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Ati health assessment final exam 2020.

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Upgrade to Quizlet Plus jeszoequiz 30 terms Vanessa_Gonzalez49 Health Assessment ATI EXAM 1 STUDY LEARN FLASHCARDS WRITE SPELL TEST PLAY MATCH GRAVITY Upgrade to remove ads Only $1/month SORT A nurse is introducing herself to a client as the first step of a comprehensive physical...

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Health Assessment in Nursing Practice

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It involves 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 includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination.

Initial comprehensive

Ongoing or partial assessment

Focused or problem-oriented

Emergency assessment

According to American Nurses Association (ANA) _______________ defines as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities and populations.

Nursing: Scope and Standards of Practice

"The Registered Nurse collects comprehensive data pertinent to the patient's health or situation."

"The Registered Nurse analyzes the assessment data to determine the diagnoses or issues"

To accomplish this pertinent and comprehensive data, the nurse:

Collects data in a systematic and ongoing process

Uses analytical models and problem-solving tools

Validates the diagnoses or issues with the client, family, and other healthcare providers when possible and appropriate

Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data

First and most critical phase of Nursing Process


Considered to be the interdependent factors that affect a person's level of health

Validation of assessment data is a crucial part of assessment that often occurs along with collection of subjective and objective data.

It forms the database for the entire nursing process and provides data for all other members of the health care team.

Analysis of data (often called nursing assessment) ?

Carrying out the plan of care

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

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

Assessing whether outcome criteria have been met and revising the plan of care if necessary

Developing a plan of nursing care and outcome criteria


Objective data is finding directly observed or indirectly observed through measurements ( e.g., body temperature)

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

A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

Health assessment can be divided into:

collecting subjective data

collecting objective data

validation of data

documentation of data

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

Objective Data

Subjective Data

Referral Problem

Collaborative Problem

Types of Nursing Assessment:

Very rapid assessment performed in life-threatening situations

The medical record provides background about

chronic diseases and gives clues to how a present illness may impact the client’s activities of daily living (ADL).

Subjective data is obtained by general observation and

by using the four physical examination techniques: inspection, palpation, percussion, and auscultation.

During this phase, you analyze and synthesize data to determine whether the data reveal a nursing concern (nursing diagnosis), a collaborative concern (collaborative problem), or a concern that needs to be referred to another discipline (referral).

A comfortable, relaxed atmosphere and an attentive interviewer are essential for a successful clinical interview

____________ assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem

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

In a community clinic, a nurse practitioner may perform the entire physical examination.

Frequency of comprehensive assessments depends on the client’s

Risk Factors

Health Status

Health promotion practices and lifestyle

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