Glossary of Ch. 15 - Nursing Assessment
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- Allows nurse to integrate element of critial thinking to make judgements and take actions based on reason.
- Nursing Process
- Used to identify, diagnose, and treat human responses to health and illness.
- Nursing Process
- What are the 5 steps to the nursing process?
- 1. Assessment
2. Diagnosis (Nursing)
- The deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
- 2 Steps in assessment:
- 1. Collection and verification of data from client.
2. Analysis of all data as basis for developing a nursing diagnosis and plan of care.
- Information that the nurse acquires through use of the five senses.
- Clients' perceptions about their health problems. Only client can provide this type of information.
- Subjective data
- Observations and measurements made by the data collector, i.e., nurse.
- Objective data
- Sources of Data:
Health Care Team Members
- Usually the best source of data (information)
- Can supply information about the client's current health status, but also are often able to indicate when changes in the client's status occurred and how the clien'ts functioning was affected.
- Family/Significant Others
- Provide information about the way the client interactas within the health care environment; the client's reatctionto information, diagnostic procedures, nursing and medical therapies, and how the client responds to visitors.
- Health Care Team Memebers
- Educational, military, and employment records that contain pertinent health care information.
- Other Records
- Nursing, medical, and pharmacological readings about a client's illness that helps the nurse complete the assessment database.
- Literature Review
- Helps nurse learn to ask right questions, choosing those taht yield the most useful information.
- Nurse's Experience
- Methods of Data Collection
- 1. Interview
2. Nursing Health History
3. Documentation of History Findings
4. Physical Examination
5. Diagnostic/Laboratory Data
- Organized converstation with thte client to obtain the client's health history and information about the current illness.
- Phases of and Interview:
- 1. orientation
- Begins with the nurse's introduction to the client, which includes the nurse's name, position, and an explanation of the purpose of the interview.
- Orientation Phase
(important in establishing trust and confidence with a client)
- When nurse gathers info. about the client's health status.
- Working Phase
- Nurse summarizes important points an asks the client whether the summary was accuarate, after giving the client a clue that the interview is coming to an end.
- Termination Phase
- Interview Techniques:
- 1.Pay attention to environment
- Questions that prompt client to describe a situation in more than one or two words and leads to a discussion.
- Open-ended questions
- Active listening techniques such as saying "all right," "go on," or "un-huh," which indicates the nurse has heard what the client said and encourages even further elaboration.
- Back Channeling
- Takes the information provided in the client's story to more fully describe and identify the client's specific problems.
- Problem-seeking interview
- Questions that limit the client's answers to one or two words such as "yes" or "no" or a number or frequency of a symptom.
- Close-ended questions
- Data collected 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.
- Nursing Health History
- Components of Nursing Health History:
- 1.Biographical Info.
2.Reason for seeking health care
3. Client Expectations
4. Present Illness or Health Concerns.
5. Health History
6. Family History
7. Environmental History
8. Psychosocial History
9. Spiritual Health
10. Review of Systems
- Factual demographic data about the client
- Biographical Information
- Why client is sekking health care, because the info. contained on the initial admission form may differ from the client's subjective reason for seeking health care.
- Reason for seeking health care
- Acknowledging what is important to the client who is seeking health care
- Client Expectations
- Essential and relevant data about the nature and onset of symptoms.
- Present Illness or Health Concerns
- Client's health care experiences and current health habits
- Health History
- Data about immediate and blood relatives
- Family History
- Data about client's home and working environments with emphasis on determining the client's safety.
- Environmental History
- Data that reveals the client's support system, which may include spouse, children, other family members, and close friends
- Psychosocial History
- Data that represents the totality of one's being and is difficult to assess quickly.
- Spritual Health
- Systematic method for collecting data on all the body systems.
- Review of systems
- Recording the nursing health history, assessment datat in a clear, concise manner using appropriate terminology.
- Documentation of History Findings
- Vital signs and other objective measurements are taken and all body systems are examined.
- Physical examination
- Physical Examination Techniques:
- inspection, palpation, percussion, auscultation, and olfaction
- Can identify or verify alterations questioned ro identified during the nursing health history and physical examination.
- Diagnostic or Laboratory Data
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