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Nursing Foundations
Taylor Ch. 12 - Assessment
34
Nursing
Undergraduate 2
09/02/2013

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Term
Assessing
Definition
The systematic and continuous collection, validation, analysis and communication of patient data
Term
Database
Definition
-Includes all the pertinent patient info collected by the nurse and other healthcare professionals

-Enables a comprehensive and effective plan of care to be designed and implemented for the patient
Term
Nursing History
Definition
Identifies the patient's health status, strengths, health problems, health risks, and need for nursing care
Term
Medical Assessment
Definition
Assessment that targets data pointing to pathologic conditions
Term
Nursing Assessment
Definition
-Assessment that focuses on the patient's responses to actual or potential health problems

-Ex: Is there interference with the patient's ability to meet basic human needs? Can the patient perform the activities of daily living?
Term
-Comprehensive Initial Assessment
-Focused Assessment
-Emergency Assessment
-Time Lapsed Assessment
Definition
Types of Nursing Assessments:
Term
Initial Assessment
Definition
Assessment that consists of collecting data concerning all aspects of the patient's health, establishing priorities for ongoing focused assessments and creating a reference for future comparison
Term
Initial Assessment
Definition
Purpose of this assessment is to establish a complete database for problem identification and care planning
Term
Focused Assessment
Definition
-Assessment where the nurse gathers data about a specific problem that has already been identified

-Helpful Questions: Symptoms? When did they start? What makes your symptoms better/worse? Taking any remedies (medical or natural) for symptoms?
Term
Focused Assessment
Definition
-Purpose of this assessment is to identify new or overlooked problems

-Routinely part of ongoing data collection
Term
Emergency Assessment
Definition
-Purpose of this assessment is to identify life threatening problems when a physiologic or psychological crisis presents

-Examples: Nursing home resident who begins choking, a bleeding patient brought to the ER w/ stab wound, an unresponsive patient in the rehabilitation unit, a factory worker threatening violence
Term
Time-Lapsed Assessment
Definition
-Assessment scheduled to compare a patient's current status to baseline data obtained earlier

-Most patients in residential settings or home bound patients are scheduled to reassess health status and make necessary revisions in the plan of care
Term
-Health orientation
-Developmental stage
-Culture
-Need for nursing
Definition
Assessment Priorities:
Term
-Establishing assessment priorities

-Systematically structuring data
collection
Definition
Two important considerations when preparing for data collection:
Term
Minimum Data Set
Definition
A standard established by healthcare institutions that specifies the information that must be collected from every patient
Term
Subjective Data
Definition
AKA symptoms or covert data

Ex: feeling nervous, nauseated, or chilly and experiencing pain
Term
Objective Data
Definition
AKA signs or overt data

Ex: elevated temperature reading, skin that is moist, and refusal to look at or eat food
Term
-Purposeful
-Complete
-Accurate
-Factual
-Relevant
Definition
Characteristics of Patient Data:
Term
-Patient
-Family & significant others
-Patient record
-Other healthcare professionals
-Nursing & other healthcare literature
Definition
Sources of Data:
Term
Observation
Definition
The conscious and deliberate use of the five senses to gather data
Term
-Preparatory Phase

-Introductory Phase

-Working Phase

-Termination
Definition
Phases of Patient Interview:
Term
Preparatory Phase
Definition
In this phase the nurse prepares to meet the patient by reading current and past records and reports, when available
Term
Working Phase
Definition
In this phase, the nurse gathers all the information needed to form the subjective database
Term
Physical Assessment
Definition
-The examination of the patient for objective data that may better define the patient's condition and help the nurse in planning care

-Usually follows the interview, and may verify data gathered during the history or yield new data
Term
-Physician's physical assessment is to identify pathologic conditions and their causes

-Nursing physical assessment focuses primarily on the patient's functional abilities
Definition
Nursing Physical Assessment vs. Physicians Physical Assessment
Term
-appraisal of health status
-The identification of health problems
-The establishment of a database for nursing intervention
Definition
Purposes of the nursing physical assessment:
Term
Review of Systems (ROS)
Definition
Physical examination of all body systems in a systematic manner as part of the nursing assessment
Term
-Inappropriate organization of the database
-Omission of pertinent data
-Inclusion of irrelevant or duplicate data
-Erroneous or misinterpreted data
-Failure to establish rapport and partnership
-Recording an interpretation of data rather than observed behavior
-Failure to update the database
Definition
Common problems encountered during data collection:
Term
Validation
Definition
-The act of confirming or verifying

-Purpose is to keep data as free from error, bias, and misinterpretation as possible
Term
1. Identify assessment priorities determined by the purpose of the assessment and the patient's condition
2. Organize or cluster the data to ensure systematic collection
3. Establish the database
4. Continuously update the database
5. Validate data
6. Communicate data
Definition
Assessing Process:
Term
Cue
Definition
-Significant information that is helpful in making decisions

-Ex: Patient does not respond when I speak to him on his left side.
Term
Inference
Definition
-The judgment/conclusion reached about a cue

-Ex: The patient's hearing may be impaired on his left side.
Term
-Physical exam, using the proper equipment and procedure
-Clarifying statements
-Sharing your inferences with other respected members of the team and seeking consensus
-Checking your findings with research reports, textbooks, or journals
-Comparing cues to knowledge base of normal function
-Checking consistency of cues
Definition
Ways that inferences may be validated:
Term
-When there are discrepancies between what the person is saying and what the nurse is observing

-When data lacks objectivity (ex: suspected hearing loss in one ear -- validate before proceeding -- Suspicions are not objective)
Definition
When does data need to be validated/verified?
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