Steps of Health Assessment: Subjective and Objective Data

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Questions and Answers

What is the primary focus of the Nursing Process?

Holistic data collection

Problem solving and decision making (correct)

Food and fluid intake

Client's physiological status

Which step of the Nursing Process involves determining outcome criteria and developing a plan?

Diagnosis

Planning (correct)

Implementation

Assessment

What is the main characteristic of the Nursing Process according to the text?

Physiological assessment

Client Centered

Interpersonal and Collaborative

Cyclic and Dynamic (correct)

What types of data are collected during a holistic data collection by nurses?

Physiological, psychologic, sociocultural, developmental, spiritual Signup and view all the answers

Which healthcare professional focuses primarily on the client's musculoskeletal system?

Physical Therapist Signup and view all the answers

What is the purpose of the Evaluation step in the Nursing Process?

"Was the plan met/effective" or "does it need revision?" Signup and view all the answers

What are the four physical examination techniques used to obtain objective data?

Inspection, Palpation, Percussion, Auscultation Signup and view all the answers

Why is validation of assessment data important?

To ensure accurate assessment data Signup and view all the answers

What is the purpose of documenting assessment data?

To form the database for the nursing process Signup and view all the answers

What is the main focus of the nursing interview?

Gathering holistic information on the client Signup and view all the answers

During which phase do nurses review the client's medical record?

Preintroductory Phase Signup and view all the answers

What are the physical characteristics that can be observed during a health assessment?

Skin Color and Posture Signup and view all the answers

When does the 'Ongoing' assessment typically take place?

After a nurse encounters the client Signup and view all the answers

What is the purpose of the 'Emergency' assessment?

To determine the client's life-sustaining physical function status Signup and view all the answers

When should the 'Focused' assessment be conducted?

After a client comes in with a special concern Signup and view all the answers

Where is the 'Collection of objective data' typically gathered?

Hospital, clinic, school, or home setting Signup and view all the answers

What type of data is collected during the 'Preparing for the Assessment' phase?

Verbalized and verified by the patient Signup and view all the answers

What is included in subjective data according to the text?

Client's personal information and beliefs Signup and view all the answers

What information should be included in the Biographical Data of a client?

Name, address, phone number, gender Signup and view all the answers

Why is the Family Health History considered important?

To identify health problems that may have affected the client due to family exposure Signup and view all the answers

What should an assessment of the Review of Systems for Current Health Problems focus on?

Client's subjective information Signup and view all the answers

What does the Lifestyle and Health Practices Profile include?

Substance Use information Signup and view all the answers

Which aspect is covered in the Nutrition and Weight Management section of the assessment?

Average 24-hour intake recall Signup and view all the answers

Why does the assessment of Sleep and Rest matter?

To assess if the client is getting enough sleep and rest Signup and view all the answers

What is the purpose of silence periods during a client interview?

To reflect and organize thoughts for accurate reporting Signup and view all the answers

Which type of question is best suited to elicit a client's feelings and perceptions?

Open-ended questions Signup and view all the answers

What is the benefit of using rephrasing during a client interview?

To reflect on and clarify information provided by the client Signup and view all the answers

Which technique involves providing the client with a list of words to choose from?

Laundry List Signup and view all the answers

How can verbal communication be described in a client interview?

Essential for effective communication in a client interview Signup and view all the answers

Which action encourages the client to continue sharing information during the interview?

'Uh-huh', 'yes', or 'I agree' phrases Signup and view all the answers

Study Notes

Nursing Process Overview

The primary focus is on delivering comprehensive client care through a systematic approach.
A key characteristic is its dynamic, continuous nature, emphasizing the need for ongoing reassessment.

Steps in the Nursing Process

The planning step involves determining outcome criteria and developing a personalized care plan for the client.
Evaluation aims to assess the effectiveness of nursing interventions and the client's progress towards goals.

Data Collection in Nursing

Holistic data collection includes physical, psychological, social, and spiritual dimensions of the client’s health.
Objective data is gathered using four examination techniques: inspection, palpation, percussion, and auscultation.

Importance of Data Validation and Documentation

Validation of assessment data ensures accuracy and reliability, preventing misinformation.
Documenting assessment data is crucial for maintaining continuity of care and legal accountability.

Client Interview Focus

The main focus of the nursing interview is to gather detailed information about the client's health status and concerns.
During the assessment phase, nurses review the client's medical record to gain medical history context.

Types of Assessments

Ongoing assessments are conducted throughout the care process to monitor changes in the client's condition.
Emergency assessments are performed when immediate care is required due to acute health crises.
Focused assessments are conducted when specific health issues are identified and require deeper investigation.

Gathering Objective Data

Objective data is typically collected through physical examinations and observations in clinical settings.

Subjective and Biographical Data

Subjective data includes the client's personal experiences and feelings related to their health.
Biographical data should capture details such as age, gender, ethnicity, and primary health concerns.

Family Health History

This history is essential as it can indicate genetic predispositions to certain health conditions.

Review of Systems and Lifestyle Assessments

The Review of Systems for Current Health Problems focuses on identifying symptoms and concerns per body system.
The Lifestyle and Health Practices Profile assesses daily habits affecting health such as exercise and substance use.

Nutrition and Sleep Assessments

The Nutrition and Weight Management section evaluates dietary habits and any weight-related concerns.
Assessment of Sleep and Rest matters because sleep quality can significantly impact overall health.

Communication Techniques in Interviews

Silence periods provide clients with space to think and can facilitate deeper conversation.
Open-ended questions effectively elicit the client's feelings and perceptions on their health experiences.
Rephrasing during the interview clarifies information and shows active listening.
The technique of offering a list of words helps clients articulate emotions accurately.
Verbal communication can be described as clear, empathetic, and focused on the client's needs.
Encouraging actions, like nodding or expressing understanding, motivate clients to share more information.

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Description

Learn about the steps involved in a health assessment including gathering subjective data like biographical information and health history, as well as objective data obtained through physical examination techniques like inspection, palpation, percussion, and auscultation.