Chapter 3

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Nursing process: assessment
updated 3 years ago by Julie_Wardia
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1

Assessment is:

The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group or community

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Assessment includes:

Collecting data, using a systematic and ongoing process, categorizing data, and recording data

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Assessment helps diagnosis by:

the data is used to identify the client's actual or potential health problems and strengths

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Assessment helps planning outcomes by:

helping you formulate realistic goals

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Assessment helps planning interventions by:

choosing the interventions most likely to be acceptable to and effective for the client

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Assessment helps implementation by:

gathering data by observing the client's responses as you perform interventions

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Assessment helps evaluation by:

assessing client responses to interventions.

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Medical assessments focus on:

disease and pathology

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Nursing assessments focus on:

the client's responses to illness

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How are data used?

By other disciplines, to plan for nursing care, to ensure clients receive: the proper car, by qualified individuals, at the time it is needed

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The ANA's cod of ethics nor Nurses provision 4 (2001), states:

The nurse... determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.

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Types of assessments:

initial, special needs, focused, ongoing, and comprehensive.

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What is comprehensive assessment?

Consists of a complete nursing history and physical examination; contains subjective and objective data

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Initial assessment is:

to be completed when the client first comes to the healthcare agency

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Ongoing assessment is:

performed as needed at any time after the intial database is completed

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Comprehensive assessment:

provides holistic information about the client's overall health status

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Comprehensive assessment includes:

Subjective and objective data, emotional status, functional abilities, & psychosocial stiuation

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Focused assessment:

performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected

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Special needs assessment is a :

type of focused assessment

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Special needs assessment provides:

in-depth info about a particular area of client functioning and often involves using a specially designed form.

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Types of special needs assessment are:

nutrition, pain, cultural, spiritual, psychosocial, wellness, family, and community

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Nutritional assessment is:

done when data suggests that the clients are undernourished at risk for imbalanced nutrition

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Pain assessment is:

should be always ongoing

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Cultural assessment is:

awareness of cultural influences

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Spritual assessment is:

an insight into how a client interprets life events and health

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Psychosocial assessment is:

data about lifestyle

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Wellness assessment is:

activities of a well person to achieve a higher level of health

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Family assessment is:

family interactions

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Community assessment:

provides info about community demographics

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The nursing intervention includes:

purposeful communication, structured communication, involves questioning the client. and the purpose is to gather subjective data for the nursing database

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Directive interviewing is also known as:

open questions

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Nondirective interviews are also known as:

closed questions

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Directive interviewing is to:

obtain factual, easily categorized information

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Nondirective interviewing allows:

the client to control the subject matter, nurse's role is to clarify and summarize

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Subjective data

information communicated to the nurse by the client, family or community

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Objective data

gathered through a physical assessment or from laboratory or diagnostic tests

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Primary data

the subjective and objective data obtained from the client: what the client says or what you observe

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Secondary data

obtained "second-hand" for example, from the medical record or from another caregiver.

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Physical assessment

produces primarily objective data and makes use of: inspection, palpation, percussion, and auscultation

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Inspection

observation and visual examination of the client, as well as use of equipment such as an otoscope or ophthalmoscope

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Palpation

Light touch, progressing to deeper touch, using the pads of the fingers

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Percussion

Striking a body surface with the tip of a finger, which produces different vibrations and sounds depending on what is under the area that is tapped

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Auscultation

Listening with the unaided ear for sounds made by the client and listening with the use of a stethoscope for normal and abnormal sounds within the body