Chapter 1: Nurse’s Role in Health Assessment: Collecting and Analyzing Data
1. What is health assessment?
- Health assessment is a collection of subjective data and objective data purposely to collect
holistic data to determine a client’s overall level of functioning in order to make a professional
judgment.
2. What is the nurse’s role in health assessment?
- The nurse’s role is to make sure the health assessment of the patient is gained prior to fully
admitting them, making sure the main health points are healthy.
3. What is the nursing process? What are the steps?
- The nursing process is the order in which a nurse takes the health assessment. The following
are the steps of the nursing process:
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
4. Define the four basic types of health assessment and an example of each.
- The four basic types of health assessment are:
• Initial Comprehensive Assessment- an example of initial comprehensive
assessment is collecting all data of the client’s perception of health of all body
parts and systems, past medical history, lifestyle or even health practices.
• Ongoing or Partial Assessment- occurs after the comprehensive database is
established.
• Focused/ Problem-oriented Assessment- A thorough assessment of a location on
the patient’s body, or problem.
• Emergency Assessment- Very rapid assessment performed in life-threatening
situations.
5. What are the four major steps of the assessment phase of the nursing process?
- The four major steps of the assessment phase of the nursing process are collection of
subjective and objective data, validation of data and documentation of data.
Chapter 2: Collecting Subjective Data: The Interview and Health History
1. What does the nurse need to understand about the process of communication?
- A nurse must understand that he/she must communicate enough with the patient. Patients
come in cultural variations, some are emotional, or anxious and some can be very
, Introduction to Health Assessment Assignment
manipulative, or seductive. Nurses must be aware of the questions being asked and be able to
respond appropriately.
2. What are the phases of a client interview? What is the purpose for each phase?
- Pre-introductory phase: reviewing patient’s medical record to easily familiarize with them.
- Introductory phase: introducing self to patient and make them aware of questions, note
taking, etc.
- Working phase: biographical data and reasons for care of patient. Learn their family history,
lifestyle, work life and be able to listen to them.
- Summary and Closing phase: a summary of the working phase by validating the problem and
goals with patient to resolve any concern or problem.
3. How does age affect the interview process?
- Age affects the interview process because sometimes kids cannot communicate effectively
because of fear of being at a doctor’s office, or hospital, and some kids can be easily distracted.
4. How does culture affect the interview process?
- In many cultures there are beliefs, and patients will not seek the same care as others. For
example, the Jehovah’s witnesses will not take blood transfusions even for emergency due to their
cultural belief.
5. How do emotional variations affect the interview process?
- Emotional variations affect the interview process if one does not know how to effectively
communicate with their feelings. If a patient is feeling depressed you must be able to understand
what they feel and not respond in manners that will make them feel worse, trying to speak in a
neutral manner to depressed, or emotional patients.
6. What is a complete health history? What are the components?
- A complete health history is a full background data of patient like past health history, family
history, biographical data, lifestyle and health practices. This will allow to completely know your
patient, sort of like a background check but medically.
7. What information should be included in the source of history?
- Some information that should be included in the source of history can be allergies, current
medications and past, emotional, or mental health problems, immunizations, chronic illnesses in both
past and present.
8. What is <reason for seeking care?= Difference between symptom and a sign?
- Reason for seeking care is what brings the client in for care, like a stomachache, back pain, or
a sore throat. A patient who is having health concerns and are worried about any diseases, or illness
especially if they knew it ran in their family. Patients usually seek care if they feel symptoms, or signs
of being sick. Symptoms is different from a sign because symptoms are felt internally like vomiting,
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