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Study sets matching "assessment nursing health history"

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Study sets matching "assessment nursing health history"

35 terms
Nursing Assessment & Health History
Nursing Process
What is Assessment?
What are the 4 features?
What are the professional standards?
1. Assess ... 2. Diagnose... 3. Plan outcomes... 4. Plan interventions…
The systematic gathering of information related to the physic…
1. Collecting data... 2. Using a systematic/ ongoing process... 3.…
-The American Nurses Association... -Minnesota Nurse Practice Ac…
Nursing Process
1. Assess ... 2. Diagnose... 3. Plan outcomes... 4. Plan interventions…
What is Assessment?
The systematic gathering of information related to the physic…
37 terms
Nursing Health History and Assessment
Purpose of Health History and Assessment
Frameworks of Health History and Asses…
Frameworks of Health History and Asses…
Head-Toe: Newborn/Infant
Establishing a database of a client's abilities... Organize/clus…
Gordon's Functional Health Patterns (FHP)
Organized manner ... How you see the patient
Keep covered, involve parents
Purpose of Health History and Assessment
Establishing a database of a client's abilities... Organize/clus…
Frameworks of Health History and Asses…
Gordon's Functional Health Patterns (FHP)
18 terms
Nursing Assessment: Complete Health History
Biographical data
Biographical data
Source of History
Reason for seeking care
what is your address
What is your date of birth?
Information from the patient's mother, who seems reliable
"I'm going overseas, so I need to see if I need my special sh…
Biographical data
what is your address
Biographical data
What is your date of birth?
48 terms
Nursing 1300 Health History and Assessment
Define the purpose of the Health Inter…
Define the difference between objectiv…
Contract terms regarding the interview…
What is the mutual goal in a nurse/pat…
To obtain important information about the client. It is the b…
is what i obtain through the physical assessment, by noting t…
Time and place of the interview... Intro of self... Purpose of inte…
establish trust so the person feels accepted and thus free to…
Define the purpose of the Health Inter…
To obtain important information about the client. It is the b…
Define the difference between objectiv…
is what i obtain through the physical assessment, by noting t…
44 terms
Nursing Health Assessment Health History Exam 1
What are the 4 types of health history ?
What is the comprehensive health histo…
Example of comprehensive health histor…
What is the focused or problem oriente…
comprehensive , focused or problem oriented , follow up , eme…
full picture of health status and current problems
Admission to the hospital
When the pt. is known to patient
What are the 4 types of health history ?
comprehensive , focused or problem oriented , follow up , eme…
What is the comprehensive health histo…
full picture of health status and current problems
75 terms
Nursing Assessment - Health History, Domestic Abuse Assessment and Pain Assessment
Health History
Percentages of nursing diagnosis
Components of the Health History
Biographical Data
- Collection of subjective data... - Uses quotes, seek to be cle…
- 80% health history... - 15% physical exam... - 5% lab results
- Biographical data (who was the source)... - Reason for seeking…
- Name... - Address and phone number... - Age and birth date... - Birt…
Health History
- Collection of subjective data... - Uses quotes, seek to be cle…
Percentages of nursing diagnosis
- 80% health history... - 15% physical exam... - 5% lab results
56 terms
Skin Nursing Health Assessment
Annular
Confluent
Discrete
Grouped
Circular (ringworm)
lesions run
distinct, individual lesions that remain separate
cluster of lesions
Annular
Circular (ringworm)
Confluent
lesions run
Nursing 206- Assessment Techniques and Comprehensive Health History
Inspection
Sitting
supine
prone
Visual examination of the body
used for chest and thorax assessment
for assessing the front of the body
for assessing the backside of the body
Inspection
Visual examination of the body
Sitting
used for chest and thorax assessment
14 terms
Nursing 301 Health Assessment Chapter 4 The Complete Health History
Biographic Data
Symptom
Sign
Chief Complaint
Name, Address, Phone Number, Age, Birth Date, birthplace, gen…
a subjective sensation that the person feels from the disorder
an objective abnormality that you as the examiner could detec…
Reason for seeking care
Biographic Data
Name, Address, Phone Number, Age, Birth Date, birthplace, gen…
Symptom
a subjective sensation that the person feels from the disorder
56 terms
Skin Nursing Health Assessment
Annular
Confluent
Discrete
Grouped
Circular (ringworm)
lesions run
distinct, individual lesions that remain separate
cluster of lesions
Annular
Circular (ringworm)
Confluent
lesions run
48 terms
Health Assessment: Health Assessment in Nursing
What does the "S" stand for in SOAP?
