Chapter 1 & 2: Importance of Health Assessment and the Interview Flashcards

1
Q

What is the purpose of a Health Assessment ?

A

it’s a systematic method of collecting and analyzing data for the purpose of planning patient-centered care

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2
Q

What are the ANA’s Standards of Practice aka The Nursing Process ?

A
  1. Assessment
  2. Analysis/Diagnosis
  3. Outcome Identification
  4. Planning
  5. Implementation
    a) coordination of care
    b) Health Teaching and Health Promotion
  6. Evaluation
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3
Q

Nursing Process:
Assessment

A

collecting data and information relative to the patient’s health or the situation
- can be through percussing, palpating, oscillation, etc
- info we gather from our patients

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4
Q

Nursing Process:
Analyze/Diagnosis

A

analyze the assessment data to determine actual or potential diagnoses, problems, or issues
- more analyze since Nurses don’t diagnosis (physicians do)

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5
Q

Nursing Process:
Outcome Identification

A

identifying expected outcomes for a plan we make for our patient or the situation
- What is the goal now ?

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6
Q

Nursing Process:
Planning

A

developing a plan that prescribes strategies to attain expected, measurable outcomes
- How will we obtain our goal and what will we do ?

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7
Q

Nursing Process:
Implementation

A

coordination of the care and putting it into action
- carrying out the plan and putting it into action

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8
Q

Nursing Process:
Evaluation

A

evaluate progress toward attainment of goals and outcome
- reaccess and see if the goals/outcomes were met

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9
Q

What are the components of a Health Assessment ?

A
  1. Conducting a Health History
  2. Physical Examination
  3. Documenting the Findings/Data
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10
Q

Health History

A

subjective data collected during an interview
- biographic data
- family history
- current medications
- preview illnesses and surgeries
- personal and psychosocial history
- review of systems

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11
Q

Primary Source Data

A

subjective data directly from the patient

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12
Q

Secondary Source Data

A

subjective data from another individual

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13
Q

Objective Data

A

data we collect and/or observe as a Nurse
- signs like rashes, enlarged lymph nodes, swelling of an extremity
- felt
- heard
- measured
- observed

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14
Q

Subjective Data

A

symptoms perceived and/or reported by the patient
- pain, itching, nausea,

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15
Q

Physical Examination

A

gathering of objective data - can be through palpation, inspective, percussion
- Ex) pulse rate, blood pressure, temperature, etc.

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16
Q

What is the purpose of the EHR (electronic health record) ?

A

to integrate documentation of care across participating health systems for any single patient

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17
Q

What are the levels of Health Promotion ?

A
  1. Primary Prevention
  2. Secondary Prevention
  3. Tertiary Prevention
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18
Q

Primary Prevention

A

steps that everyone takes to prevent the development of a disease through the promotion of a healthy lifestyle
- immunization
- healthy diet
- exercise
- drinking water
- wear sunscreen and avoid the sun

19
Q

Secondary Prevention

A

Screening efforts that at-risk people take to promote the early detection of disease
- mammograms
- pap smears
- prostate exams
- blood pressure screenings
- concussion screenings

20
Q

Tertiary Prevention

A

Steps that people take to minimize the severity of a disease that they already are diagnosed with
- insulin management
- hypertension management
- diet for diabetes management
- cardiac rehabilitation

21
Q

What is the difference between Health Promotion and Health Protection ?

A
  • Health Promotion is behavior motivated by the desire to increase you’re well-being and actualize human health potential
  • Health Protection is behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within it’s constraints
22
Q

What is a Comprehensive Assessment ?

A

detailed history and physical exam at the onset of care in a primary care setting
- includes a full examination of the body systems
- like admission to a hospital or long-term care facility
- encompasses things like health problems the patient has, health promotion, disease prevention, etc

23
Q

What is a Problem Based/Focused Assessment ?

A

limited to a specific problem or complaint
- like for a sprained ankle
- commonly used in walk-in clinics or the ER

24
Q

What is an Episodic/Follow-Up Assessment ?

A

when a patient is following up with a healthcare provider for a previously identified problem
- like a pneumonia follow-up or regular visits for diabetes

25
Shift Assessment
head-to-toe assessment at routine times during a shift or based on changes - purpose is to identify changes to the patient's condition
26
Screening Assessment/Examination
short, focused on a specific potential problem - can be performed in a healthcare provider's office or a health fair - blood pressure screenings - glucose screenings - cholesterol screenings
27
What is the purpose of a Health History?
obtain important info from the patient so a plan to promote health, prevent disease, resolve acute health problems can be developed
28
Chief Complaint/Presenting Problem
the main reason you go to seek care - you record this in quotes
29
Review of Systems
subjective data collected directly from the patient regarding his/her perception of the body systems
30
What are the Components of the Past Health History ?
1. childhood illnesses 2. surgeries 3. hospitalizations 4. accidents or injuries 5. immunizations 6. last examinations 7. obstetric history
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What are the components of the Present Health Status ?
1. current health conditions 2. medications 3. allergies
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Why is the Family History important ?
it can affect the patient's current or future health - a genogram is an easy way to diagram any illnesses or dieases
33
What are the Phases of the Interview ?
1. Intro- introduce yourself, describe the purpose of the interview, describe interview process 2. Discussion- facilitate and maintain patient-centered discussion 3. Summary- summarize the data with the client, allow patient to clarify the data, plan for the next steps and end interview
34
Active Listening
listening with a purpose - concentrate on what the patient is saying and don't try to anticipate what they may say - noticing verbal and nonverbal cues and focus on the patient's response
35
Facilitation
using phrases to encourage patient to continue - "go-on" and "ok" - nodding, shifting forward in seat
36
Clarification
obtaining more information about conflicting, vague, or ambiguous statements - "what do you mean by that"
37
Restatement
a way to gain clarification by restating a phrase - encourages elaboration and confirms interpretation
38
Reflection
responding to the content and emotional components of a message by stating the patient's feelings - Ex.) "that must have been frustrating to go through" - empathizing
39
Confrontation
used when inconsistencies are noted between reports and observation - careful with your tone of voice because it's easy for this to go negative
40
Interpretation
opportunity to share conclusions drawn from given data - allows patients to confirm, deny, or revise information
41
Summary
condenses and orders data obtained during the interview to help clarify a sequence of events
42
Context of Care
the circumstances or situations related to the health care delivery - environment, setting - physical, psychological, or socioeconomic circumstances surrounding patients
43