Explain the purpose of a nursing health assessment
Purpose of nursing health assessment = collect holistic subjective and objective data to determine a
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client’s overall level of functioning to professional clinical judgment. \\ the main idea is something
we should understand. This was a question about the test. Clinical judgment.
*Holistic data collected* by the nurse from the client during a nursing health assessment =
- Physiologic
- Psychological
- Sociocultural
- Developmental
- spiritual data \\
Compare and contrast medical assessment from nursing health
assessment.
Holistic nursing assessment = Collects holistic subjective and objective data to determine a client’s
overall level of functioning in order to make a professional clinical judgment \\
the nurse assesses during nursing health assessments = how clients interact within their family and
community, and how the clients’ health status affects the family and community.
Ex. a diabetic client may not be able to eat the same foods that the rest of the family enjoys \ \
Physical medical assessment = Focuses primarily on the client’s physiologic development status \\
- there is a question that in which you are doing a physical on a patient and she tells you that
“the doc already did this”, what would you tell her? It’s not that both the nurse and the doc
are just as important and we will collaborate together to determine your order. It is literally
the highlighted above just put into one sentence.
Physical medical assessment focuses less on = psychological, sociocultural, or
spiritual well-being.
Ex. a physical therapist would focus primarily on the client’s musculoskeletal system and the effects
on ability to perform ADL \\
Describe the phases of the nursing process involved in health
assessment by the nurse.
Nursing Process: Assessment: Collecting subjective and objective data, gathering info about patient
health status, analyzing and synthesizing data, making [clinical] judgments about interventions and
evaluation of care outcomes \\
Most critical phase during the nursing process = assessment; if the data is not correct or inaccurate,
nursing judgements affect the other phases in the process. \\
The assessment phase of the nursing process has four major steps =
- Collection of subjective data
- Collection of objective data
- Validation of data. There were questions about this. Know when you should do this.
- Documentation of data//
Compare and contrast the four basic types of nursing assessment: (a) initial comprehensive,
(b) ongoing or partial, (c)focused/problem oriented, (d) emergency.
The four basic types of assessment are =
- *Initial comprehensive* assessment; admitted to ER.
- *Ongoing or partial* assessment; flowsheet, nurse comes to check vitals routinely.
- Focused or problem-oriented assessment; like quick care visits.
- Emergency assessment; like SOB, chest pain. \\
Initial comprehensive assessment =
- 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) .
- objective data gathered during a step-by-step physical examination. \\
Ongoing or partial assessment =
- after the comprehensive visit; patient is established.
- Follow up on health status to detect any changes from the baseline data in the patient’s body system or
holistic health patterns.
- Reassessment on any of the changes. \\ Question asks about a patient who has been evaluated already,
what is the purpose of going back to check on the patient again? It would be this answer. The other
answeres were to go back and check anything that was omitted, for documentation purposes
Focus or Problem-Orientated Assessment =
- Does not replace the comprehensive health assessment.
- Patient comes to office for specific health concern and that concern is assessed accordingly. \\ I think
there was a question about this asking what assessment would be done if there was a patient who had a
problem with a specific part of their body.
Emergency Assessment =
- Rapid assessment performed in life-threatening situations; evaluate ABC’s.
- Assesses the client’s life sustaining physical functions. \\
Preparing for the assessment =
- Review *client’s record*.
- Review client’s status with other health care team members; *collaborate*.
- *Educate* about client’s diagnosis and tests performed. \\
Reviewing the clients record to prepare for the assessment =
- Biographical data (age, sex, religion, education, occupation).
- Personal medical history to gather information in how it affects ADLs.
- Past med history and current gives a better guided interaction and care. \\
Nursing Process: Diagnosis: Analyzing subjective and objective data to make a professional nursing
judgment (nursing diagnosis, collaborative problem, or referral) \\
Nursing Process: Planning: Determining outcome criteria and developing a plan \\
Nursing Process: Implementation: Carrying out the plan \\
Nursing Process: Evaluation: Assessing whether outcome criteria have been met and revising the
plan as necessary \\
Compare and contrast subjective from objective data
Subjective data include =
- Biographical information.
- History of present health concern; physical symptoms related to each
body part or system.
- Past health history.
- Family history.
- Health and lifestyle practices; consider ADLs that can be/have been
affected by past med history.
- Review of symptoms \\
Example of biographical data and type of data = name, age, religion,
occupation. Subjective data. \\
Example of History of present health concern and type of data = eyes and ears, abdomen.
Subjective data.
Example of Health and lifestyle practices and type of data = health practices that put the client at
risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function,
community environment. Subjective data. \\
Subjective data are = know what subjective data is such as anything that the
patient says.
- Sensations
- Symptoms
- Feelings
- Perceptions
- Desires
- Preference
- Beliefs
- Idea
- Values
- Personal info \\
Objective data= know what this is. Anything that is observed and not what
the patient says.
- Physical characteristics.
- Body functions.
- Appearance.
- Behavior.
- Measurements.
- Results of laboratory testing. \\
- Have a clear understanding what are objective and subjective data and
know how to determine what is what such as what is an objective data?
Patient’s skin was warm and dry. What is subjective data? Patient stated
they have been having pain for blah blah blah.
Example of Physical characteristics and type of data = skin color, posture. Objective \\
Example of Body functions and type of data = heart rate, respiratory rate. Objective. \\
Example of Appearance and type of data = dress and hygiene. Objective. \\
Example of Behavior and type of data = mood, affect. Objective. \\
Example of Measurements and type of data = blood pressure, temperature, height, weight.
Objective. \\
Example of Results of laboratory testing and type of data = platelet count, x-ray findings. Objective.
\\
Describe the three phases of a client interview process. Give
examples on what occurs in each phase.
Phases of the interview =
1. Preintroductory phase
2. Introductory
3. Working
4. Summary and closing \\
Preintroductory phase = nurse review the med record before meeting with
the patient; why they are seeking care. Helps with conducting an interview.
Otherwise, nurse must interview and for reliable and valid data.\\ Question
asks about what is done before seeing a patient. There were other options in
addition to this which was to introduce yourself and place the patient in the
chair or something like that. [Show Less]