2023/2024 VERIDIED Q&A
objective data
what the health professional observes by inspecting, palpating, percussing, and auscultating during
the physical examination
Define "Assessment" in the nursing process
The deliberate and systematic collection of data to determine a patient's current and past health
status, functional status and past and present coping patterns
What is assessment?
systematic gathering of relevant and important patient data and analysis of data
Purpose of Assessment
To establish a database about the patient's perceived needs, health problems, and responses to these
problems
Continual
How to assess
Collect data
Cluster cues, inferences, identify patterns and problem areas
Critically anticipate
subjective data
Information perceived only by the affected person; these data cannot be perceived or verified by
another person.
Types of Assessment
Focused
Complete
focused assessment
assessment conducted to assess a specific problem; focuses on pertinent history and body regions
complete assessment
review and physical examination of all body systems
,What determines the type of assessment?
Reason for exam
Clients condition
Amount of time
primary source
Directly from patient
secondary source of data
Information gathered from other sources
Family, emr...
assessment techniques
IPPA
Inspection
Palpation
Percussion
Auscultation
inspection
general observation of the patient as a whole
Direct and indirect
Visual and smell
Palpation
to examine by touch
percussion
tapping on a surface to determine the difference in the density of the underlying structure
ascultation
listening to sounds of the body, such as heart, blood vessels, lungs, abdomen, etc...
Ten Traps of Interviewing
1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
, 5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions
Two types of questions
open-ended and close-ended
how you communicate
-Genuineness
-Respect
-Empathy
Purpose of health history
to collect subjective data
Identify patient strengths
Identify actual and potential health problems
Components of Health History
Biographic data
source of history,
reason for seeking care
present health or history of present illness
past history
family history
review of systems
functional assessment or activities of daily living
How is BMI calculated?
weight in kg/height in meters squared
What is included in cultural assessment
Attitudes, beliefs, self definitions, norms, roles and values
cultural competence
having an awareness and acceptance of cultures and the ability to interact effectively with people of
diverse cultures
implicit bias