Podcast
Questions and Answers
The first step in health assessment is the collection of ______ data through interview and health history
The first step in health assessment is the collection of ______ data through interview and health history
subjective
Nurses play a crucial role in health assessment by collecting both ______ and objective data
Nurses play a crucial role in health assessment by collecting both ______ and objective data
subjective
Physical examination techniques include ______, positioning, and IPPA
Physical examination techniques include ______, positioning, and IPPA
preparation
Validation of data is an important step to ensure the ______ of the information collected
Validation of data is an important step to ensure the ______ of the information collected
Holistic nursing assessment includes evaluation of general status, vital signs, and ______
Holistic nursing assessment includes evaluation of general status, vital signs, and ______
Assessment of pain, violence, culture, and spirituality falls under the ______ aspect of health assessment
Assessment of pain, violence, culture, and spirituality falls under the ______ aspect of health assessment
Documentation of data can be done through written notes or ______ documentation
Documentation of data can be done through written notes or ______ documentation
Flashcards
Subjective data
Subjective data
Information a patient tells you about their health, collected through interviews and history-taking.
Collecting subjective and objective data
Collecting subjective and objective data
Nurses gather data about a patient's health, which includes what they say (subjective) and what the nurse observes (objective).
Physical examination preparation
Physical examination preparation
The process of getting ready to examine a patient, including positioning them comfortably for the examination.
Data validation
Data validation
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Holistic nursing assessment
Holistic nursing assessment
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Psychosocial aspect of health assessment
Psychosocial aspect of health assessment
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Documentation of health assessment data
Documentation of health assessment data
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Study Notes
Overview of Nursing Process
- The nursing process is represented by the acronym ADPIE, which stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation.
Health Assessment in Nursing Practice
- There are four types of health assessments:
- Initial or Comprehensive Assessment
- On-going or Partial Assessment
- Focused or Problem-Oriented Assessment
- Emergency Assessment
Nurses' Role in Health Assessment
- The nurses' role in health assessment involves collecting subjective and objective data, validating the data, and documenting the findings.
Steps in Health Assessment
- Collection of Subjective Data:
- Includes interview and health history
- Covers 10 areas:
- Biographic data
- Reason for seeking health care
- Chief complaint
- History of present illness
- Past health history
- Family health history
- Current medications
- Lifestyle
- Developmental level
- Psychosocial history
- Collection of Objective Data:
- Includes physical examination, preparation, positioning, and techniques (IPPA)
- Includes diagnostic tests and procedures
- Includes other sources, such as client charts
- Validation of Data:
- Ensuring accuracy and reliability of collected data
- Documentation of Data:
- Guidelines for documentation include written notes and electronic documentation
- Important for maintaining accurate and reliable records
Holistic Nursing Assessment
- Includes general status and vital signs
- Covers mental status for:
- Children and adolescents
- Adults
- Includes psychosocial, cognitive, and moral development
- Covers pain, violence, culture, and ethnicity
- Covers spirituality and religious beliefs
- Covers nutritional status
- Assessment of the skin or integumentary system
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