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Terms in this set (83)
What is an assessment? -A data collection process
-A continuous process
-A method to establish a baseline
What is primary subjective data? Give an Client reports feelings/thoughts
example. Ex. "I have a headache"
What is secondary subjective data? Give an Anyone, other than the client, reports feelings/thoughts.
example. Ex. Spouse states, "She complained of pain in her abdomen
this morning."
What is primary objective data? Give an Nurse reports seeing, feeling, smelling, or hearing. (DO NOT
example. taste).
Ex. "I can see redness and swelling of her right lower
extremity."
What is secondary objective data? Give an Anyone, other than the nurse, reports seeing, feeling,
example. smelling, or hearing. (DO NOT taste).
Ex. AP states, "Her urine smells odorous."
What is a comprehensive assessment? Consists of a complete nursing history and physical
examination.
What is a focused assessment? Based around the patients immediate problems.
What is the nursing process? Assessment
Diagnosis
Planning
Implementation
Evaluation
(ADPIE)
What is the "A" in the nursing process? Assessment - gather information and review the patients
history
What is the "D" in the nursing process? Diagnose - identify problem list
, What is the "P" in the nursing process? Plan - develop SMART goals, desired outcomes, and action
plans
What is the "I" in the nursing process? Implementation - perform nursing actions
What is the "E" in the nursing process? Evaluate - were desired outcomes and goals achieved?
List 5 'Communication' skills nurses must -Eye Contact
implement at all times. -Eye Level
-Personal Space
-Active Listening
-LISTEN to them!!!
List 4 'Cognitive' skills you must implement in -Critical Thinking Skills
the assessment process. -Inductive & Deductive Reasoning Skills
-Clinical Decision Making Skills
-Problem Solving Skills
What are 'Psychomotor' skills? Skills needed to perform the 4 techniques of physical
assessment.
What are 'Interpersonal/Affective' skills? Affective skills needed to develop caring, therapeutic nurse-
patient relationships.
List 4 'Ethical' skills. -Responsible & accountable for practice
-Patient advocate
-Respect patients' rights
-Assure confidentiality
What are the 2 types of interviews? Directive or Non-directive
What is an open ended question? Give an A question that requires more than a "yes" or "no" answer.
example. Ex. "What does the pain in your foot feel like?"
What is a close ended question? Give an A question that requires a "yes" or "no" answer.
example. Ex. "Do you have a headache?"
What is the 'Introductory Phase' of the -Introduce self
interview process? -Put patient at ease
-Explain purpose of interview
-Explain time frame
What is the 'Working Phase' of the interview -Data collection, structured
process? -Longest phase
What is the 'Termination Phase' of the -End of interview
interview process? -Summarize and restate findings
Observation -Use your senses
-Look at patient and environment
What are the steps to a 'Physical -Inspection
Assessment' in order of performance? -Palpation
-Percussion
-Auscultation
When does the order to a 'Physical When assessing the abdomen.
Assessment' change?