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Questions and Answers
In nursing, what is the primary role of health assessment?
In nursing, what is the primary role of health assessment?
- To strictly adhere to established protocols and guidelines.
- To delegate patient care tasks efficiently.
- To gather data for making informed clinical judgments. (correct)
- To minimize patient interaction time.
Which of the following is encompassed by the term 'health assessment'?
Which of the following is encompassed by the term 'health assessment'?
- Scheduling follow-up appointments.
- Gathering, analyzing, and synthesizing patient health status information. (correct)
- Documenting insurance information.
- Administering medication and treatments.
A nurse is collecting data from a patient. Per AACN what does a health assessment include?
A nurse is collecting data from a patient. Per AACN what does a health assessment include?
- A medication reconciliation and a review of systems
- A psychological profile and a nutritional analysis
- A detailed surgical report and a family history
- A health history and a physical assessment (correct)
A nurse is using a systematic approach to collect and analyze patient data. What is the purpose of this approach in nursing care?
A nurse is using a systematic approach to collect and analyze patient data. What is the purpose of this approach in nursing care?
While taking the patient's Health history, which of these factors should a nurse also consider?
While taking the patient's Health history, which of these factors should a nurse also consider?
During a health assessment, a nurse gathers information on various aspects of a patient's life. Which category includes the patient's marital status, occupation, and living arrangements?
During a health assessment, a nurse gathers information on various aspects of a patient's life. Which category includes the patient's marital status, occupation, and living arrangements?
A patient reports experiencing chest pain. What information is most important for the nurse to collect?
A patient reports experiencing chest pain. What information is most important for the nurse to collect?
A nurse is assessing a patient in an emergency department. What type of health assessment data would the nurse collect?
A nurse is assessing a patient in an emergency department. What type of health assessment data would the nurse collect?
What does performing a health assessment allow the nurse to do?
What does performing a health assessment allow the nurse to do?
How would you describe the nursing process?
How would you describe the nursing process?
Which phase of the nursing process is considered the first and most critical?
Which phase of the nursing process is considered the first and most critical?
A nurse analyzes and synthesizes patient data, and is making judgments about the effectiveness of nursing interventions. What process is the nurse following?
A nurse analyzes and synthesizes patient data, and is making judgments about the effectiveness of nursing interventions. What process is the nurse following?
What are the three key components of health assessment?
What are the three key components of health assessment?
What significantly influences the amount of information a nurse collects during a health history and physical examination?
What significantly influences the amount of information a nurse collects during a health history and physical examination?
During which part of the examination is it most appropriate to obtain information about subjective data?
During which part of the examination is it most appropriate to obtain information about subjective data?
When is subjective data considered to be a primary source?
When is subjective data considered to be a primary source?
During a physical examination, a nurse collects objective data. What is another term used to describe this type of data?
During a physical examination, a nurse collects objective data. What is another term used to describe this type of data?
A patient reports feeling nauseous. How is this information classified?
A patient reports feeling nauseous. How is this information classified?
When documenting data, what is a key characteristic the documentation should have?
When documenting data, what is a key characteristic the documentation should have?
Which of the following is a benefit of having complete, accurate, and descriptive documentation?
Which of the following is a benefit of having complete, accurate, and descriptive documentation?
What is the primary goal of electronic health records?
What is the primary goal of electronic health records?
A nurse is preparing to perform a health assessment for a patient in the clinic. What should you do first?
A nurse is preparing to perform a health assessment for a patient in the clinic. What should you do first?
What are the three common types of nursing assessments?
What are the three common types of nursing assessments?
In which situation would the nurse perform an emergency assessment?
In which situation would the nurse perform an emergency assessment?
Which mnemonic serves as an efficient basis for triage assessment in emergency situations?
Which mnemonic serves as an efficient basis for triage assessment in emergency situations?
When assessing a patient, the nurse assesses airway, breathing, circulation, disability, and exposure. What type of assessment is being performed?
When assessing a patient, the nurse assesses airway, breathing, circulation, disability, and exposure. What type of assessment is being performed?
What should a comprehensive assessment consist of?
What should a comprehensive assessment consist of?
When performing a comprehensive assessment, what would you do first?
When performing a comprehensive assessment, what would you do first?
Which of the following would be included in a comprehensive assessment/physical examination?
Which of the following would be included in a comprehensive assessment/physical examination?
When is it most appropriate to perform a focused assessment?
When is it most appropriate to perform a focused assessment?
What symptoms would a nurse focus on when performing a health history for a patient presenting to the clinic with a cough?
What symptoms would a nurse focus on when performing a health history for a patient presenting to the clinic with a cough?
What best describes clinical reasoning in nursing?
What best describes clinical reasoning in nursing?
What does the nurse do when health assessment is underway?
What does the nurse do when health assessment is underway?
What should a nurse do with the data after collecting and documenting it?
What should a nurse do with the data after collecting and documenting it?
How may data collected during a physical assessment be organized?
How may data collected during a physical assessment be organized?
What is the proper order of placing the list?
What is the proper order of placing the list?
Which factor most significantly influences a nurse's clinical judgment?
Which factor most significantly influences a nurse's clinical judgment?
What always takes higher priority?
What always takes higher priority?
A patient is deemed stable. What decides what needs to be top priority?
A patient is deemed stable. What decides what needs to be top priority?
What determines the frequency of assessments?
What determines the frequency of assessments?
A nurse is using health assessment to determine the extent to which a patient attains their optimum level of wellness. Which nursing goal does this describe?
A nurse is using health assessment to determine the extent to which a patient attains their optimum level of wellness. Which nursing goal does this describe?
A patient reports feeling anxious and having difficulty sleeping before a surgery. How should the nurse classify and address this data?
A patient reports feeling anxious and having difficulty sleeping before a surgery. How should the nurse classify and address this data?
After gathering and documenting patient data, the nurse must organize the information. Which approach demonstrates effective organization that facilitates clear problem identification?
After gathering and documenting patient data, the nurse must organize the information. Which approach demonstrates effective organization that facilitates clear problem identification?
What is the significance of reconciling a patient's medication list during a comprehensive health assessment?
What is the significance of reconciling a patient's medication list during a comprehensive health assessment?
A nurse is conducting a comprehensive assessment in a clinic. What should be prioritized when discussing a patient's history of illness?
A nurse is conducting a comprehensive assessment in a clinic. What should be prioritized when discussing a patient's history of illness?
A nurse notes that a patient's oxygen saturation is low, and they are using accessory muscles to breathe. Which action should the nurse prioritize following the assessment?
A nurse notes that a patient's oxygen saturation is low, and they are using accessory muscles to breathe. Which action should the nurse prioritize following the assessment?
Which one of the following scenarios reflects the use of clinical judgment by a nurse?
Which one of the following scenarios reflects the use of clinical judgment by a nurse?
The nurse is preparing to conduct a health assessment on an acutely ill patient. How does the seriousness of a patient's condition affect a physical assessment?
The nurse is preparing to conduct a health assessment on an acutely ill patient. How does the seriousness of a patient's condition affect a physical assessment?
Which nursing action exemplifies the principle that the nursing process should be thought of as circular rather than linear?
Which nursing action exemplifies the principle that the nursing process should be thought of as circular rather than linear?
After providing care, a nurse documents interventions and patient responses in the electronic health record. What is the primary reason for this action?
After providing care, a nurse documents interventions and patient responses in the electronic health record. What is the primary reason for this action?
A patient experiencing a stroke has difficulty communicating. What is the best action for the nurse to obtain an accurate patient history?
A patient experiencing a stroke has difficulty communicating. What is the best action for the nurse to obtain an accurate patient history?
A nurse is conducting an emergency assessment. Which assessment findings require the most immediate intervention?
A nurse is conducting an emergency assessment. Which assessment findings require the most immediate intervention?
A new graduate nurse wants to improve clinical judgment skills. Which strategy is most effective?
A new graduate nurse wants to improve clinical judgment skills. Which strategy is most effective?
In which scenario is a focused assessment most appropriate?
In which scenario is a focused assessment most appropriate?
When gathering subjective data for a health history, what should nurses primarily consider?
When gathering subjective data for a health history, what should nurses primarily consider?
Flashcards
Health Assessment
Health Assessment
A systematic method of collecting and analyzing patient data for planning patient-centered care.
Health Assessment
Health Assessment
gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes
Use Informatics
Use Informatics
A core competency involving the use of data to improve healthcare.
Patient Data
Patient Data
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Assessment Phase
Assessment Phase
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First Step - Assessment
First Step - Assessment
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Health Assessment Definition
Health Assessment Definition
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Nursing Process
Nursing Process
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Signs
Signs
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Symptoms
Symptoms
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Primary Source Data
Primary Source Data
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Secondary health data
Secondary health data
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Objective Data
Objective Data
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Frequency
Frequency
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Comprehensive physical examination
Comprehensive physical examination
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Standard of care
Standard of care
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Health record
Health record
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Health assessment
Health assessment
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Focused assessment
Focused assessment
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Documenting the findings
Documenting the findings
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The health record
The health record
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The emergency assessment
The emergency assessment
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Study Notes
- Health assessment, guided by Asst. Prof. Gizem Yağmur Yalçın, falls under the NUR111 lecture series.
Core Topics
- Health assessment introduction
- Examination of health
- Health assessment components
- Health & nursing assessments
- Clinical reasoning & judgement
- Data management & analysis
- Priority assignment
- Assessment frequency
Professional Nursing
- Professional nurses continuously make observations and gather data and use nursing judgement.
- Nursing assessment is performed to influence the health status of patients, families, and communities.
- The setting is irrelevant, the process is still important for nurses to collect data and use their nursing judgment.
Nursing Fundamentals
- Protecting the the patient, promotion of health, and optimizing abilities
- Preventing illness and injury
- Advocating for individuals, families, and communities
- Alleviating suffering through treatment
Core Competencies
- Providing patient-centered care is crucial
- Working in interdisciplinary teams
- Using evidenced-based practice
- Applying quality improvements
- Using informatics
Patient-Centered Care
- Care needs to be patient-centered
- Provide a diagnosis and devise treatment for human responses
- Base accurate client assessments on how effective nursing interventions are
- Promote health and prevent illness and injury
Health Assessment Defined
- A systematic method for gathering and analyzing patient data to plan patient-centered care.
