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Unit 1 - Assessment
Test 1
20
Nursing
Undergraduate 3
01/31/2014

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Cards

Term
What is an assessment?
Definition
The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of the individual, group, or community.
Term
What is an initial assessment?
Definition
Information gathered from the patient that goes into the database. Nursing history interview & physical examination.
Term
What is an ongoing assessment?
Definition
Patient's progress. Interview. Examination and observation.
Term
What is a comprehensive assessment?
Definition
Provides holistic information about the client's overall health status.
Term
What is a focused assessment?
Definition
Performed to obtain data about an actual, potential, or possible problem that has been identified or suspected.
Term
What is an initial focused assessment?
Definition
Follow up on the client reported symptoms or unusual findings during the first examination.
Term
What is an ongoing focused assessment?
Definition
Evaluate the status of existing problems and goals.
Term
What is a special needs assessment?
Definition
A type of focused assessment. Provides info about a particular area of the client functioning and often involves using a specially designed form.
Term
What are some examples of a special needs assessment?
Definition
Nutritional, pain, fxnal abilty, cultural, spiritual, psychosocial, wellness, family, community.
Term
What does a physical assessment produce?
Definition
Objective data.
Term
What are the 4 skills used during a physical assessment?
Definition
1.) Inspection - visual
2.) Palpation - light touch
3.) Percussion - striking a body surface
4.) Auscultation - listening w or w/o stethoscope
Term
According to JAICO, the assessment is identified as?
Definition
An essential element of patient care. Must be performed within 24 hours of inpatient admission.
Term
What are the standards of assessment set by JAICO?
Definition
Must be written, comprehensive, and used to identify and assign priorities for care.
Term
Agency policy designates what 2 things?
Definition
1.) When each patient is to be reassessed
2.) Which disciplines can make which assessments
Term
Who is assessed for pain?
Definition
All patients!
Term
Who can perform a full comprehensive assessment?
Definition
ONLY NURSES! CNA/LPN can provide contributing information to the assessment that is done by the nurse.
Term
What is subjective data?
Definition
The information communicated to the nurse by the client, family, or community. Reveals the perspective of the person giving the data and includes thoughts, feelings, beliefs and sensations.
Term
Why is subjective data not always valid?
Definition
Some people are unable to provide it, and others can provide it but it is questionable.
Term
What is objective data?
Definition
Gathered through physical assessment or lab/diagnostic tests.
Term
When should you validate data?
Definition
1.) When sub and ob do not match or make sense together
2.) The patient's statements differ at different times
3.) The data is outside of the normal range
4.) Factors are present that interfere with accurate measurement.
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