25 terms

1155 Health assessment

What is a health assessment?
- A systemic system of collecting data
- components include conducting a health history (subjective data), performing a physical exam (collection of objective data) and document the findings
What kind of data is objective?
Signs E.g. Fever
What kind of data is subjective?
Symptoms E.g. belly ache
What is a clinical manifestation?
A term used when signs(objective) & symptoms (subjective) are presented by a client
What factors are taken into consideration when collecting data?
Ethnicity, race, gender, age, culture, physical, physiological, socioeconomically status
What do we call data given by someone other than the client?
Secondary source of a data
What are the components of a health assessment?
1. Health history (symptoms/ subjective data)
2. Physical exam (signs/objective data)
3. Documentation of data
What are the core physical examination skills we will learn in nursing?
Skin, Head(eyes, ears, nose & throat), Chest & lungs, Cardiovascular, Musculoskeletal, Abdomen, Neurological, & Genitalia.
What are the standards of the nursing practice "The Nursing Process"?
Assessment, DX, Outcome Identification, Planning, Implementation, Evaluation .
What are the 4 steps of Implementation?
1. Coordination of Care (RN delivers care)
2. Health teaching & promotion
3. Consolation
4. Prescriptive authority & treatment (perform procedures, referrals, therapy, etc.)
Information gained during an assessment are dependent on what factors?
1. Context of care
2. The clients need
3. A nurse's experience
What is a Comprehensive assessment?
These types of assessments are usually found in a primary care setting or before admission into long term care facilities, they are a detailed health & physical history.
What is problem-based/focused assessment?
This type of assessment has a history & examination that is limited to a specific problem, often found in walk-in clinics & emergency rooms.
What is an Episodic follow-up assessment?
A follow up
What is a Shift assessment?
A type of an episodic follow-up assessment preformed by nurses in acute care settings.
What is a screening assessment?
An assessment focused on disease prevention they are shot & often inexpensive E.g. BP, cholesterol, or glucose screenings.
Once a nurse collects data during an assessment what 2 forms can she use to help her better organize the data she has gathered?
1. "Gordon's" Functional Health Pattern
2. NANDA (North American Nursing Diagnosis Association)
What does the term "Clinical Judgment" refer to?
Interpretation or a conclusion about a patients' needs, concerns, & whether to act or not as well as make modifications to their treatment as deemed appropriate by the patient.
What are the steps of making a Clinical Judgment?
1. Noticing (a grasp of the situation)
2. Interpreting (understanding the situation)
3. Responding (o the station)
4. Reflecting (considering the outcome)
What is the focus of Primary Prevention?
Avoid disease, educate & promote a healthy lifestyle.
What is the focus of Secondary prevention?
Includes screening to catch disease early in the game.
What is the focus of Tertiary prevention?
Directed toward minimizing the effects or disabilities of acute/chronic diseases or illness.
getting more information
1. previous history
2. onset
3. location
4. duration
5. character
6. alleviating/aggravating factors
7. radiation
8. timing
9. severity/self-treatment
documentation of data
1. organization involves organizing or clustering data that allows problems to be clearly apparent, e.g. body systems, systematic
2. needs to be complete, accurate, descriptive
3. must be recorded concisely, accurately, legibly, w/o bias or opinion
what is a health history?
consists of subjective data nurses collect when interviewing clients