chapter 1 Flashcards
what is health assessment
a systematic method of collecting and analyzing data, plan of care
componenets of health assessment
history (subjective data) physical examination (objective data) documentation data
healthy people 2020
objectives adress most significant preventable threats to health with goals to reduce threats
health promotion
central component
begins with health ass.
interpretation of data allowed the nurse to target health promotion needs
knowing pt. issues = help them
components of health assessment
data collection
- symptom- subjective
- sign- clinical findings- objective
- clinical manifestation- signs and symptoms found
three levels of health promotion
primary
secondary
tertiary
primiary
preventing dieases through promtoing healthy lifestyle
secondary
screening efforts to promote early detection of disease
tertiarty
minimizing disabiltiy from acute or chronic illness or injury and allowing for most productive life with limitations
why is documenting of data important
- improves plan of care
- legal document
- baseline for evaluation, changes and decisions related to care
- accurate, concise, without bias
- done at time of care
where is a comprehensive health assessment done?
outpatient clinic/ doctor office
hospital setting/acute care
promblem- based or focused health assessment
emergency department
hospital setting
ex) having chest pain
episodic assessment
eposide of stroke, domestic violence
where are screening assessment taken place
health fair, public place that provides bp readings or cholesterol checks
experience of the nurse
gained with specialization within and area
ex) nurse in adult intensive care has expertise with pt who has hemodynamicinstability
organization and clustering
- allow problems to be more clearly apparent
- based on body system
- based on conceptual format (oxygenation, perfusion, mobility)
- identifying abnormal findings
- interpreting findings to select an appropriate plan of care
- applying clinical judgment to interpret the conclusion
- applying appropriate interventions
data analysis, interpretation, clinical judgment
steps to nursing process
assesment, analysis/diagnosis, planning, implenation, evaulation
nursing process explained
plaining client-centered care, realistic goals, plan of care, effectiveness
assessment
systematic, dynamic way to collect and analyze data about client
includes
-physiological data, sociocultural, spiritual, economic, lifestyle factors
diagnosis
clinical judgment about clients response to health condition and needs
(pt is pain, pain causes other problems)
outcome/planning
based on ass and diagnose nurse sets out measurable and achievable goals
implemenation
care is implemented according to care plan
evaluation
status and effectiveness countinuously evaluated
theraputic communication
important factor, gains pt trust, affected by numerous factors
TC techniques:clarifying
checking clients message for accuracy and clarity
TC techniques: focusing
centering on key elements
TC techniques:paraphrasing
breifily restating the message in ones own words
TC techniques:reflection
responding to content and emotional components by restating clients feelings
TC techniques:summarizing
reviews important aspects of communication
TC techniques:confrontation
point out inconsistencies in clients behaviors and feelings
TC techniques:providing information
client make a decison and feel safe and secure
Levels of communication: Transpersonal
within a persons spiriutal domain, prayer, imagery
Levels of communication: intrapersonal`
self talk, verbilization of inner thought. allows for development of self awareness and expression
Levels of communication: interpersonal
face to face interation. results in exchange of ideas, problem solving, expression feeling, personal growth
levels of communication: public
interation with an audeince, presenation to community group about a health care topic
assertive
most effective
direct but kind
orientation phase
nurse elicits, ask for info
- verbal or nonverbal techniques may be used
- arm position
- facial expression
- body position
communication process: feedback
indicates whether the client understands the message
communication process: channel
means of conveying and receiving messages through the use of sense
communication process: environment
the setting for the interaction between nurse and client
communication process: message
content of communication
communcation break down
passive response
showing disapproval
false reassurance
sympathy
