Health Assessment, Health History, and Physical Examination Flashcards
The first and most critical phase of the nursing process
Health Assessment
On-going and continuous throughout all the phases of the nursing process
Health Assessment
The nurses analyzing the data and evaluating the client care outcomes
Nursing Process
Is circular, not linear
Nursing Process
Phases of the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
Collection of subjective data and objective data / Subjective Data / Objective Data
Assessment
Analysis of subjective data and objective data / NANDA
/ Actual, Risk, and Wellness
Diagnosis
Bound generation of solutions / ABC / High, Intermediate, and Low
Planning
Taking actions / SMART
Implementation
Assessing outcomes / Independent, Dependent, and Interdependent
Evaluation
The collection of holistic subjective and objective data
Focus of Health Assessment in Nursing
Composition of a Health Assessment
Health History
Physical Examination
Data of a Health Assessment
Physiological Manner
Psychological Manner
Sociocultural Manner
Developmental Manner
Spiritual Manner
Interdependent Factors of a Health Assessment
Mind
Body
Spirit
The organized information of each and every data
Framework for Health Assessment in Nursing
Four Sections of a Health Assessment
History of present health concern
Personal health history
Family health history
Lifestyle and health practices
The supposed knowledge of physiology
Using Evidence to Promote Health and Prevent Disease
Evidence-Based Health Promotion and Disease Prevention
Health People 2030
US Preventive Services Task Force / USPSTF
Aims to increase life span and improve quality of health for all Americans
Health People 2030
Determines risk versus benefits in screenings
US Preventive Services Task Force / USPSTF
The variation of the data collected
Types of Health Assessment
Four Basic Types of Nursing Assessment
Initial Comprehensive Assessment
Ongoing or Partial Assessment
Focused or
Problem-Oriented Assessment
Emergency Assessment
Collection of subjective data / Age, Risk Factors, Health Status, Health Promotion Practices, and Lifestyle
Initial Comprehensive Assessment
Composition upon comprehensive database / Acuity
Ongoing or Partial Assessment
Specific health concerns
Focused or
Problem-Oriented Assessment
Rapid life-threatening issues
Emergency Assessment
The client’s assessment phase of the nursing process
Steps of Health Assessment
Four Major Steps of Nursing Assessment
Collection of Subjective Data
Collection of Objective Data
Validation of Data
Documentation of Data
Functioned data / Biographical Information, History of Present Health Concern, Personal Health History, Family History, Health and Lifestyle Practices, and Review of Systems
Collection of Subjective Data
Physiological data / Physical Characteristics, Body Functions, Appearance, Behavior, Measurements, and Results of Laboratory Testing
Collection of Objective Data
Checked data
Validation of Data
Documented Data
Documentation of Data
The flow of the nurse meeting the client
Preparing for the Assessment
Nurse reviews the client’s medical record
Before
Nurse educates self about client’s diagnoses or tests performed / Nurse reflects on personal feelings about client’s encounter / Nurse obtains needed materials for client’s assessment
During
Nurse reviews the client’s status with others
After
The nurse using clinical judgement on the client
Analyzing Cues to Identify Client Concerns
Physiological complications
Collaborative Concern / Collaborative Problem
Client problems
Client Concern / Nursing Problem
Whole being alongside other healthcare professionals
Medicine or Discipline Concern / Referrals
Process of Data Analysis
Identify abnormal cues and supportive cues
Cluster cues
Draw inferences and identify and prioritize client concerns
Propose possible collaborative problems to notify primary care provider
Identify need for referral to primary care provider
Document conclusions
Collection of Data
Holistic Nursing Assessment
Medical Nursing Assessment
The content of the data to be verified / Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information
Subjective Data
The communication process of the nurse and client for subjective data / Establishment of rapport and gathered information.
Interviewing
Phases of the Interview
Preintroductory Phase
Introductory Phase
Working Phase
Summary and Closing Phase
Nurse reviews the client’s medical record / Interview
Preintroductory Phase
Nurse explains to the client
Introductory Phase
Nurse listens, observes cues, and uses critical thinking towards the client
Working Phase
Nurse summarizes the client’s supposed needs / Interventions
Summary and Closing Phase
Communication During the Interview
Nonverbal Communication
Verbal Communication
How the nurse is perceived by the client / Appearance, Demeanor, Facial Expression, Attitude, Silence, and Listening
Nonverbal Communication
How the client is probed by the nurse / Open-Ended Questions, Closed-Ended Questions, Laundry List, Rephrasing, Well-Placed Phrases, Inferring, and Providing Information
Verbal Communication
The variations of communication to be used
Special Considerations During the Interview
Geriatric Care
Gerontologic Variations in Communication
Culture Care
Cultural Variations in Communications
Emotional Care
Emotional Variations in Communication
The foundation of all clinical judgement
Complete Health History
Seven Sections of Health History
Biographical Data
Reasons for Seeking Health Care
History of Present Health Concern
Personal Health History
Family Health History
Review of Systems for Current Health Problems
Lifestyle and Health Practices Profile
Primary Source and all other Secondary Source
Biographical Data
What and How Question and Answers
Reasons for Seeking Health Care
Concern Description
History of Present Health Concern
Earliest Beginnings
Personal Health History
Genetics
Family Health History
Highlighted Issues
Review of Systems for Current Health Problems
Typical Day, Nutrition and Weight Management, Activity Level and Exercise, Sleep and Rest, Substance Use, Self-Concept and Self-Care Responsibilities, Social Activities, Relationships, Values and Beliefs System, Education and Work, Stress Levels and Coping Styles, and Environment
Lifestyle and Health Practices Profile
COLDSPA
Character
Onset
Location
Duration
Severity
Palliative
Associated Factors
The content of the data to be validated / Types and operation of equipment needed for the particular examination, preparation of the setting, oneself, and the client for the physical assessment, and the performance of the four examination techniques
Objective Data
The essential embodiment of clinical judgements / Assessing own feelings and anxieties, preventing transmission of infectious agents.
Preparing Oneself
General Principles of a Physical Assessment
Wash your hands
Always wear gloves
Discard pins
Wear your mask and protective eye googles
The establishment of a nurse-client relationship
Approaching and Preparing the Client
Respecting Client Desires and Requests
Present family or friend
Simple non-exposure of a certain body part
The nurse’s thorough and complete assessment of the client
Physical Examination Techniques
Four Basic Examination Techniques
Inspection
Palpation
Percussion
Auscultation
Comfortable temperature / Good lighting / Look and observe before touching / Completely expose the body part you are inspecting / Color, patterns, size, location, consistency, symmetry, movement, behavior, odor, or sounds / Appearance of symmetric body parts or both sides of any individual body part
Inspection
Texture / Temperature / Moisture / Mobility / Consistency / Strength of pulses / Size / Shape / Degree of tenderness / Light Palpation, Moderate Palpation, Deep Palpation, and Bimanual Palpation
Palpation
Determining location, size, and shape / Determining density / Determining abnormal masses / Eliciting reflexes / Direct, Blunt, Indirect
Percussion
Intensity / Pitch / Duration / Quality / Sound
Auscultation
Documentation
Communication
Legal Evidence of Care
Education
Financial Billing
Evaluation of Quality Care Rendered
Research and Statistical Information