Exam 1 Flashcards
Health Histoy consits of what type of data?
Subjective date
Subjective Data
Info about current state of health of patient, meds they take, previous illnesses, and surgeries, family history, and review of systems
Primary source data
Subjective data acquired directly from the patient
Secondary source data
Data acquired from another individual like family
Physical examination
A collection of objective data, sometimes referred to as signs. Data is collected by using techniques of inspection, palpation, percussion and auscultation. Also includes height, weight, blood pressure, temp, pulse rate, and respiratory rate
Signs
Objective data observed, felt, heard, or messured. Exp: rash, enlarged lymph nodes, and swelling of extremity
Symptoms
Subjective data perceived and reported by the patient. Exp: pain, itching, and nausea
Documentation of data
Require data to be recorded accurately, concisely, without bias or opinion, and at the point of patient care
Context of care
Circumstances contribute to the setting or environment; physical, psychological, or socioeconomic circumstances involving patients, and nurse expertise
Patient needs
Patient’s: age, general level of health, presenting problems, knowledge level, and support systems are among the variables that impact patient need
Types of health assessments(5)
Comprehensive assessment, Problem-based/focused assessment, Episodic/follow-up assessment, Shift assessment, and Screening assessment/examination
Comprehensive assessment
A detailed history and physical examination performed at the onset of care in a primary care setting
Problem-based/focused assessment
History and examination that are limited to a specific problem or complaint
Episodic/follow-up assessment
The assessment is done when a patient is following up with a health care provider for a previously identified problem
Shift assessment
Identify changes to a patient’s condition from the baseline
Screening assessment/examination
A short examination focused on disease detection
The nursing process(systemic)
Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
Health promotion
A behavior motivated by the desire to increase well-being and actualize human health potential
Health protection
A behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within constraints
3 levels of health promotion
Primary prevention: promotion of healthy lifestyles
secondary prevention: screening efforts for early detection
tertiary prevention: minimizing the disability from acute and chronic disease and maximize health
Interview process
How the health history is obtained and the success of an interview is the communication skills of the nurse
Phases of the interview(3)
Introduction, discusion, and summary
Introduction phase
Introduce self to patient and describes her role in the patients care, describe the purpose and process of the interview, you want a respectful and effective relationship
Discussion phase
Facilitates and maintains a patient-centered discussion and uses various communication techniques to collect data, detect disease early and prevent complications