HEALTH ASSESSMENT - INTRO - S2 Flashcards
- essential nursing function
- helps identify clinical needs and problems
HEALTH ASSESSMENT
state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 1948)
HEALTH
collecting data about client’s health status
HEALTH ASSESSMENT
evaluation of health status by performing physical exam
ASSESSMENT
HEALTH HISTORY + PHYSICAL EXAMINATION =
HEALTH ASSESSMENT
a response of a person to a disease
ILLNESS
4 CLASSIFICATION OF ILLNESS
- ACUTE
- CHRONIC
- TERMINAL
- AGE-RELATED ILLNESS
collects holistic subj and obj data to determine a client’s overall level of functioning
HOLISTIC NURSING ASSESSMENT
focuses on client’s physiologic development status
PHYSICAL MEDICAL ASSESSMENT
corresponding to his state of health without discrimination within the limits of the resources
RIGHT TO APPROPRIATE MEDICAL CARE
right to clear, truthful and substantial explanation
RIGHT TO INFORMED CONSENT
EXAMPLES OF EXCEPTION OF INFORMED CONSENT
- Emergency cases of imminent risk of physical injury
- When the health population is dependent
informed consent shall be obtained
spouse
child of legal age
parents
bro/sis
guardian
privacy of the patient must be assured at all stages of his treatment
RIGHT TO PRIVACY AND CONFIDENTIALITY
in the course of treatment, the patient or his legal guardian has the right to be informed of the result of evaluation
RIGHT TO INFORMATION
free to choose medical practitioner that will serve him/her
RIGHT TO CHOOSE HEALTH CARE PROVIDER AND FACILITY
right to avail himself of any recommended diagnostic and treatment
RIGHT TO SELF DETERMINATION
right to refuse medical treatment/procedures which may be contrary to his religious beliefs
RIGHT TO RELIGIOUS BELIEFS
entitle to a summary of his medical history and condition
RIGHT TO MEDICAL RECORDS
right to leave the hospital
RIGHT TO LEAVE
has the right to be advised if the health ace provider plans to involve him/her in medical research
RIGHT TO REFUSE PARTICIPATION IN MEDICAL RESEARCH
right to communicate with relatives and other persons and to receive visitors
RIGHT TO CORRESPONDENCE AND TO RECEIVE VISITORS
right to express complaints about the care and services
RIGHT TO EXPRESS GRIEVANCES
duty of any health care institution to inform their patients of his right
RIGHT TO BE INFORMED OF HIS RIGHTS AND OBLIGATIONS AS A PATIENT
5 PHASES OF NURSING PROCESS
ASSESSMENT, DIAGNOSIS, PLANNING, IMPLEMENTATION, EVALUATION
collecting subj and obj data (COLLECTION)
ASSESSMENT
analyzing subj and obj data to make nursing judgement (nursing diagnosis) (ANALYSIS)
DIAGNOSIS
determining outcome criteria and developing a plan (PLAN SOLUTION)
PLANNING
carrying out the plan (TAKE ACTIONS)
IMPLEMENTATION
assessing whether outcome criteria have been met and revise plan if necessary (ASSESS OUTCOME)
EVALUATION
2 comprehensive HA
- HEALTH HISTORY
- PHYSICAL EXAMINATION
from patient (SYMPTOMS)
SUBJ
seen by examiner (SIGNS)
OBJ
4 TYPES OF HA
INITIAL COMPRE
ONGOING/PARTIAL
FOCUSED OR PROBLEM ORIENTED
EMERGENCY ASSESSMENT
3 STEPS OF HA
- COLLECTION (SUBJ & OBJ)
- VALIDATION OF DATA COLLECTED
- DOCUMENTATION OF DATA
