Health Assessment: Nurse's Role in Health Assessment

Nursing Diagnoses

Analysis of subjective and objective data to make a professional nursing judgment

Implementation

Carrying out the plan of care

Nursing Diagnosis

Collection of Subjective and Objective Data

Planning

Developing a plan of nursing care and outcome criteria

perception of pain

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's

allow the client to ventilate his or her feelings

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to

encourage the client to quit smoking

The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should

'how do you manage your stress"

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

prone position

client lies on abdomen with head turned to side; may be used to asses back and mobility of hip joint

palpation

during a comprehensive assessment, the primary technique by the nurse throughout the examination is

dorsal surface of the hand

while examining a client, the nurse plans to palpate temperature of the skin by using the

maintain eye contact while asking the questions from the form

while interviewing a client for the first time, the nurse is using a standardized nursing history form. the nurse should

Evaluation

Assessing whether outcome criteria have been met and revising the plan as necessary.

using closed-ended questions

During an interview with an adult client, the nurse can keep the interview from going off course by

Objective data

Findings directly observed or indirectly observed through measurements (e.g., body temperature)

Collaborative problem

Physiologic complications that nurses monitor to detect their onset or changes in status

sitting position

Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

Subjective data

Sensations or symptoms that can be verified only by the client (e.g pain)

provide structure and set limits with the client.

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to

expressing interest in a neutral manner

The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by

explain the role and purpose of the nurse

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should

wash both hands with soap and water

Wash beginning a physical assessment of a client, the nurse should first

Continuous

although the assessment phase of the nursing process precedes the other phases, the assessment phases is

supine position

back-lying position used for examination of the abdomen (with one small pillow under the head and another under knees); this position also allows easy access for palpation of peripheral pulses

Nursing Assessment

clinical judgement about individual, family, or community responses to actual or potential health problems and life processes.

identify risk factors to the client and his or her significant others

during a client interview, the nurse asks questions about the clients past health history. the primary purpose of asking about past health problems is to.

1 1/2 inch diaphragm

during a comprehensive assessment of an adult client, the nurse best hear high-pitched sounds by using a stethoscope with a

Hyperresonance

during a comprehensive assessment of lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit

working

during an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. this occurs during the phase of the interview termed

rephrasing the client's statements

during an interview with an adult client fro the first time, the nurse can clarify the client's statements by

knowledge of his or her own thoughts and feelings about these issues

for a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

Diaphragm

larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds

fingerpads

part of examiner's hand used to feel fine discriminations: pulses, texture, size, consistency, shape and crepitus

dorsal surface of hand

part of examiner's hand used to feel for temperature

ulnar surface or palm of hand

part of examiner's hand used to feel fro vibration, thrills, or premitus

standing position

position used to examine male genitalia and to asses gait, posture, and balance

Referral problem

problem that requires the attention or assistance of other health care professionals.

Sims position

side-lying position used during the rectal examination

rapid advances in biomedical knowledge and technology.

the depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of

indirect percussion

the most commonly used method of percussion is

indicate acceptance of the client's cultural differences

the nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. the nurse should.

explain each procedure being performed and the reason for the procedure

to alleviate a client's anxiety during a comprehensive assessment, the nurse should

review the client's health care record

to prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

comprehensive

when a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

avoids excessive eye contact with the client

During a client interview, the nurse uses nonverbal expressions appropriately when the nurse

Formulation of nursing diagnoses

The result of a nursing assessment is the

asses the client's hearing acuity

the nurse is interviewing a 78-year-old client for the first time. The nurse should first

use very basic lay terminology

the nurse is interviewing a client in the clinic for the first time. the client appears to have a very limited vocabulary. the nurse should plan to

avoid premature judgment about the client

the nurse is preparing to meet a client in the clinic for the first time. after reviewing the client's record, the nurse should

blunt percussion

when the nurse places one hand flat on the body surface and uses the first of the other hand to strike back of the hand flat on the body surface, the nurse is using

review the ChoosemyPlate information with the client

while interviewing an adult client about her nutrition habits, the nurse should

check for the presence of defining characteristics

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next

bone

while percussing an adult client during physical examination, the nurse can expect to hear flatness over the client's

Physiologic status

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

lithotomy position

Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum

arrive at conclusions about the client's health

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the propose of the assessment is to

Bell of stethoscope

Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)

deep palpation

an adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infection. to detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing

ongoing or partial assessment

an assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

deep palpation

during palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. the nurse is performing

provide the client with information as questions arise

during the interview of an adult client, the nurse should

percussion

while performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

use minimal position changes

while performing a physical examination on an older adult, the nurse should plan to