Chapter 14 Assessing

objective data
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Terms in this set (24)
objective data
information that is seen, heard, felt, or smelled by an observer; signs
Subjective Data
things a person tells you about that you cannot observe through your senses; symptoms
What sources of information can you use when assessing a patient with cognitive deficit
information include family and significant others, the patient record, assessment technology, other health care professionals, and the nursing and other literature
proper documentation
timely and complete, meets requirements for content, and reflects total care
-Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.
-Use good grammar and standard medical abbreviations.
-Know your facilities approved abbreviation list
-Whenever possible, use patient's own words.
-Avoid nonspecific terms subject to individual interpretation or definition.
nursing assessments should have the following characteristics:
purposeful, prioritized, complete, systematic, accurate, relevant, and recorded in a standard format.
Types of Nursing Assessments
1. Initial Assessment.
2. Focused Assessment.
3. Emergency Assessment.
4. Time-lapsed Assessment.
The nursing history identifies
the patient's health status, strengths, health problems, health risks, and need for nursing care
Four phases of patient interview
1. The preparatory phase.
2. Introduction.
3. Working phase.
4. Termination.
Four methods are used to collect data during a physical assessment
Inspection, Palpation, Percussion, Auscultation
The nurse performs a physical assessment
The nursing physical assessment involves the examination of all body systems, review of systems (ROS), in a systematic manner, commonly using a head-to-toe format.
ObservationObservation is the conscious and deliberate use of the five senses to gather data.Common problems in data collection include-inappropriate organization of the database - omission of pertinent data - inclusion of irrelevant or duplicate data - erroneous or misinterpreted data - failure to establish rapport and partnership with the patient - recording an interpretation of data rather than observed behavior - and failure to update the database.Validationact of confirming or verifyingThe purpose of validatingto keep data as free from error, bias, and misinterpretation as possible (invalid information can lead to inappropriate nursing care)The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility's policy.(1) Purposeful (2) Prioritized (3) Complete (4) systematic (5) Accurate (6) RecordedThe nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a)Comprehensive b)Initial c)Time-lapsed d)Quick priorityd)Quick Priority Based: are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlierThe nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a)"The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b)"It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c)"I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d)"We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e)"We need to check your health status and see what kind of nursing care you may need." f)"We need to see if you require a referral to a physician or other health care professional."A)"The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." E)"We need to check your health status and see what kind of nursing care you may need." F) "We need to see if you require a referral to a physician or other health care professional."A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? a) Correct the initial assessment form. b)Redo the initial assessment and document current findings. c) Conduct and document an emergency assessment. d)Perform and document a focused assessment of skin integrity.d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected.A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? a) "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b) "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c) "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d) "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."b) Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation.The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A) patient tells the nurse that she is feeling nauseous. B) patient's ankles are swollen. C) patient tells the nurse that she is nervous about her test results. D) patient complains that the skin on her arms is tingling. E) patient rates his pain as a 7 on a scale of 1 to 10. F) patient vomits after eating supper.A C D EWhen a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? A) Thank the wife for being present. B) Ask the wife if she wants to remain. C) Ask the wife to leave. D)Ask the patient if he would like the wife to stay.d. The patient has the right to indicate whom he would like to be present for the nursing history and exam.A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A Maslow's human needs B Gordon's functional health patterns C Human response patterns D Body system modelb. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchyThe nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? A Inform the charge nurse. B Inform the surgeon. C Validate the finding. D Document the finding.c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data.A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A "You made an inference that she is fine because she has no complaints. How did you validate this?" B "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C "Sometimes everyone gets lucky. Why don't you try to help another patient?" D "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems