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Terms in this set (218)
holistic nursing assessment collect subjective and objective data to determine
overall level of functioning to make a professional
clinical judgement (nursing diagnosis)
physical medical assessment primarily physiologic status
initial comprehensive client's perception of body parts/systems, past
medical history, family history, lifestyle/health
practices (upon admission)
ongoing/partial assessment after comprehensive assessment (reassess, shift
assess)
focused/problem-oriented particular client problem, not areas not related to the
assessment problem (e.g. pain assessment=only talking about
pain)
emergency assessment rapid assessment, life-threatening situations (rapid
response, chest pain, ABCs)
subjective data things the patient tells you-biological information, hx
of present health concern (physical symptoms,
feelings, perceptions, preferences, beliefs), personal
health hx, family hx, health and lifestyle practices
,objective data things you observe with your senses-physical
characteristics (skin color, posture), body functions
(vital signs), measurements, appearance, behavior,
results of lab or diagnostic testing, results of
assessment findings (inspect, palpate)
analysis identify abnormal data and strengths, cluster the
data, draw inference and identify problems, propose
possible nursing diagnosis, check for identifying
characteristics/confirm or rule out nursing diagnosis,
document conclusions
pre-introductory phase of interview review health record
process
introductory phase of interview explain purpose of the interview, assure client is
process comfortable and has privacy, develop trust and
report with verbal/nonverbal skills
working phase of interview process biological data, hx of present health concern/reason
for seeking care, past health hx and family hx, review
of body systems (current health problems), lifestyle
and health practices/developmental level,
listening/observing/critical thinking to
interpret/validate info, identify client's problems and
goals
summary/closing phase of interview end gracefully not abruptly, summarize information
process obtained, validate problems/goals with client,
identify/discuss possibly plan to resolve problems, as
about concerns/further questions
biographical data name, gender, address, phone, provider of history,
birth date/place, race/ethnic background,
primary/secondary languages, marital status,
religious/spiritual practices, occupation, significant
others or support people
, patient exam prepare setting by providing for comfort/warm
temperature, private/quiet area free of interruption,
firm examination table or bed, good lighting, bed
waist high
supine lying flat on back; used for abdominal,
cardiovascular, and general exams
dorsal recumbent lying on back with legs bent and feet flat; used for
abdominal exams if patient has back pain
sims' lying on left side with the upper knee flexed and
raised toward the chest; used for rectal exams and
enemas
lithotomy lying on back with legs in stirrups; used for pelvic
exams and Pap smears
knee-chest the patient rests on his or her knees and chest, the
head is turned to one side, and the arms are
extended on the bed, the elbows flexed and resting
so that they partially bear the weight of the patient;
used for rectal and prostate exams
prone lying flat on the stomach; used for back, hip, and
musculoskeletal exams
physical assessment inspection, palpation, percussion, auscultation
abdomen physical assessment inspection, auscultation, percussion, palpation
diaphragm high-pitched sounds, FIRM pressure (lungs, bowel,
normal heart sounds)
bell low-pitched sounds, LIGHT pressure (abnormal heart
sounds-murmurs, bruits)