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NUR 302 Chapter 16 Nursing Assessment
Terms in this set (29)
is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and to promoting human functions and responses to health and illness. The ______ is continuous and dynamic, so you may move back and forth among the steps.
helps nurses to form a clear definition of the patient's problems, which in turn provides the foundation for planning and implementing nursing interventions and evaluating the outcomes of care.
assess, diagnose, plan, implement, evaluate
5 steps of the nursing process
involves collecting information from the patient and from secondary sources (e.g., family members), along with interpreting and validating the information to form a complete database.
collect, verify, analyze
Assessment has two stages:
First, to ___ and ___ data from the patient (primary source) and from family, health care providers, and medical records (secondary sources)
Second step is to ___ the data
You perform assessment to gather information needed to make an accurate ____ about a patient's current condition.
Experience, knowledge, standards, and attitudes all influence _____ in assessment
is a vital part of assessment.
Establishing a nurse-patient ____ allows you to know the patient as a person. This relational process mobilizes hope for a patient and nurse; allows for an acceptable interpretation and understanding of the patient's illness, pain, fear, and anxiety; and helps the patient use support from health care providers.
is a vital opportunity to build trust with patients, increasing the likelihood that you will gain more information that will help you identify and communicate their health care problems more accurately and effectively.
A ___ is information that you obtain through use of the senses.
An ___ is your judgment or interpretation of these cues.
Always try to interpret ____ from the patient to know how in depth to make your assessment. Assessment is dynamic and allows you to freely explore relevant patient problems as you discover them.
A ___ moves from the general to the specific. Typically certain aspects of a situation stand out as most important. You then ask more focused questions on the basis of the patient's responses and physical signs.
second approach for conducting a comprehensive assessment is ____. You focus on a patient's presenting situation and begin with problematic areas such as incisional pain or limited understanding of postoperative recovery.
Remember to always have ____ before you make an inference. Your inferences direct you to further questions
type of data, often reflect physiological changes, which you further explore through objective review of body systems
Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of ______, ______is measured on the basis of an accepted standard such as the Fahrenheit or Celsius measure on a thermometer, inches or centimeters on a measuring tape, or a rating scale (e.g., pain)
is usually your best source of information. ____ who are conscious, alert, and able to answer questions without cognitive impairment provide the most accurate information.
Family members and significant others
are primary sources of information for infants or children, critically ill adults, and patients who are mentally handicapped or have cognitive impairment. In cases of severe illness or emergency situations, _____ are often the only sources of information for health care providers.
The family and significant others are also important ____ of information. Not only do they supply information about the patient's current health status, but they are also able to tell when changes in the patient's status occurred.
health care team
You frequently communicate with other ____ members to assess patients. In the acute care setting, the change-of-shift report, bedside rounds, and patient hand-off are ways that nurses from one shift communicate information to nurses on the next shift.
The _____ is a source for the patient's medical history, laboratory and diagnostic test results, current physical findings, and the primary health care provider's treatment plan. The ____ is a valuable tool for checking the consistency and similarities of data with your personal observations
level of function
Observation of _____ differs from observations you make during an interview. You assess ______ by watching what a patient does when eating or making a decision about preparing a medication rather than what the patient tells you that he or she can do.
The successful ongoing ____ and ____ of assessment data ensures that you have collected a complete database. Ultimately this leads you to the second step of the nursing process, in which you make clinical decisions in your patient's care.
When _____ assessment information, you determine the presence of abnormal findings, recognize that further observations are needed to clarify information, and begin to identify the patient's health problems
____ of assessment data is the comparison of data with another source to determine data accuracy.
Use clear, concise appropriate terminology
Becomes baseline for care
Visual representation that allows you to graphically show the connections among a patient's many health problems
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