Term
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Definition
| The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of the individual, group, or community. |
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Term
| What is an initial assessment? |
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Definition
| Information gathered from the patient that goes into the database. Nursing history interview & physical examination. |
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Term
| What is an ongoing assessment? |
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Definition
| Patient's progress. Interview. Examination and observation. |
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Term
| What is a comprehensive assessment? |
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Definition
| Provides holistic information about the client's overall health status. |
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Term
| What is a focused assessment? |
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Definition
| Performed to obtain data about an actual, potential, or possible problem that has been identified or suspected. |
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Term
| What is an initial focused assessment? |
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Definition
| Follow up on the client reported symptoms or unusual findings during the first examination. |
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Term
| What is an ongoing focused assessment? |
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Definition
| Evaluate the status of existing problems and goals. |
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Term
| What is a special needs assessment? |
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Definition
| A type of focused assessment. Provides info about a particular area of the client functioning and often involves using a specially designed form. |
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Term
| What are some examples of a special needs assessment? |
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Definition
| Nutritional, pain, fxnal abilty, cultural, spiritual, psychosocial, wellness, family, community. |
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Term
| What does a physical assessment produce? |
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Definition
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Term
| What are the 4 skills used during a physical assessment? |
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Definition
1.) Inspection - visual
2.) Palpation - light touch
3.) Percussion - striking a body surface
4.) Auscultation - listening w or w/o stethoscope |
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Term
| According to JAICO, the assessment is identified as? |
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Definition
| An essential element of patient care. Must be performed within 24 hours of inpatient admission. |
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Term
| What are the standards of assessment set by JAICO? |
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Definition
| Must be written, comprehensive, and used to identify and assign priorities for care. |
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Term
| Agency policy designates what 2 things? |
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Definition
1.) When each patient is to be reassessed
2.) Which disciplines can make which assessments |
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Term
| Who is assessed for pain? |
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Definition
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Term
| Who can perform a full comprehensive assessment? |
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Definition
| ONLY NURSES! CNA/LPN can provide contributing information to the assessment that is done by the nurse. |
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Term
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Definition
| The information communicated to the nurse by the client, family, or community. Reveals the perspective of the person giving the data and includes thoughts, feelings, beliefs and sensations. |
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Term
| Why is subjective data not always valid? |
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Definition
| Some people are unable to provide it, and others can provide it but it is questionable. |
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Term
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Definition
| Gathered through physical assessment or lab/diagnostic tests. |
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Term
| When should you validate data? |
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Definition
1.) When sub and ob do not match or make sense together
2.) The patient's statements differ at different times
3.) The data is outside of the normal range
4.) Factors are present that interfere with accurate measurement. |
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