the process of collecting data, validating, and clustering data
assessment
identifying and prioritizing actual or potential health problems or responses
nursing diagnosis
what is the purpose of assessment?
to solve problems; to pinpoint actual health problems and identify risk factors for health problems
what are the skills of assessment?
a. psychomotor skills
b. cognitive skills
c. affectionate interpersonal skills
what type of skill involves touching and/or doing the most during an assessment? used to perform the four techniques of physical assessment (inspection, palpation, percussion, and auscultation)..
psychomotor skills
what type of skill requires mostly critical, creative, and clinical thinking during an assessment?
cognitive skills
what type of skill requires mostly personality and feelings during an assessment? used to practice the "art" of nursing. essential in developing caring, therapeutic nurse-patient relationships.
affectionate interpersonal
what part of the nursing diagnosis involves setting goals and outcomes for the patient?
planning
what part of the nursing process involves carrying out your plan to achieve goals and outcomes?
implementation/intervention
what part of the nursing process involves determining the effectiveness of your plan?
evaluation
what is the purpose of assessment?
the purpose of assessment is to collect data pertinent to the patient's health status, to identify deviations from normal, to discover the patient's strengths and coping resources, to pinpoint actual problems, and to spot factors that place the patient at risk for health problems.
what level of preventive care focuses on health promotion and guards against health problems?
primary preventive care
what level of preventive care focuses on early detection, prompt intervention, and health maintenance for patients with health problems?
secondary preventive care
what level of preventive care deals with rehab or extended care?
tertiary preventive care
what level of preventive care would include health fairs, immunizations, and nutritional instructions?
primary preventive care
what level of preventive care includes blood pressure checks and pap smears?
secondary preventive care
what level of preventive care includes home care, a hospice, or long-term care facilities?
tertiary preventive care
covert, not measurable symptoms; what the patients says he/she is experiencing. (e.g. health history)
subjective data
overt, measurable signs
objective data
what are the four techniques of physical assessment in order?
inspection. palpation. percussion. auscultation.
what is the most frequently used assessment technique, although its value is often over looked?
inspection
using your sense of touch to collect data to assess characteristics such as texture, consistency, and temperature
palpation
used to assess density of underlying structures, areas of tenderness, and deep tendon reflexes. it entails striking a body surface with quick light blows and eliciting vibrations and sounds.
percussion
using your sense of hearing to collect data by listening to sounds produced by the body such as heart sounds, lung sounds, bowel sounds, and vascular sounds.
auscultation
applying very gentle pressure with the tips and pads of your fingers to a body area and then gently moving the over the area, pressing about a 1/2 inch. best for assessing surface characteristics, such as temp, texture, mobility, shape and size, pulses, areas of edema and areas of tenderness.
light palpation
directly tapping your hand or fingertip over a body surface to elicit a sound; used to assess sinus tenderness
direct/mediate percussion
using a percussion hammer to test reflexes
indirect/mediate percussion
percussion used to assess organ tenderness
fist or blunt percussion
what are the four assessment areas for wellness?
rest and sleep. exercise. stress. safety/injury prevention.
you are performing a preschool examination on your patient. you have just taken his vital signs, height, and weight. which phase of the nursing process do these activities describe?
A. assessment
what activities are performed during the assessment phase of the nursing process?
A. collecting data
you are working as a community health nurse, teaching a drug awareness program to fifth-grade students at a local school. which level of preventive health-care does this situation exemplify?
B. primary
in which situation would a focused assessment be most appropriate?
A. patient admitted with chest pain
when obtaining a health history, what would be the appropriate distance between you and the patient?
B. 3-4 feet
which of the following is the best example of an open-ended question?
B. what does the pain feel like?
you are obtaining an admission history, and you say "as you were saying, you came to the hospital for.." this statement is an example of:
D. redirecting
which of the following tasks are performed during the working phase of an interview?
C. collecting data
you are performing a cardiac assessment on your patient and you think u hear a murmur, but you are not sure. what would be the best way to validate your finding?
