Chapter 1: Importance of Health Assessment Flashcards
Standards of Practice
The first six standards are based on the nursing process (i.e.,
assessment, diagnosis, outcome identification, planning,
implementation, and evaluation
signs
are objective data observed, felt, heard, or measured.
Examples of signs include rash, enlarged lymph
nodes, and swelling of an extremity.
Standard 5: Implementation
The registered nurse implements the identified plan.
5A: Coordination of Care—The registered nurse coordinates
care delivery.
5B: Health Teaching and Health Promotion—The registered
nurse uses strategies to promote health and a safe
environment.
5C: Consultation—The graduate level–prepared specialty
nurse or APRN provides consultation to influence the
identified plan, enhance the ability of others, and effect
change.
5D: Prescriptive Authority and Treatment—The APRN uses
prescriptive authority, procedures, referrals, treatments,
and therapies in accordance with state and federal laws
and regulations.
symptoms
are subjective data perceived and reported by
the patient. Examples of symptoms include pain, itching,
and nausea.
clinical judgment
“an interpretation
or conclusion about a patient’s needs, concerns, or health
problems and/or the decision to take action (or not), use or
modify standard approaches, or improvise new ones asdeemed appropriate by the patient’s response.”
According to Tanner
clinical judgment is
influenced more by the nurse’s experiences, knowledge, attitudes,
and perspectives than the data alone
the process of clinical
judgment includes four components
noticing, interpreting,
responding, and reflecting.
Primary prevention
Protection to prevent occurrence of disease Immunizations, pollution control, nutrition, exercise
secondary prevention
Early identification of disease before it
becomes symptomatic to halt the
progression of the pathologic process Screening examinations and self-examination
practices (e.g., colorectal screening, mammography,
blood pressure screening)
tertiary prevention
Minimize severity and disability from disease through appropriate therapy for chronic disease Diabetes mellitus management Cardiac rehabilitation Hypertension management
comprehensive assessment
This involves a detailed
history and physical examination performed at the onset of
care in a primary care setting or on admission to a hospital
or long-term care facility. The comprehensive assessment
encompasses health problems experienced by the patient;
health promotion, disease prevention, and assessment for
problems associated with known risk factors; or assessment
for age- and gender-specific health problems
problem based/focused assessment
The problem based
or problem-focused assessment involves a history
and examination that are limited to a specific problem or
complaint (e.g., a sprained ankle). This type of assessment
is most commonly used in a walk-in clinic or emergency
department, but it may also be applied in other outpatient
settings. Although the focus of data collection is on a specific
problem, the potential impact of the patient’s underlying
health status also must be considered.
episodic/follow up assessment
This type of assessment
is usually done when a patient is following up with a
health care provider for a previously identified problem. For
example, a patient treated by a health care provider for
pneumonia might be asked to return for a follow-up visit
after completion of antibiotics. An individual treated for an
ongoing condition such as diabetes is asked to make
regular visits to the clinic for episodic assessment
shift assessment
When individuals are hospitalized,
nurses conduct assessments each shift. The purpose of
the shift assessment is to identify changes in a patient’s
condition from baseline; thus the focus of the assessment
is largely based on the condition or problem the patient is
experiencing. Adapting an assessment to the hospitalized
patient is discussed in
screening assessment
A screening assessment, or
screening examination, is a short examination focused on
disease detection. A screening examination might be performed
in a health care provider’s office (as part of a comprehensive
examination) or at a health fair. Examples
include blood pressure screening, glucose screening, cholesterol
screening, and colorectal screening.
Health promotion
is
behavior motivated by the desire to increase well-being and
actualize human health potential.
Health protection
is behavior
motivated by a desire to actively avoid illness, detect it
early, or maintain functioning within its constraints
Standard 1: Assessment
The registered nurse collects comprehensive data pertinent
to the health care consumer’s health and/or the situation.
Standard 2: Diagnosis
The registered nurse analyzes the assessment data to determine
the diagnoses or issues.
Standard 3: Outcome Identification
The registered nurse identifies expected outcomes for a plan
individualized to the health care consumer or the
situation.
Standard 4: Planning
The registered nurse develops a plan that prescribes strategies
and alternatives to attain expected outcomes
Standard 6: Evaluation
The registered nurse evaluates progress toward attainment
of outcomes
The Institute of Medicine identified five core competencies as essential for health care professionals to demonstrate how to respond effectively to patient care needs:
provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics
Pain assessment, review of symptoms, surgical history, and social history are considered
subjective data
The context of care refers the
circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to physical, psychological, or socioeconomic circumstances involving patients, or the expertise of the nurse
