Chapter 1: Intro to Health Asses Flashcards
Health assessment refers to
A systematic method of collecting and analyzing data for the purpose of planning patient-centered care.
When collecting health data you should take into account the patient’s…
age, gender, culture, ethnicity, physical, psychological, and socioeconomic status. Alao the patient’s strengths, weaknesses, health problems, and deficits. Lastly, the patient’s knowledge, motivation, support systems, coping ability, and preferences.
What are the six standards listed within the American Nurses Association’s Standards of Practice?
Assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
What are the five core competencies identified by the institute of medicine?
Provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics.
Are symptoms objective or subjective?
Subjective
Are signs objective or subjective?
objective
How are you gathering objective data during a physical assessment?
Inspections, palpation, percussion, auscultation.
What objective data are you gathering during a physical assessment?
Height, weight, blood pressure, temperature, pule rate, respiratory rate, oxygen saturation
What is clinical manifestation?
a term used to describe the presenting signs and symptoms experienced by the patient.
Standards of Practice: Define Assessment
RN collects pertinent data/info relative to the consumer’s health or the situation.
Standards of Practice: Define Diagnosis
RN analyzes the assessment data to determine actual or potential Dx, problems, or issues.
Standards of Practice: Define Outcome Identification
RN identifies expected outcomes specifically for the health care consumer/situation
Standards of Practice: Define Planning
RN develops a plan that prescribes strategies to attain expected, measurable outcomes
Standards of Practice: Define Implementation
RN implements identified plan through COORDINATION OF CARE and HEALTH TEACHING AND HEALTH PROMOTION
Standards of Practice: Define Evaluation
RN evaluates progress toward attainment of goals and outcomes
5 steps to plan care?
Collect health history, perform phys exam, document data, analyze/interpret data, develop plan of care.
What are the five types of health assesments?
Comprehensive, problem-based/focused, episodic/follow up, shift, screening
Health Assessments: Comprehensive
Involves detailed hist and phys exam performed at onset of care (primary setting) or admission to hosp/long term care facility. Encompasses: health promotion, disease prevention, and assessment for problems associated with known risk factors, asses for age/gender specific
Health Assessments: Problem-Based/Focused
Req hist and phys exam that is limited to a specific problem or complaint. Commonly used in walk-in clinics or emergency dpt, outpatient. Must also consider whether underlying health will impact issue at hand.
Health Assessments: Episodic/Follow up
FUV w/ health care provider.
Health Assessments: Shift
Assessments conducting by nurses each shift in a hospital environment. Assessment is usually focused around issue at hand
Health Assessments: Screening
short exam focused on disease detect. performed at provider’s office as part of comp exam (BG screening, BP screening, cholesterol screening)
How do nurses make judgments
Under an umbrella of context (nurse’s knowledge, experience, ethical perspective, and knowing the patient) a nurse interprets and reflects on info and goes between noticing and responding.
