Term
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Definition
| specify what data are collected and by whom. Agency policy may set time frames for when assessments should be done and how they should be documented. Nursing knowledge identifies “how” data are to be collected. The Joint Commission sets detailed standards regarding what and when to assess. |
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Term
| When should information be validated? |
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Definition
| When the client’s statements are inconsistent. Not necessary for lab data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale. |
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Term
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Definition
| what someone other than the patient can observe (e.g., from physical assessments or lab and diagnostic tests). |
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Term
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Definition
| information given by the client. |
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Term
| What does the Joint Commission require |
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Definition
| requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors. |
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Term
| What is an ongoing assessment? |
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Definition
| when a previously identified problem is being reassessed. |
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Term
| What is a focused assessment |
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Definition
| xamining the mouth is a focused assessment to explore the patient’s complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. |
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Term
| What is a special needs assessment |
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Definition
| A detailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing. |
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Term
| How often should the nurse make observations about the patient |
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Definition
| each time she enters the room to gain ongoing data about the patient and detect problems early. |
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Term
| What is the benefit to open ended questions |
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Definition
| are broad so as to encourage the patient to elaborate |
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Term
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Definition
| focuses the attention on the patient and lets her know you are trying to understand her needs. |
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Term
| Name the human needs from most basic to highest |
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Definition
| is physiologic; safety and security; love and belonging; esteem; and self-actualization. |
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Term
| What does medical history focus on? |
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Definition
| the patient’s current and past medical/surgical problems |
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Term
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Definition
| on the patient’s responses to and perception of the illness/injury, his coping ability, and resources and support. |
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Term
| Interactions of herbs and nutritional supplements |
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Definition
| can interact with prescription medications |
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Term
| Interactions of complementary and alternative treatments |
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Definition
| can interfere with conventional therapies. |
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Term
| Tests that assess nutritional deficiency |
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Definition
| Physical assessment and laboratory tests |
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Term
| Nondirective interviewing |
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Definition
| helps build rapport and facilitates communication. Because it puts the patient in control, it can be very time consuming (inefficient) and produce information that is not relevant. |
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Term
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Definition
| should be used to focus anxious patients. |
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