Nursing 110 Unit 1: Assessment
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Nursing 110 Unit 1: Assessment
step 1 of the nursing process
systematic and continuous collection, organization, validation, and documentation of data
characteristics of data (assessment) collection. remember s c c
systematic, continuous, and complete
what are two types of systematic collection of assessments
system approach, and head-to-toe approach
type of assessment usually upon admission
type of assessment that is ongoing, based on patient problem(s)
type of assessment during a crisis or change in a patient's status
type of assessment several months after initial assessment
What of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer?
a. emergency b. focused c. initial comprehensive d. time-lapsed
kind of data detectable by an observer. can be measured
kind of data detectable only to person affected
Source of data from the patient
source of data from patient's support persons, significant others, patient records, health care professionals, or other literature
method of data collection using vision, smell, hearing, and touch
What are the methods of data collection?
observation, interview, examination/physical assessment
method of data collection using a planned communication with a purpose to obtain information, identify problems, evaluate change, teach, or provide info
what are the two types of an interview?
type of interview that is highly structured, nurse uses questions, and is used during admission
type of interview in which the nurse allows the patient to control the interview
type of question that requires only one word answers
type of question that requires an answer of multiple words
type of question that can be answered without pressure. is open ended. "How do you feel about that?"
type of question that almost makes patient say what the nurse wants. usually closed ended. "You're angry, aren't you?"
stage of an interview that established rapport
stage of interview in which patient's thoughts, perceptions, feelings in response to questions
stage of interview needed info has been obtained
method of data collection that uses observation techniques to detect health problems. uses cephalocaudal (head-to-toe) and system approach
method of physical assessment that includes a visual exam of body. first done. need good lighting, exposed body. inspects size, shape, movement position, color, etc.
method of physical assessment in which nurse listens to sounds within the body. can be direct (done with unaided ear) or indirect (done with the aid of a stethoscope)
method of physical assessment in which the body's surface is struck to elicit sounds or vibrations. location, size, density of underlying organs
method of physical assessment that assesses through touch using fingers and hands. two types: light (pulse, temp, etc) and deep (feel organs)
method of physical assessment that uses smell while performing other exam methods. smell casts, drainage, breath, etc.
what is the order of physical assessment?
inspection, auscultation, percussion, palpation