Health assessment ch. 1
Studied by 0 people
Call with Kai
Learn
Practice Test
Spaced Repetition
Match
Flashcards
Knowt Play1/50
There's no tags or description
Looks like no tags are added yet.
Name | Mastery | Learn | Test | Matching | Spaced | Call with Kai |
|---|
No study sessions yet.
51 Terms
What type of data is gathered using the nurse’s five senses?
Objective data
What type of data comes from what the patient says about feelings or pain?
Subjective data
Which step of the nursing process comes first?
Assessment
Which step of the nursing process involves professional judgment?
Diagnosis
Which step sets goals and plans care?
Planning
Which step performs interventions?
Implementation
Which step evaluates goal achievement?
Evaluation
What does assessment primarily involve?
Collecting subjective and objective data
Why is assessment the most important step?
Errors lead to inaccurate clinical judgments
When does assessment occur?
Continuously throughout all phases of care
What does physical medical assessment focus on?
Physiologic development and status
What does holistic nursing assessment include?
Mind, body, and spirit
What is the goal of holistic assessment?
Determine overall level of functioning
What are the four basic sections of a health framework?
Present concern, personal history, family history, lifestyle and practices
What guides evidence-based health promotion?
Healthy People 2030
What organization evaluates screening risks and benefits?
USPSTF
What assessment is done at first contact?
Initial comprehensive assessment
What determines frequency of comprehensive assessments?
Age, risks, health status, lifestyle
What assessment is a mini overview?
Ongoing or partial assessment
What assessment focuses on one problem?
Focused assessment
What assessment is used in life-threatening situations?
Emergency assessment
What is the goal of emergency assessment?
Prevent death with prompt treatment
What are the four steps of health assessment?
Collect subjective data, collect objective data, validate data, document data
Why do assessment steps overlap?
Nurses often perform steps at the same time
What should the nurse do before assessing?
Review record and organize materials
Why should the nurse reflect before meeting a client?
Identify personal feelings and bias
What is included in subjective data collection?
Biographical info, symptoms, histories, lifestyle, review of systems
What is included in objective data collection?
Appearance, behavior, measurements, lab results
What ensures accuracy of assessment data?
Validation
Why is validation important?
Prevents inaccurate documentation
What is the purpose of documentation?
Forms the database for the nursing process
Who uses documented data?
All healthcare team members
What are cues?
Pieces of patient information
What are abnormal cues?
Findings outside normal limits
What are supportive cues?
Findings confirming a problem
What does clustering cues mean?
Grouping related signs and symptoms
Why do nurses draw inferences?
Identify and prioritize client concerns
When does a nurse notify a provider?
When collaborative problems are identified
When does a nurse refer a patient?
When care is beyond nursing scope
Why must conclusions be documented?
Ensure continuity and accuracy of care
What factors influence health assessment?
Culture, family, community
Why must nurses be self-aware during assessment?
Prevent bias or “poker face” responses
What happens if assessment is incomplete?
Incorrect clinical judgments occur
What is more than just gathering information?
Nursing assessment
What makes assessment holistic?
Considering interdependent mind-body-spirit factors
What helps screen for health risks?
Evidence-based tools
What does reviewing team input before assessment do?
Improves accuracy of care
What does organizing supplies before assessment prevent?
Delays and interruptions
What supports proper nursing judgment?
Accurate assessment data
What ensures the assessment process is not ended early?
Validation
What links assessment to the rest of the nursing process?
Documentation