Assessment Flashcards
i. Diagnosis & treatment of human response
ii. Actual & potential responses
Nursing Diagnosis
Interview Considerations
i. Obtain good health history
ii. Open approach
iii. Verbal/non-verbal communication
iv. SOLER
v. Active historian-do they remember their health history
vi. Determine is pt priority same as our priority
Important Health Information
Medications
Allergies
Surgery or other treatments
PE: Objective Data
General Survey
General Survey Statement has what included?
Body Features mental state speech body movements obvious physical signs nutritional status behavior Vitals signs & BMI (may be included)
i. Emergency or life-threatening situation
ii. Rapid history/examination of pt while supporting vital functions
Emergency assessment
i. Includes a detailed health history & PE of all body systems
ii. Done on admission to hospital or onset of care in PC setting
Comprehensive assessment
i. Abbreviated health history/examination
ii. Assess particular problem
Focused assessment
i. How patient best learns & how we assess what they need to know at that time
ii. What do they need to know about the topic?
Learning assessment
Learning assessment includes: (5 things)
Readiness to learn Prior experiences Motivation to learn orientation to learning self concept