Chapter 1 & 2: Importance of Health Assessment and the Interview Flashcards
What is the purpose of a Health Assessment ?
it’s a systematic method of collecting and analyzing data for the purpose of planning patient-centered care
What are the ANA’s Standards of Practice aka The Nursing Process ?
- Assessment
- Analysis/Diagnosis
- Outcome Identification
- Planning
- Implementation
a) coordination of care
b) Health Teaching and Health Promotion - Evaluation
Nursing Process:
Assessment
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
Nursing Process:
Analyze/Diagnosis
analyze the assessment data to determine actual or potential diagnoses, problems, or issues
- more analyze since Nurses don’t diagnosis (physicians do)
Nursing Process:
Outcome Identification
identifying expected outcomes for a plan we make for our patient or the situation
- What is the goal now ?
Nursing Process:
Planning
developing a plan that prescribes strategies to attain expected, measurable outcomes
- How will we obtain our goal and what will we do ?
Nursing Process:
Implementation
coordination of the care and putting it into action
- carrying out the plan and putting it into action
Nursing Process:
Evaluation
evaluate progress toward attainment of goals and outcome
- reaccess and see if the goals/outcomes were met
What are the components of a Health Assessment ?
- Conducting a Health History
- Physical Examination
- Documenting the Findings/Data
Health History
subjective data collected during an interview
- biographic data
- family history
- current medications
- preview illnesses and surgeries
- personal and psychosocial history
- review of systems
Primary Source Data
subjective data directly from the patient
Secondary Source Data
subjective data from another individual
Objective Data
data we collect and/or observe as a Nurse
- signs like rashes, enlarged lymph nodes, swelling of an extremity
- felt
- heard
- measured
- observed
Subjective Data
symptoms perceived and/or reported by the patient
- pain, itching, nausea,
Physical Examination
gathering of objective data - can be through palpation, inspective, percussion
- Ex) pulse rate, blood pressure, temperature, etc.
What is the purpose of the EHR (electronic health record) ?
to integrate documentation of care across participating health systems for any single patient
What are the levels of Health Promotion ?
- Primary Prevention
- Secondary Prevention
- Tertiary Prevention
Primary Prevention
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
Secondary Prevention
Screening efforts that at-risk people take to promote the early detection of disease
- mammograms
- pap smears
- prostate exams
- blood pressure screenings
- concussion screenings
Tertiary Prevention
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
What is the difference between Health Promotion and Health Protection ?
- 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
What is a Comprehensive Assessment ?
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
What is a Problem Based/Focused Assessment ?
limited to a specific problem or complaint
- like for a sprained ankle
- commonly used in walk-in clinics or the ER
What is an Episodic/Follow-Up Assessment ?
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
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
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
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
Chief Complaint/Presenting Problem
the main reason you go to seek care
- you record this in quotes
Review of Systems
subjective data collected directly from the patient regarding his/her perception of the body systems
What are the Components of the Past Health History ?
- childhood illnesses
- surgeries
- hospitalizations
- accidents or injuries
- immunizations
- last examinations
- obstetric history
What are the components of the Present Health Status ?
- current health conditions
- medications
- allergies
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
What are the Phases of the Interview ?
- Intro- introduce yourself, describe the purpose of the interview, describe interview process
- Discussion- facilitate and maintain patient-centered discussion
- Summary- summarize the data with the client, allow patient to clarify the data, plan for the next steps and end interview
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
Facilitation
using phrases to encourage patient to continue
- “go-on” and “ok”
- nodding, shifting forward in seat
Clarification
obtaining more information about conflicting, vague, or ambiguous statements
- “what do you mean by that”
Restatement
a way to gain clarification by restating a phrase
- encourages elaboration and confirms interpretation
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
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
Interpretation
opportunity to share conclusions drawn from given data
- allows patients to confirm, deny, or revise information
Summary
condenses and orders data obtained during the interview to help clarify a sequence of events
Context of Care
the circumstances or situations related to the health care delivery
- environment, setting
- physical, psychological, or socioeconomic circumstances surrounding patients
