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Definition
| The systematic and continuous collection, validation, analysis and communication of patient data |
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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 |
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| Identifies the patient's health status, strengths, health problems, health risks, and need for nursing care |
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| Assessment that targets data pointing to pathologic conditions |
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-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? |
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-Comprehensive Initial Assessment
-Focused Assessment
-Emergency Assessment
-Time Lapsed Assessment |
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Definition
| Types of Nursing Assessments: |
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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 |
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Definition
| Purpose of this assessment is to establish a complete database for problem identification and care planning |
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-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? |
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Definition
-Purpose of this assessment is to identify new or overlooked problems
-Routinely part of ongoing data collection |
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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 |
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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 |
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Term
-Health orientation
-Developmental stage
-Culture
-Need for nursing |
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Definition
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Term
-Establishing assessment priorities
-Systematically structuring data
collection |
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Definition
| Two important considerations when preparing for data collection: |
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Term
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Definition
| A standard established by healthcare institutions that specifies the information that must be collected from every patient |
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Definition
AKA symptoms or covert data
Ex: feeling nervous, nauseated, or chilly and experiencing pain |
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Definition
AKA signs or overt data
Ex: elevated temperature reading, skin that is moist, and refusal to look at or eat food |
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Term
-Purposeful
-Complete
-Accurate
-Factual
-Relevant |
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Definition
| Characteristics of Patient Data: |
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Term
-Patient
-Family & significant others
-Patient record
-Other healthcare professionals
-Nursing & other healthcare literature |
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Definition
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Term
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Definition
| The conscious and deliberate use of the five senses to gather data |
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Term
-Preparatory Phase
-Introductory Phase
-Working Phase
-Termination |
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Definition
| Phases of Patient Interview: |
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Term
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Definition
| In this phase the nurse prepares to meet the patient by reading current and past records and reports, when available |
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Definition
| In this phase, the nurse gathers all the information needed to form the subjective database |
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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 |
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-Physician's physical assessment is to identify pathologic conditions and their causes
-Nursing physical assessment focuses primarily on the patient's functional abilities |
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Definition
| Nursing Physical Assessment vs. Physicians Physical Assessment |
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Term
-appraisal of health status
-The identification of health problems
-The establishment of a database for nursing intervention |
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Definition
| Purposes of the nursing physical assessment: |
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Term
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Definition
| Physical examination of all body systems in a systematic manner as part of the nursing assessment |
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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 |
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Definition
| Common problems encountered during data collection: |
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Term
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Definition
-The act of confirming or verifying
-Purpose is to keep data as free from error, bias, and misinterpretation as possible |
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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 |
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Definition
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-Significant information that is helpful in making decisions
-Ex: Patient does not respond when I speak to him on his left side. |
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Definition
-The judgment/conclusion reached about a cue
-Ex: The patient's hearing may be impaired on his left side. |
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-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 |
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Definition
| Ways that inferences may be validated: |
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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) |
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Definition
| When does data need to be validated/verified? |
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