- Nurses compare health data with the ideal, considering the patient's age, gender, culture, ethnicity, and socioeconomic status.
- Patient strengths, weaknesses, health problems, and deficits are identified and addressed.
- The nurse incorporates the patient's knowledge, motivation, support systems, coping ability, and preferences into the plan.
Health Assessment
- Gathering health status information, analyzing data, making judgements on nursing interventions, and evaluating patient care outcomes
- Incorporate a health history and physical assessment
- First step in dynamic delivery of patient care, gathering basic information about the patient and analyzing
Assessment Includes
- Physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors
Assessment Dynamics
- Assessment is dynamic
- Assessment varies depending on the seriousness of a patient's condition, health history, and current symptoms.
- Assessments in emergencies will help pinpoint the source of the issues and treat the current conditions.
Health Assessment Performance
- Used for further insight into a patient’s condition
- Used to establish a database against future assessment
- to identify patterns and trends to determine whether a patient’s condition is improving or worsening, as well as what interventions should be made
- Allows for continuous evaluation of the patient
Nursing Process Defined
- A systematic approachto identifying and treating health issues
- Provides individualized care to individuals, but also families and communities
- Patient-centered and focuses on fixing problems and enhancing strengths.
- Applicable no matter the stage of life or setting
Nursing Process:
- Assessing the patient
- Analyze patient data
- Diagnosing patient
- Determine outcomes
- Caring for the patient
- Adjusting plan
- Implementing changes
American Nurses Association (ANA) Standards of Practice
Assessment Process
- The first and most critical phase in nursing
- Critical that data collection is accurate
- Must be ongoing and continuous
Health Assessment Defined
- More than information gathering, involving client judgements
- Analyzes and synthesizes effectiveness of outcomes
- Should be thought of as circular rather than linear
Health Assessment Components
- Conducting a health history
- Doing physical examination
- Reviewing health records
- Documenting findings
Key Steps
- Data analysis and interpretation lead to patient-centered plans
- This will depend on patient setting and needs
Clinical Holistic Health Assessment Approach
- Collect health history
- Perform a physical examination
- Analyze & interpret data
- Document the data
- Develop a plan of care
Health History
- A health history consists of subjective data
- Data is collected during interviews.
- Details the patient’s current state of health, medications, illnesses, surgeries, family and psychosocial history, and a review of their systems
- Documented feelings or experiences are tracked
Subjective Data
- Called ''Symptoms"
- Primary source comes directly from the patinet
- Secondary source comes from a family member
Signs vs Symptoms
- signs are measured where as symptoms are reported
Physical Examination
- Involves the collection of Objective Data, reffered to as ''Signs''
- Includes inspection, palpation, percussion, and auscultation.
- Includes weight, height, pulse rate, blood pressure, respiratory rate and oxygen saturation
Data Documentation
- Health assessment data must be documented at the time of the health care encounter
- Health care information must be shared
- Documentation improves the care and prevents patients repeating information
- Serves as the legal record of the patient
- Should be accurate, concise and with out opinion
Data Recording Guidlines
- Document electronically
- Documentation must allow for information to be reviewed from multiple records
Nursing Assessment Types
- Emergency, comprehensive & focused
- Emergency & Focused are based on immediate problem
- Comprehensive is more broad and complete
- Type of information varies on data collection as well as nurse abilities
Emergency Assessment
- Centers on life-threatening conditions
- Use of a triage system to determine level of importance A-Airway B-Breathing C-Circulation D-Disability E-Exposure
- Assessments and critical interventions are performed at once.
Comprehensive Assessment Defined
- includes a complete health history as well as physical assessments
- Clarification is critical to accurate assessment
- Date of diaogneses and treatment must be recorded
- Must contain patient's views on health, strengths, risk factors, function, methods and support
- Important to reconcile medications with patient
- Secondary data is critical when patient can't undergo data
Comprehensive Physical Examinations:
- Head-to-toe format
- Includes analysis of arms, legs, head, neck and all systems
- Rectal and Genital assessments are optional
Focused Assesment
- Centers on the patients issues
- Typically smaller in scope than comprehensive assessments
- A patient presenting a cough is an example
- Health must focus on the nose, lungs etc..
Judgement:
- Is a portrait of a patients health, abilities and resources
- Includes analysis and interpretation
- Must not just be a task
- All information is to benefit the patient
Clinical Judgement
- Critical for monitoring changes
- Be aware of change
Data Organization
- Nurses must document so all issues are solved
- Can be done by body
Data Analysis
- Used to find expected and abnormal findings
- Helps nurses solve issues for patients
Clinical Judgement Defined
- Defined as the interpretation or conclusion about patient's need and helath
- Interpretation guides the nursing actions
- Influenced by experience
Priority Settig
- Take priority always
- Should be determined by expertis and judgement
- Should be determined by patient
Assesment Frequency
- Varies depending on data collection
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