Flashcards
assessment
Cards in this deck (12)
- 1Nursing Process Roper, Logan & Tierney, (1980)a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. Includes assessment, nursing diagnosis, planning, implementation, and evaluation. The first phase of the nursing process is assessment, which consists of data collection by such means as interviewing, physical examination, and observation. It requires collection of both objective and subjective data. The second phase is nursing diagnosis, a clinical judgment about individual, family, or community nursing responses to actual or potential health problems/life processes. Provides the basis for selection of nursing intervention to achieve outcomes for which the nurse is accountable (NANDA, 1990). The third phase is planning, which requires establishment of outcome criteria for the client's care. The fourth phase is implementation (intervention). This phase involves demonstrating those activities that will be provided to and with the client to allow achievement of the expected outcomes of care. Evaluation is the fifth and final
- 2Describe a visual assessment of P at 1st meetingAPPEARANCE
Well groomed
Brushed hair
Clean clothes
Well fitting
trimmed, clean nails
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Posture
Non-verbal cues of anxiety
Ambivalence
Relaxed - 3Describe Subjective InfoInfo collected from P
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Info collected that is not directly measurable - levels of anxiety
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Nurses view on how P can process information - Physical state, understanding English. - 4Describe Objective InfoP may not be able to engage in the assessment directly - Level of cognition, acceptance of condition.
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Info collected from tests and other sources
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Taking baseline obs. - 5What tool can be used to assess alcohol intake?Audit C
3 item alcohol screening tool that can identify persons who are hazardous drinkers or have active alcohol use disorders.
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Scoring 0-12
Men - 4 and over
Women - 3 and over. - 6Name an alcohol assessment tool geared towards the elderly.Michigan Alcoholism Screening Tool - Geriatric Version.
(MAST-G) - 7Name a tool used when P is acutely unwellABCDE Tool
Airway
Breathing
Circulation
Disability (Neuro status)
Exposure - 8Name an assessment tool for PsoriasisPSORIASIS AREA AND SEVERITY INDEX
(PASI)
Assesses 3 areas -
Erythema (redness)
Scaling
Induration (Plaque thickness) - 9Name an assessment tool used for Anxiety.HAM-A
Hamilton Anxiety Rating Scale
Features both psychic and somatic anxiety sub scales.
Psychic - anxious mood, tension, fears, difficulty concentrating.
Somatic - Autonomic arousal, respiratory and cardiovascular (good reason to do obs). - 10Name another possible tool used to measure anxiety.Severity Measure for Generalized Anxiety Disorder - Adult.
Maybe use as the questions are based on specific situations and events. This may help P identify issues and stressers.
Mainly used when P has a diagnosis of GAS. - 11Name a tool used to assess nutritionMUST tool
Malnutrition Universal Screening Tool
A 5 step tool used to identify adults who are/at risk of malnutrition or obesity.
Step 1 - Measure height and weight to get BMI.
Step 2 - Note unplanned percentage weight loss and score it.
Step 3 - Establish acute disease effect and score.
Step 4 - Add 1, 2 and 3 together to get overall risk malnutrition score.
Step 5 - Develop Care Plan - 12—
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- Flashcards on assessment, created by Andrew Pope on 17/09/2015.
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- Andrew Pope
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