What does the "O" stand for in SOAP?
What does the "A" stand for in SOAP?
What does the "P" stand for in SOAP?
Subjective data... -health history obtained through questions an…
Objective data ... -examination of body systems and expected fin…
Assessment... -diagnosis
Plan
What does the "S" stand for in SOAP?
Subjective data... -health history obtained through questions an…
What does the "O" stand for in SOAP?
Objective data ... -examination of body systems and expected fin…
96 terms
Health Assessment in Nursing
H.I.P.P.A
COLDSPA
ISOBAR
6 F's - Abdomen
History... Inspect... Palpation... Percussion... Ausculation
Character... Onset... Location... Duration... Severity... Pattern... Associated…
Identify... Situation... Observation... Background... Assessment... Recommen…
1. Fat... 2. Faeces... 3. Foetus ... 4. Fibroids ... 5. Fatulence... 6. Fluid
H.I.P.P.A
History... Inspect... Palpation... Percussion... Ausculation
COLDSPA
Character... Onset... Location... Duration... Severity... Pattern... Associated…
16 terms
Assessment Exam 1 (Nursing Health History and Assessement Overview)
head to toe assessment
body systems assessment
functional assessment
Primary data
organized matter, head to toe
focus on specific body systems (cardiovascular)
Gordon functional heath patterns (FHP)
information form the client
head to toe assessment
organized matter, head to toe
body systems assessment
focus on specific body systems (cardiovascular)
Skin Nursing Health Assessment
Annular
Confluent
Discrete
Grouped
Circular (ringworm)
lesions run
distinct, individual lesions that remain separate
cluster of lesions
Annular
Circular (ringworm)
Confluent
lesions run
167 terms
Health Assessment in Nursing
H.I.P.P.A
COLDSPA
ISOBAR
6 F's - Distension of the Abdomen
History... Inspect... Palpation... Percussion... Ausculation
Character... Onset... Location... Duration... Severity... Pattern... Associated…
Identify... Situation... Observation... Background... Assessment... Recommen…
1. Fat... 2. Faeces... 3. Foetus ... 4. Fibroids ... 5. Fatulence... 6. Fluid
H.I.P.P.A
History... Inspect... Palpation... Percussion... Ausculation
COLDSPA
Character... Onset... Location... Duration... Severity... Pattern... Associated…
70 terms
Nursing - Health Assessment
collection of subjective data during t…
first action when beginning to collect…
immediate action before performing a p…
what a nurse does first before perform…
Does this mean what info is collected??... -biographical data... -r…
Confirm identity (name and DOB)... Introduction... explain purpose…
introduce... wash hands... provide for privacy... provide for safety
explain procedure
collection of subjective data during t…
Does this mean what info is collected??... -biographical data... -r…
first action when beginning to collect…
Confirm identity (name and DOB)... Introduction... explain purpose…
110 terms
Coping, stress, and adaptation/Nursing health history and assessment/nursing process
Therappeutic communication
Types of communication
Written communication
Verbal communication
-a learned skill (unnatural) ... -focuses on client
-written... -verbal... -non-verbal... -metacommunication
documentation, instructions for procedures, medication inform…
Talking between people, giving report
Therappeutic communication
-a learned skill (unnatural) ... -focuses on client
Types of communication
-written... -verbal... -non-verbal... -metacommunication
153 terms
Health Assessment In Nursing
Assessment
Diagnoses
Planning
Implementation
Collection of subjective and objective data
Analysis of subjective and objective data to make a professio…
Developing a plan of nursing care and outcome criteria
Carrying out the plan of care
Assessment
Collection of subjective and objective data
Diagnoses
Analysis of subjective and objective data to make a professio…
38 terms
Health Assessment in Nursing-Abdomen
RUQ
RLQ
LUQ
LLQ
Ascending and transverse colon, duodenum, gallbladder, hepati…
Appendix, ascending colon, cecum, right kidney, right ovary a…
Left adrenal gland, left kidney, left ureter, pancreas body a…
Left kidney, left ovary and tube, left ureter, left spermatic…
RUQ
Ascending and transverse colon, duodenum, gallbladder, hepati…
RLQ
Appendix, ascending colon, cecum, right kidney, right ovary a…
74 terms
Nursing Health Assessment and Skills
Who Needs A Health Assessment?
Preventative Care
Subjective
Objective
Every person needs to have a complete assessment... Ideally done…
Primary prevention... -Focuses on improving overall wellness and…
- Symptoms... What the patient tells you... History... Chief complaint…
- Signs... What you see... Physical examination... Laboratory reports…
Who Needs A Health Assessment?
