines of Examining
_______ explain every step to be undertaken
Always
141
Principles / Guidlines of Examining
Compare _______ from one side of the body to the other
findings
142
Principles / Guidlines of Examining
Consider the ______ _______ of the body
underlying structures
143
Principles / Guidlines of Examining
Use all ______ during the exam
senses
144
What are the 6 Positioning in Examining?
✓ Standing position
✓ Supine position
✓ Prone position
✓ Dorsal recumbent position
✓ Sims’ position
✓ Lithotomy position
145
4 Techniques used during Physical Examination
Inspection
Palpation
Percussion
Auscultation
146
Assessment of the patient’s general appearance
Inspection
147
Technique in Examining wherein sense of sight, hearing and smell are used
Inspection
148
Uses the sense of touch; “therapeutic touch”
Palpation
149
Tools used for palpation
Dorsum, Palm, Fingertips, Index-Thumb
150
2 Types of Palpation
Light and Deep
151
Type of Palpation wherein the skin is depressed for about 1-2 cm using the finger pads
Light Palpation
152
Type of Palpation used to assess texture, tenderness, temp., moisture, elasticity
Light Palpation
153
Type of Palpation can also be used to assess pulsations and masses
Light Palpation
154
Type of Palpation that can be done with 1 or 2 hands, skin is depressed for about 4-5 cm
Deep Palpation
155
Type of Palpation - used when trying to feel for the internal organs
Deep Palpation
156
Type of Palpation - used to feel mass size, shape, tenderness, symmetry, and mobility
Deep Palpation
157
Involves the striking of a body surface, usually with a tip of the finger to elicit a sound or vibration
Percussion
158
Types of Percussion
Direct and Indirect
159
uses pads of 2, 3, or 4 fingers or with a pad of the middle finger
Direct Percussion
160
commonly used when percussing adult sinuses
Direct Percussion
161
the nurse strikes an object (another finger) held against a body area
Indirect Percussion
162
Indirect Percussion uses _____ (finger placed on the skin), ______ (striking finger)
pleximeter, plexor
163
Involves the process of listening to sounds produced within the body and could either be direct or indirect
Auscultation
164
use of unaided ear
Direct Auscultation
165
use of stethoscope
Indirect Auscultation
166
Constitutes another source of objective data, which is important in assessing many health problems and conditions
USING LABORATORY RESULTS
167
7 Conceptual Models/Frameworks used in Organizing Data
1. Gordon’s 11 Functional Health Patterns
2. The Review of Systems
3. Maslow’s Hierarchy of Needs
4. Henderson’s 14 Fundamental Needs
5. Abdellah’s 21 ADLs
6. Orem’s Self-Care Model
7. Roy’s Adaptation Model
168
This model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development
Orem’s Self-Care Model
169
4 data used in Roy's Adaptation Model
a. Physiologic needs
b. Self-concept (Physical and Personal Self)
c. Role function
d. Interdependence
170
the act of double-checking or verifying data to confirm that it is accurate and factual
Validation
171
Helps the nurse ensure completion of tasks
DATA VALIDATION
172
The nurse needs to _______ ______ especially when there are discrepancies
validate data
173
Data are recorded in a factual manner and not interpreted by the nurse
DOCUMENTATION
174
To increase accuracy, the nurse records subjective data in
the client’s own words, using ________ _______.
quotation marks
175
Accurate __________ is essential and should include all data collected about the client’s health status.
documentation
