Intro To Health Assessment Flashcards
overview of what health assessment is
- Data
- Collection (objective and subjective)
- Clinical Judgment
- Evaluation
- Comprehensive or Focused
- Plan of Care (specific to them)
- Health Record
- Skills
- Body Systems
what is the nursing process and the steps (Exam)
Problem-Solving Approach
* Steps
* Assessment
* Analysis/Diagnosis
* Planning
* Implementation
* Evaluation
Scope of Practice Variations
basic skills of health assessment (Exam)
- Ethical Principles
- Nonmaleficence - cause no harm
- Beneficence - promote the best for the patient
- Autonomy - right to self-decision
- Justice - fairness for all
- Confidentiality - respecting right and maintaining privacy
- Safety
- Infection Control
- Privacy
- Mandated Reporting
- Communication skills
- Personal factors
therapeutic communication in health assessment
verbal
nonverbal
ISBARR
Identify (self and patient)
situation
background
assessment
recommendations
read-back orders
assessment techniques for health assessment
inspection
auscultation
palpation
percussion
documentation in health assessment
General Principles
* what needs to be documented?
* Electronic Records
* Paper Records
* Try to do it in “real-time”
comprehensive versus focused assessment
- comprehensive is of the whole body
- focused is likely just what is important to that specific person
(laboring mom, post surgery, person in the ER)
inspection
auscultation
palpation
percussion
inspection - looking
auscultation - listening to body sounds, often with the stethoscope
palpation - examination using the hands and fingers
percussion - striking or tapping and listening to the sounds produced
when would you auscultate before palpate
GI
- belly