Every person needs to have a complete assessment... Ideally done…
Preventative Care
Primary prevention... -Focuses on improving overall wellness and…
97 terms
NURSING HEALTH ASSESSMENT-2
why do we collect objective and subjec…
4 forms for the basis of physical asse…
we use palpitation and percussion when…
we are going to listen for venus humms…
to detect an actual or potential problem 1. identify the prob…
1. Inspection-every assessment we do, always observe and comp…
to elicit tenderness and pain, the way we distinguish pain fr…
abdomen... clicks
why do we collect objective and subjec…
to detect an actual or potential problem 1. identify the prob…
4 forms for the basis of physical asse…
1. Inspection-every assessment we do, always observe and comp…
280 terms
Fundamentals of Nursing, Health Assessment
Functions of the skin include:... A. pro…
You are conducting an in-service on ag…
Casey Galen, a student nurse, conducts…
Mrs. Jones is a 65-year-old patient wh…
C. All of the above.
D. All of the above
C. lifetime of environmental trauma.
B. keratosis and lentigines.
Functions of the skin include:... A. pro…
C. All of the above.
You are conducting an in-service on ag…
D. All of the above
20 terms
Nursing Fundamentals- Health Assessment
When taking a health history, the nurs…
Before palpating the abdomen during an…
The nurse would attempt to gather whic…
The nurse would document which of the…
B. Using therapeutic communication skills to identify the cli…
B. Auscultate bowel sounds... Rationale: Before palpating the a…
A. Who lives with the client and the client's support systems…
B. Loss of hair on lower legs bilateral... Rationale: Subjectiv…
When taking a health history, the nurs…
B. Using therapeutic communication skills to identify the cli…
Before palpating the abdomen during an…
B. Auscultate bowel sounds... Rationale: Before palpating the a…
74 terms
Nursing Health Assessment and Skills
Who Needs A Health Assessment?
Preventative Care
Subjective
Objective
Every person needs to have a complete assessment... Ideally done…
Primary prevention... -Focuses on improving overall wellness and…
- Symptoms... What the patient tells you... History... Chief complaint…
- Signs... What you see... Physical examination... Laboratory reports…
Who Needs A Health Assessment?
Every person needs to have a complete assessment... Ideally done…
Preventative Care
Primary prevention... -Focuses on improving overall wellness and…
39 terms
Nursing Health Assessment
Cardiac Output
S1
S3
S4
what goes out to body;... amt of blood ejected by left ventricle…
"lub" best heard at apex with diaphragm; sound produced by cl…
Kentucky. Abnormal heart sound. Occurs early in diastole duri…
Tennessee. 4th sound, if present occurs late in diastole or j…
Cardiac Output
what goes out to body;... amt of blood ejected by left ventricle…
S1
"lub" best heard at apex with diaphragm; sound produced by cl…
51 terms
Introduction to Nursing Health Assessment
Nursing process
Assessment
Diagnosis
Planning
-diagnosis and treatment of human responses to actual or pote…
-review clinical history... -assess patient
problem list/diagnosis... -problem identification
interpersonal care plan
Nursing process
-diagnosis and treatment of human responses to actual or pote…
Assessment
-review clinical history... -assess patient
Nursing Health Assessment
Bradycardia
Tachycardia
Alopecia
Bulla
heart rate <50 beats per minute in the adult
heart rate >90 beats per minute in the adult
(baldness) hair loss
elevated cavity containing free fluid larger than 1 cm diameter
Bradycardia
heart rate <50 beats per minute in the adult
Tachycardia
heart rate >90 beats per minute in the adult
181 terms
Health Assessment In Nursing
Assessment
Diagnoses
Planning
Implementation
Collection of subjective and objective data
Analysis of subjective and objective data to make a professio…
Developing a plan of nursing care and outcome criteria
Carrying out the plan of care
Assessment
Collection of subjective and objective data
Diagnoses
Analysis of subjective and objective data to make a professio…
Health Assessment in Nursing
Nursing Assessments
Nursing Scope and Standards of Nursing…
Scope and Standards of practice for nu…
Assess is the
determine nursing interventions that directly or indirectly i…
the protection, promotion, and optimization of health and abi…
1. collect comprehensive data relevant to patient's health/si…
FIRST and most critical phase of the nursing process (ongoing…
Nursing Assessments
determine nursing interventions that directly or indirectly i…
Nursing Scope and Standards of Nursing…
