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Fundamentals of Nursing Chapter 16
Nursing Assessment
19
Nursing
Undergraduate 2
01/30/2010

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Term
What is the nursing process?
Definition
a professional nurses approach to identify, diagnose, and treat human responses to health and illness.
Term
What are the 2 steps of nursing assesment?
Definition
Collection and verification of data from a primary source and secondary sources.

The analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care.
Term
What is the purpose of assessment?
Definition
establish a database about the client's perceived needs, health problems, and responses to these problems.
Term
What are the two approaches to a comprehensive assessment?
Definition
one involves use of a structured database format, based upon an accepted theoretical freamework or practice standard.
2) problem oriented approach.
Term
Where do you start in the problem oriented approach?
Definition
you start by focusing on the client's presenting situation and bgin with problematic areas, such as back pain, difficulty breathing, or apprehension over a procedure.
Term
What is subjective data?
Definition
data your patient verbally describes of their health problem.
Term
What is objective data?
Definition
observations or measurments of a client's health status
Term
Where can data be gathered from?
Definition
Client, Family and significant others, health care team, medical records, Other records and the literature, nurse's experience.
Term
During an initial interview with a patient what do you have a chance to do?
Definition
1) introduce yourself to the client, explain your role, and explain others role in HC
2) Establish a caring therapeutic relationship with the client
3) Get insight about the client's concerns and worries
4)determien the client's goals and expectation of the health care system
5) obtain cues about which parts of the data collection phase require further in-depth investigation.
Term
What is one important goal for the orientation stage?
Definition
to make the foundation for understanding the client's primary needs. Another is to begin a relationship that allows the client to become and active partner in decisions about care.
Term
What are non-verbal behaviors conductive to a nurse-client relationship?
Definition
client-directed eye gaze
Affirmative head nodding
Smiling
Forward leaning
touch
Term
What do you gather (information wise) during the working phase of a relationship?
Definition
information about the clients status
Term
What does the nursing health history include?
Definition
data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness.
Term
Why is back channeling important?
Definition
it shows you have active listening to the patient and are following the conversation.
Term
Why should a nurse probe to exhaustion?
Definition
to get the whole story, it also allows the client to end the conversation because they can think of no more things to say.
Term
What is the problem-seeking interview technique?
Definition
it takes the information the patient provides and then more fully describes and identifies specific problem areas.
Term
What is typically contained in a nursing health history?
Definition
Biographical information
Reason for seeking health care
client expectations
present illness or health concerns
health history
family history
environmental history
psychosocial history
spiritual health
review of systems documentation of history findings
Term
Why should you ask why the client is seeking HC?
Definition
because the subjective reason the client states may be different from what is on the form.
Term
Why should we ask what the clients expectations are?
Definition
because their expectations may be different from ours, failure to do this could result in poor client satisfaction.
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