Exam 1 Flashcards
Health History: ADPIE
Assessment 🡪 collecting _______ and _______ ___
______ and most ______
May lead to inaccurate or inadequate, incorrect clinical judgements if completed incorrectly
ongoing and continuous through all phases!
More than just gathering information
Assessment 🡪 collecting subjective and objective data
first and most critical
May lead to inaccurate or inadequate, incorrect clinical judgements if completed incorrectly
ongoing and continuous through all phases!
More than just gathering information
Health History: ADPIE
Diagnosis 🡪
analyzing subjective and objective data to make a professional nursing judgement (nursing diagnosis, collaborative problem, or referral)
Health History: ADPIE
Planning 🡪
determining outcome criteria and developing a plan
Health History: ADPIE
Implementation 🡪
Implementation 🡪 carrying out the plan
Health History: ADPIE Evaluation 🡪
assessing whether outcome criteria have been met and revising the plan as necessary.
Physical medical assessment 🡪
focuses primarily on the client’s physiologic development status
Holistic Nursing Assessment 🡪
collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment
(Mind, body, and spirit interdependent factors that affect each client’s level of health)
Health History: four basic sections-
History of Present Health Concern
Personal Health History
Family History
Lifestyle and health practices
Types of nursing assessments: ______ or _____
Ongoing or partial:
Continued data collection after comprehensive assessment
Mini overview
Reassessed any problems
Detect any new problems
Types of nursing assessments: (2)
Focused:
Does not replace comprehensive assessment
Thorough assessment of particular client problem
Does not address areas not related to problem
Type of nursing assessments: (3)
Emergency:
- Very rapid assessment in life-threatening situations
- Goal = provide prompt treatment
- Only concern is preventing death
Type of nursing assessments: (4)
Comprehensive:
- Subjective data
- Past health history
- Family history
- Lifestyle and health - practices
- Objective data
- Frequency depends on age, risk factors, health status, health promotion practices, lifestyle
Steps of Health Assessment: step 1- preparing for assessment
Review clients record & status with other health care team members
Educate about client’s diagnosis and tests performed
Reflect on personal feelings regarding initial encounter with client
Obtain and organize materials needed for assessment.
Steps of Health Assessment: step 2- collection of _____ data
Collection of subjective data – what the patient tells you
Biographical information
History of present health concern; physical symptoms related to each body part or system
Personal health history
Family history
Health and lifestyle practices
Review of systems
Steps of Health Assessment step 3- Collection of objective data – what you observe
Physical characteristics
Appearance
Body functions
Behavior
Measurements
Results of lab tests
Steps of Health Assessment step 4- ______ of data
Validation of data
Crucial part of assessment
Ensures assessment process is not ended before all relevant data have been collected
Helps prevent documentation of inaccurate data
Steps of Health Assessment, step 5-
Documentation of data
Forms the database for entire nursing process
Provides data for all other members of health care team
Ensures valid conclusions are made
***Steps tend to overlap – may perform 2-3 steps concurrently
Steps of Health Assessment: step 6-
Finally 🡪 analyzing cues to identify client concerns
Identify abnormal cues and supportive cues 🡪 cluster cues!
Draw inferences and identify and prioritize client concerns
Propose possible collaborative problems to
notify primary care giver
Identify need for referral to primary care provide
Document conclusions
Components of health history assessments: 1
Biographic data:
a) Name, address, and phone number
b) Age, birth date, and birthplace
c) Gender (identification) and relationship status
d) Race and ethnic origin
e) Occupation: usual and present
f) Primary language
g) Source of history:
Judge reliability of informant and how willing he or she is to communicate - reliability leads to consistency of information (record who provides information)
Note any special circumstances, such as use of interpreter
Patient = primary source & all other sources (including health record) = secondary source
Components of health history assessments: 2
Reason for seeking care:
a) What is your major health concern? How do you feel about having to seek care?
b) NOT a diagnostic statement
c) Symptom – subjective sensation, documented in “quotes”
d) Sign – objective abnormality detected on physical exam or lab reports
COLDSPA- C
Character= s/s? descriptive terms?
COLDSPA- O
Onset = when did it begin
COLDSPA- L
Location = where is it? does it radiate?
COLDSPA- D
Duration = how long? recurring
COLDSPA- S
Severity = how bad? how much does it bother pt?
COLDSPA- P
Pattern = what makes it better? what makes it worse?
COLDSPA- A
Associated factors = other accompanying s/s and how it affects the pt
Third component of health history assessment is
Present Health or HPI (COLDSPA, PQRSTU):
PQRSTU (for pain)- P
Provocative
Palliative
what provokes or relieves pain?
PQRSTU (for pain)- Q
Quality - describe character of pain (sharp, stabbing, aching)
PQRSTU (for pain)- R
Radiates - is pain localized or does it radiate?
PQRSTU (for pain)- S
Severity- how bad is the pain? interfere with ADLs or sleep? rate 1-10
PQRSTU (for pain)- T
Timing- when does pain occur & how long does it last? how long before it reoccurs?
PQRSTU (for pain)- U
Understand= pt’s perception of problem
What is the purpose of the review of systems
Evaluate past and present state of each body system, assess all pertinent data relative to each body system & evaluate health promotion practices
What is considered Holistic Patient care
Review of systems & Health Promotions
Health Promotions 🡪
process of enabling people to increase control over, and to improve, their health.