the protection, promotion, and optimization of health and abi…
24 terms
Health Assessment for Nursing
First level Priority Problem
Second level Priority Problem
Third Level Priority Problem
Collaborative problems
-those that are emergent, life threatening, and immediate, su…
Are those that are next in urgency-those requiring your promp…
-Those that are important to the patients health but can be a…
-those in which the approach to treatment involves multiple d…
First level Priority Problem
-those that are emergent, life threatening, and immediate, su…
Second level Priority Problem
Are those that are next in urgency-those requiring your promp…
220 terms
Health Assessment in Nursing- VOCABULARY
ADLs
adrenarche
adventitious breath sounds
alopecia
activities of daily living
adrenocortical maturation, which occurs during puberty
abnormal breath sounds heard during auscultation of the lung…
hair loss
ADLs
activities of daily living
adrenarche
adrenocortical maturation, which occurs during puberty
189 terms
Nursing Health Assessment Terminology
Kyphosis
Pectus carinatum
Pectus excavatum
Barrel Chest
abnormal anterior-posterior curvature of the spine
sternum protruding from the chest
sternum sunken into the chest
chest wall increased anterior-posterior; ribs horizontal, cos…
Kyphosis
abnormal anterior-posterior curvature of the spine
Pectus carinatum
sternum protruding from the chest
32 terms
Nursing Health Assessment 4
ABCT
LOC
A standardized objective assessment th…
In temporal lobe associated with langu…
Appearance, Behavior, Cognition and Thought Process
Loss of Consciousness
Glascow coma scale
Wernicke's Area
ABCT
Appearance, Behavior, Cognition and Thought Process
LOC
Loss of Consciousness
126 terms
NURS228 Health Assessment in Nursing
assessment
diagnosis
planning
implementation
subjective and objective data
Analyze the subjective and objective data to make a nursing j…
determine the outcome and develop a plan
carry out the plan
assessment
subjective and objective data
diagnosis
Analyze the subjective and objective data to make a nursing j…
39 terms
BASIC NURSING HEALTH ASSESSMENT
Inspection
palpation
percussion
auscultation
visual examination of the exterior surface of the body
an examination technique in which the examiner's hands are us…
A diagnostic technique that uses tapping on the body to diffe…
listening for sounds in blood vessels or other body structure…
Inspection
visual examination of the exterior surface of the body
palpation
an examination technique in which the examiner's hands are us…
nursing final - health assessment
State of complete physical, mental, an…
Alcohol
Primary health prevention
secondary health prevention
What is health?
Third leading lifestyle-related cause of death for the nation…
prevent/slow the onset of disease
detect and treat illnesses in early stages
State of complete physical, mental, an…
What is health?
Alcohol
Third leading lifestyle-related cause of death for the nation…
153 terms
Health Assessment In Nursing
Assessment
Diagnoses
Planning
Implementation
Collection of subjective and objective data
Analysis of subjective and objective data to make a professio…
Developing a plan of nursing care and outcome criteria
Carrying out the plan of care
Assessment
Collection of subjective and objective data
Diagnoses
Analysis of subjective and objective data to make a professio…
9 terms
Nursing Health Assessment
Macule
Papule
Nodule
Tumor
Flat, nopalpable (freckle)
Palpable, circumscribed, elevated.
Elevated solid mass (deeper than papule)
Solid mass, deep subcutaneous
Macule
Flat, nopalpable (freckle)
Papule
Palpable, circumscribed, elevated.
153 terms
Health Assessment In Nursing
Assessment
Diagnoses
Planning
Implementation
Collection of subjective and objective data
Analysis of subjective and objective data to make a professio…
Developing a plan of nursing care and outcome criteria
Carrying out the plan of care
Assessment
Collection of subjective and objective data
Diagnoses
Analysis of subjective and objective data to make a professio…
131 terms
Health Assessment in Nursing
COLDSPA
HIPPA
ISOBAR
What is the golden rule?
Character... Onset... Location ... Duration... Severity... Pattern... Associate…
History... Inspection... Palpation... Percussion... Auscultation
Identify... Situation... Observation... Background ... Assessment... Recomen…
Explain, Explain, Explain
COLDSPA
Character... Onset... Location ... Duration... Severity... Pattern... Associate…
HIPPA
History... Inspection... Palpation... Percussion... Auscultation
74 terms
Nursing Health Assessment and Skills
Who Needs A Health Assessment?
