Ch. 1 - Collecting and Analyzing Data
The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional ______.
clinical judgment
______ are defined as certain "physiological complications that nurses monitor to detect their onset or changes in status"
collaborative problems
What are the four steps of assessment?
collection of subjective data, collection of objective data, validation of data, and documentation of data
Admission assessment for hospital is an example fo what type of assessment?
initial comprehensive assessment
An ______ involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client's overall functioning) as well as objective data gathered during a step-by-step physical examination.
initial comprehensive assessment
Analyzing subjective and objective data to make a professional nursing judgement is what part of the nursing process?
diagnosis
Change of status assessment is an example for what type of assessment?
focus or problem-oriented assessment
What are the two models used to analyze health promotion and disease prevention?
health belief model and health promotion model
Law that governs the practice of nursing for registered nurses (RN) and licensed practical nurses (LPN) in the state of Indiana.
Indiana's Nurse Practice Act
Collecting subjective and objective data is what part of the nursing process?
assessment
______ is the first and most critical phase of the nursing process.
assessment
What are the steps of the nursing process?
assessment, diagnosis, planning, implementation, and evaluation
The nurse reflects on her personal feelings about the client and his circumstances so that he/she can......
avoid biases and judgement
The nursing process should be thought of as ______, not linear.
circular
A ______ consists of both a health history and physical examination.
comprehensive health assessment
What is used throughout the nursing process?
critical thinking
Nursing assessment focuses on the client's.....
effect of health on functional status
An ______ is a very rapid assessment performed in life-threatening situations.
emergency assessment
Assessing whether outcome criteria have been met and revising the plan as necessary is what part of the nursing process?
evaluation
Systematic approach to practice that emphasizes the use of best evidence in combination with the clinician's experience, as well as the patient preferences and values, to make decisions about care and treatment.
evidence-based practice
A ______ does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern.
focused or problem-oriented assessment
The questions asked in each physical system's focus on that particular body system and are broken down into four sections:
history of present health concern, personal health history, family history, lifestyle and health practices
Carrying out the plan is what part of the nursing process?
implementation
A ______ is defined by the North American Nursing Diagnosis Association as "a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable."
nursing diagnosis
Physical characteristics, body functions, appearance, behavior, measurements, and results of laboratory testing is what type of data?
objective
The examiner directly deserves what type of data?
objective data
______ is obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation.
objective data
An ______ of the client consists of data collection that occurs after the comprehensive database is established. This consists of a minioverview of the client's body systems and holistic health patterns as a follow up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data
ongoing or partial assessment
Shift assessment is an example of what type of assessment?
ongoing/partial assessment
Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ______ and ______ throughout all phases of the nursing process.
ongoing; continuous
In a hospital setting the ______ usually performs a total physical examination when the client is admitted
physician
Determining outcome criteria and developing a plan is what part of the nursing process?
planning
______ occur because nurses assess the "whole" (physical, psychological, social, cultural, and spiritual) client, often identifying problems that require the assistance of other health care professionals
referrals
Defines procedures, actions, and processes that are permitted by law for a specific profession.
scope of practice
Biographical data, history of present health concern, personal health history, family history, health and lifestyle practices, and review of systems are what type of data?
subjective data
______ are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
subjetive data
