Name 6 settings that Health Assessments occur in
1. Acute Care
2. Outpatient Clinic
3. Surgical Centers
6. In Patient's home
What is a health Assessment?
It is done by an interview.
The systematic method of collecting data about a patient for the purpose of determining the patient's health. This should accurately define the health and sick needs of the individual at that specific moment in time. the information obtained in the interview and physical exam will be used to formulate the basis for the nursing care plan that will be developed. this baseline will help you prioritize your care.
True or False - Nursing is always accountable for health assessment of clients.
True or False - Nursing is dereasingly responsible for obtaining health histories and performing physical exams.
False - Nursing is INCREASINGLY responsible for obtaining health histories and performing physical exams.
What is subjective data?
what the patient tells you.
- it is not measurable.
- Shortness of breath
- Pain level
What is a Health Risk appraisal?
- Has been identified as a valuable component of health programs.
- Nurses can use this in combination with a physical assessment, to target needs of those at heightened risk for certain health problems and to determine appropriate wellness oriented education and counseling.
What does the Physical Assessment Address?
1. Will address the changes in biological structure and function in adults related to age as we look at each body system.
2. age variations will be addressed within each area.
Name 10 Factors that affect Health Assessment
1. Growth and Development
2. Biophysical Status (are they able)
3. Emotional Status (highly anxious, chest pains --> MI?
4. Cultural, religious, and socioeconomic background
5. Performance of ADL's
6. Patterns of coping (everyone is different)
7. Interaction patterns
8. client/patient perception of and satisfaction with his or her health status.
9. environment (physical, emotional, social, ecological)
10. available and access human and material resources.
Name 4 Psychosocial Values
1. personal values
2. Previous experiences
3. Uncomfortable providing personal information
4. Need reassurance of confidentiality (HIPPA)
1. Culturally Competent
2. Be aware of customs and rituals
3. Assess health related beliefs and practices.
3A. causes of illness (biomedical, naturalistic, magico-religious)
- Folk healers
- Transcultural expression of symptoms:pain
1. Quiet environment (free of distractions)
3. Room Temperature: adequate
5. Use of examination gloves
6. Well Lit
7. Table for examination items raised to a height that allows the performance of exam without stooping.
8. bed or table with easy access to both sides.
6 Components of the Health Assessment
1. mental history
2. Mental Health history
3. Sexual Health Assessment
4. Nutritional Assessment
5. Functional Assessment
6. Physical Assessment
How much Data for a diagnosis comes from the Health History?
Is the Health History subjective data or objective data?
Subject data - it is only what the patient is telling you.
10 components of the Past health history
1. Childhood Illnesses
2. Accidents injuries
3. serious or chronic illness
6. Obstetric History
8. Allergies (list of reactions also)
9. Date of last medical (list primary care physician, and any other physicians currently being seen by the patient)
10. Current medications
Family history can be tracked on what form?
Functional Assessment 10 Components
5. Interpersonal relationship/resources
6. Coping and stress management
7. Personal Habits
9. Occupational Health
10. Perception of own health
How to calculate a tobacco use history?
multiply the number of years smoking by the number of packs per day./
A 10 year smoker smoked 3 packs per day. How many pack years is this?
10 x 3 = 30 pack years
what are the 4 parts of the mental status assessment?
3. Cognitive Functions
4. Thought Processes and perceptions