introduction to health assessment Flashcards
why learn health assessment? What do nurses use it for?
- health assessment is a systematic method of collecting and analyzing data
- used to create patient centered plan of care
- utilize the American standard of nursing practice
what are the 3 components of a health assessment?
- history
- physical exam / objective data
- take both and document the data
what is health history? what step of the health assessment is it?
- history consists of subjective data, what the patient and their family says about the patients condition / current problem
what is a physical examination or objective data? and what part if the health assessment is it?
- it’s what the nurse can see, smell, hear
- also doing a physical assessment like vital signs
what are the two main components of data collection?
- subjective data
- objective
what is the third part of the health assessment?
- document the data of subjective and objective data (health history & physical exam)
- the nurse wants to be able to have a clear picture of everything other staff need to know about the patient to take the best care of them
what is subjective data? what are some examples?
- what the patient says, feels, states
- ex: pain levels & descriptions, emotional state, symptoms that aren’t directly observable
what are objective findings? and what are some examples?
- signs, clinical findings collected during examination
- vital signs, blood levels, height & weight, ect
what are clinical manifestations?
- signs & symptoms put together
what does the amount of info gained during a health assessment depend on?
- multiple factors:
- context of care; how the ER or urgent care is different from just a check up
- patient need; maybe the PT needs a TB best for school vrs. if they have a heart attack and need immediate attention
- health assessment skills; staffs skills will change with time, experience, & unit
what are the 5 different types of health assessments?
- comprehensive health assessment
- problems based / focused based health assessment
- shift assessment
- episodic assessment / follow up
- screening assessment
what is a comprehensive health assessment?
- full head to toe assessment
- assessment of everything
- most in depth & detailed
what is a problem based / focused based health assessment?
- an exam based on what the pt is being seen for
- on one area
what is a shift assessment?
- assessment on what was at a scheduled time to assess their needs, regardless of patient condition
what is an episodic or follow up assessment?
- going back to check on PT if the complained of something, or gave them something to improve a symptom or health issue
- ex: if PT requested pain meds, going back in 30 min to see if pain was improved or not
what is a screening assessment?
- screening for something just to be safe, PT does not have any complaints or signs, just to check everything off
what is health promotion?
- behavior motivated by the desire to increase wellbeing and actualize human health potential
what is health promotion/prevention?
- behavior motivated by the desire to actively avoid illness detected early to maintain functining within its limitations
what are the 3 levels of health promotion?
- primary
- secondary
- tertiary
what is primary health promotion / prevention
- preventative measures that prevent the onset of illness or injury before the disease process begins
- ex: regular immunizations, regular exercise
what is secondary health promotion / prevention
- preventive measures that lead to early diagnosis and prompt treatment of disease, illness, or injury to prevent more severe problems developing
-ex: screening for high bp, breast self exam
what is tertiary health promotion / prevention
- preventive measures that stops a already present disease from getting worse
