Health Assessment Flashcards
Primary Health Promotion
Protection to prevent occurrence of disease
Example: immunization, nutrition, exercise
Secondary Health Promotion
Early ID of disease before It becomes symptomatic to hold the progression of pathological process.
Example: Screenings, self-exams ie. scoliosis, skin cancer, mammogram
Tertiary Health Promotion
Minimize severity and disability from disease through appropriate therapy for chronic disease. Example diabetes management, cardiovascular rehab)
Types of Assessments (CPESS)
-Comprehensive (head to toe/physical)
-Problem Based (severe cough)
-Episodic
-Shift (f/up)
-Screenings (disease detection)
Subjective Data
Symptoms reported from patient
Objective Data
Signs observed, felt,, heard, or measured.
Clinical Manifestations
Presenting signs and symptoms
Biological Data
Name, DOB, Gender, Race, Martial Status, Occupation
Reason for Seeking Care
If ill, Hx of present illness, including OLDCARTS
Present Health Status
Scale poor-excellent, Ht/wt, allergies, meds
Present Health History
Childhood illness, injuries, surgeries, hospitalization, immunization, last exams
Family History
Including: Integumentary, Head, Eyes, Ears, Nose, Mouth, Neck, Breast, Heart, Peripheral Vascular, Respiratory, GI, Urinary, Genitalia, Musculoskeletal,CNS, Endocrine,
Personal & Psychosocial Status/Hx
Mental health, support system, health promotion, drugs,tobacco, alcohol use
ROS
Integumentary, Head, Eyes, Ears, Nose, Mouth, Neck, Breast, Heart, Peripheral Vascular, Respiratory, GI, Urinary, Genitalia, Musculoskeletal,CNS, Endocrine,
ISBAR
I- Self Intro
S- Situation
B-Background
A-Assessment
R-Recommendations
Culture
Knowledge, beliefs, art, morals, laws, customs specific to a group of people
Ethnicity
Shared culture characteristics, languages, and beliefs Example (Filipino, Viet, Mexican)
Race
Asian, Caucasian, Hispanic, Black
Mental Status
Degree of intellectual, emotional, psychological, and personal competence. Involves memory, calculating, communication, judgment & reasoning.
Standard Drink
-12 oz of regular beer
-8-9 oz of malt liquor
-5 fl oz of table wine
-1.5 shots of spirits
Screening Tools
-PHQ-9 (Depression)
-C-SSR (Columbia-Suicide Severity Rating Scale)
-COWS (Drugs, Clinical Opiate Withdrawal Scale)
-AUDIT (Alcohol Use Disorders ID Test)
-SADQ (Severity of Alcohol Dependence Questionnaire)
-Human Trafficking
CLAS
Culturally and Linguistic Appropriate Services. Eliminate racial and ethnic disparities
A&Ox4
Awake, Alert, and Oriented to Person, Place, Time, and Event
Prone
Lying on stomach with hands flexed under head over a pillow
Area Assessed: Musculoskeletal
Supine
Laying on your back
Area Assessed: Head, Neck, Anterior Thorax & Lungs, Breast, Axilla, Heart, Abdomen, Extremities, Pulses
Sim’s
On your stomach with one leg up
Area assessed: Rectum and Vagina
Semi-Flower’s
Elevated to at least 30 degrees
Normal VS: Infant
HR: 100-160
Respiratory Rate: 30-53
BP:
-Systolic: 72-104
-Diastolic: 37-56
Normal VS: Toddler
HR: 98-140
RR: 22-37
Systolic: 86-106
Diastolic: 42-63
Normal VS: School-Age Child
HR: 75-118
RR: 18-25
Systolic: 97-115
Diastolic: 57-76
Normal VS: Adolescent
HR: 60-100
RR: 12-20
Systolic: 110-131
Diastolic: 64-83
Normal VS: Adult
HR: 60-100
RR: 12-20
BP: <120/<80
Assessment
A systematic method of collecting and analyzing data of for the purpose of planning patient centered care
3 levels of health promotion
Working out, eating healthy, sleeping, taking vitamins
Culture Competence
Adapting to your clients culture, acknowledge own biases and avoid stereotypes, non biased care
Ways to increase cultural sensitivity
learn about different cultures, respect opinions, and ask questions
CSSRS
Columbia Suicide Severity Rating Scale
COWS
Clinical Opiate Withdrawal Scale
CIWA & SADQ
Clinical Institute Withdrawal Assessment for Alcohol-Revised
Severity of Alcohol Dependence Questionnaire
PHQ-9
Patient Health Questionnaire for Depression
Nursing Proccess
A-Assessment
D-Decision
P-Process
I-Implementation
E-Evaluation
L.E.A.R.N
Listen, Explain, Acknowledge, Recommend, Negotiate
Mental Status
Degree of competence that a person shows in intellectual, emotional, psychological, and personality. A&Ox4
Mental Health
How the patient is doing, able to realize and recognize their own abilities and cope with normal stressors.
Interpersonal violence
Human trafficking screening tool
Open Ended Question
Done at the beginning of the exam if you or patient needs to describe something
Close Ended Questions
Short quick answers for medical history
Directive Questioning
Answer to a specific question such as “what is your eye color?”
Strategies to make Pt comfortable during challenging moments in an interview
-be comfortable
-“many patients use illicit drugs”
Personal and Psychosocial Status
“Have you had any thoughts of harming yourself or others? Do you feel safe at home and in your relationships?”
Health History Components
Biographical Data, Chief Complaint, Mental Status, Hx of present illness, Present Health Status, Past Health History (illnesses, surgery, immunizations, last ann phy, & menstrual cycle), Psychosocial Status (family and social relationships, support system, tobacco, illicit drugs, & alcohol use, ROS
Stethoscope
Auscultation do the heart and other organs & body cavities