Preventative Care
Subjective
Objective
Every person needs to have a complete assessment... Ideally done…
Primary prevention... -Focuses on improving overall wellness and…
- Symptoms... What the patient tells you... History... Chief complaint…
- Signs... What you see... Physical examination... Laboratory reports…
Who Needs A Health Assessment?
Every person needs to have a complete assessment... Ideally done…
Preventative Care
Primary prevention... -Focuses on improving overall wellness and…
39 terms
Nursing Health Assessment Review
Cardiac Output
S1
S3
S4
what goes out to body;... amt of blood ejected by left ventricle…
"lub" best heard at apex with diaphragm; sound produced by cl…
Kentucky. Abnormal heart sound. Occurs early in diastole duri…
Tennessee. 4th sound, if present occurs late in diastole or j…
Cardiac Output
what goes out to body;... amt of blood ejected by left ventricle…
S1
"lub" best heard at apex with diaphragm; sound produced by cl…
39 terms
Nursing Health Assessment
Cardiac Output
S1
S3
S4
what goes out to body;... amt of blood ejected by left ventricle…
"lub" best heard at apex with diaphragm; sound produced by cl…
Kentucky. Abnormal heart sound. Occurs early in diastole duri…
Tennessee. 4th sound, if present occurs late in diastole or j…
Cardiac Output
what goes out to body;... amt of blood ejected by left ventricle…
S1
"lub" best heard at apex with diaphragm; sound produced by cl…
280 terms
Fundamentals of Nursing, Health Assessment
Functions of the skin include:... A. pro…
You are conducting an in-service on ag…
Casey Galen, a student nurse, conducts…
Mrs. Jones is a 65-year-old patient wh…
C. All of the above.
D. All of the above
C. lifetime of environmental trauma.
B. keratosis and lentigines.
Functions of the skin include:... A. pro…
C. All of the above.
You are conducting an in-service on ag…
D. All of the above
280 terms
Fundamentals of Nursing, Health Assessment
Functions of the skin include:... A. pro…
You are conducting an in-service on ag…
Casey Galen, a student nurse, conducts…
Mrs. Jones is a 65-year-old patient wh…
C. All of the above.
D. All of the above
C. lifetime of environmental trauma.
B. keratosis and lentigines.
Functions of the skin include:... A. pro…
C. All of the above.
You are conducting an in-service on ag…
D. All of the above
20 terms
Health Assessment in Nursing (Intro)
SOAP (S)
SOAP (O)
SOAP (A)
SOAP (P)
Subjective Data: Health history patients relays to the health…
Objective Data: Examination of body systems and expected find…
Assessment: Diagnosis
Plan
SOAP (S)
Subjective Data: Health history patients relays to the health…
SOAP (O)
Objective Data: Examination of body systems and expected find…
24 terms
Health Assessment for Nursing
First level Priority Problem
Second level Priority Problem
Third Level Priority Problem
Collaborative problems
-those that are emergent, life threatening, and immediate, su…
Are those that are next in urgency-those requiring your promp…
-Those that are important to the patients health but can be a…
-those in which the approach to treatment involves multiple d…
First level Priority Problem
-those that are emergent, life threatening, and immediate, su…
Second level Priority Problem
Are those that are next in urgency-those requiring your promp…
280 terms
Fundamentals of Nursing, Health Assessment
Functions of the skin include:... A. pro…
You are conducting an in-service on ag…
Casey Galen, a student nurse, conducts…
Mrs. Jones is a 65-year-old patient wh…
C. All of the above.
D. All of the above
C. lifetime of environmental trauma.
B. keratosis and lentigines.
Functions of the skin include:... A. pro…
C. All of the above.
You are conducting an in-service on ag…
D. All of the above
12 terms
Health Assessment - Nursing Process
steps of health assessment
preparation for assessment
Collection of Subjective Data (Step 1)
Collection of Objective Data (Step 2)
1.Collection of subjective data. 2.Colleciton of objective da…
1.Review medical record. 2.Keep open mind/avoid premature jud…
Sensation or symptoms (pain/hunger) , feelings (happiness/sad…
Directly observed by the examiner; Data taken from the client…
steps of health assessment
1.Collection of subjective data. 2.Colleciton of objective da…
preparation for assessment
1.Review medical record. 2.Keep open mind/avoid premature jud…
98 terms
Health assessment in nursing
Assessment
What shape should the nursing process…
Purpose of a nursing health assesment
Initial comprehensive assessment
Most critical phase of the nursing process
Circular
Collect holistic subjective and objective data to determine a…
Involves collection of subjective data about the client's per…
Assessment
Most critical phase of the nursing process
What shape should the nursing process…
Circular
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