-
The purpose is to collect subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgement
nursing health assessment
-
helps to organize information and promotes the collection of holistic data
nursing framework
-
what are the phases of the nursing process?
- ADPIE
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
-
The four basic types of nursing assessment:
- -Initial comprehensive assessment
- -Ongoing or partial assessment
- -Focused or problem-oriented assessment
- -Emergency assessment
-
collection of subjective data about the client's perception of their health of all body parts or systems, past health history, family history, lifestyle and health practices, as well as objective data gathered during step-by-step physical examination
Initial comprehensive assessment
-
Data collection that occurs after the comprehensive data is established. Holistic health patterns are reassessed to determine any changes from the baseline data.
Ongoing or partial assessment
-
It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern
Focused or problem-oriented assessment
-
a very rapid assessment performed during life-threatening situations
emergency assessment
-
provides information about chronic diseases, medications, allergies, and gives clues to how a present illness may impact the client's activities of daily living
medical record
-
An example of an emergency assessment when cardiac arrest is suspected
- ABC's
- airway
- breathing
- circulation
-
are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
subjective data
-
The major areas of subjective data:
- -Biographical data
- -History of present health concern
- -Past Health History
- -Family history
- -health and lifestyle practices
- -review of systems
-
steps of health assessment:
- 1.Collection of subjective data
- 2.Collection of objective data
- 3.Validation of data
- 4.Documentation of data
-
Collecting objective data:
- -Physical characteristics(e.g. skin color, posture)
- -Body functions(e.g. heart rate, respi rate)
- -Appearance(e.g. dress, hygiene)
- -Behavior(e.g. mood, affect)
- -Measurements(e.g. Bp, temp., height, weight)
- -lab results(e.g. cbc, platelet count, x-ray findings)
-
this type of data is obtained by general observation and by using the four physical examination techniques
objective data
-
The four physical examination techniques:
- -Inspection
- -Palpation
- -Percussion
- -Auscultation
-
Ensures that the assessment process has not ended before all relevant data has have been collected. Helps to prevent documentation of inaccurate data.
Validating assessment data
-
Forms the database for the entire nursing process and provides data for all other members of the health care team.
documenting data
-
A problem of a client that have been identified and prioritized by nurses to plan nursing interventions to treat and evaluate the client concern.
nursing problem(client concern)
-
are defined as certain physiological complications that nurses monitor to detect their onset or changes in status. Nurses manage these problems by implementing both physician- and nurse-prescribed interventions to reduce further complications
collaborative concern
-
A concern that needs to be referred to medicine or another discipline. Occurs because nurses assess the "whole" client, often identifying problems that require the assistance of other health care professionals
referral
-
One must undergo these steps to identify client concerns, collaborative problems, or need for referral.
process of data analysis
-
is a communication process that focuses, establishing rapport and a trusting relationship with the client , and gather information on the client's developmental, psychological, physiological, sociocultural and spiritual status.
Nursing interview
-
phases of interview:
- -Preintroductory phase
- -Introductory phase
- -Working phase
- -Summary and closing phase
-
The nurse reviews the medical record before meeting with the client. Knowing some of the client's already documented biographical information may assist the nurse with conducting the interview
preintroductory phase
-
After introducing himself/herself to the client, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential.
Introductory phase
-
During this phase, the nurse elicits the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client.
working phase
-
During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. She also identifies and discusses possible plans to resolve the problem with the client.
summary and closing phase
-
Your appearance, demeanor, posture, facial expression and attitude strongly influence how the client perceives the questions you ask. Never overlook this type of communication or take it for granted.
Nonverbal communication
-
take care to ensure that your appearance is professional. The client is expecting to see a health professional; therefore, you should look the part.
Appearance
-
When you enter a room to interview a client, display poise. Focus on the client and the upcoming interview and assessment. Do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath.
Demeanor
-
are often an overlooked aspect of nonverbal communication. Often shows what you are truly thinking
facial expressions
-
One of the most important nonverbal skills to develop as a health care professional is a nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle and healthcare practices.
attitude
-
allow you and the client to reflect and organize thoughts, which facilitates more accurate reporting and data collection.
silence
|
|
