Lesson 1 Flashcards
A state of complete physical, mental, and social well being and not merely the absense of disease or infirmity
Health of WHO
It focuses on both health history and physical examination
Nursing Health Assessment
It is used to evaluate the overall status of an individual
Nursing Health Assessment
It involves systematic data gathering that provides pertinent information (verbal/nonverbal) to facilitate a plan to deliver the quality nursing care for thr patient
Health Nursing Assessment
The systematic and continuous collection, organization, validation, and documentation of information
Assessment
Involved gathering of data
Assessment
Those that can be described only by the patient by the patient / the person
Subjective
Those that can be observed or measured
Objective
What type of data: dizzeness
Subjective
What type of data: Paleness / palor
Objective
What type of data: results of diagnostics
Objective
What type of data: nausea / vomiting
Can be both depends
What type of data: quality of pain
Subjective
What type of data: rashes
Objective
What type of data: bp, rr, pr, temperature
Objective
What type of data: diaphoresis
Objective
What type of data: fear, nervousness, anxiety
Subjective
What type of data: skin discoloration
Objectibe
What type of data: facial crimase
Objective
It is a planned, purposeful conversation
Interview
Who’s the primary source of data
Patient
What do you use in gathering data for health history
Interview
The method of data collection that uses of senses
Ovservation
The method of data collection that use units of measure
Observation
The method of data collection : interpretation of laboratory results
Observation
What are the secondary sources of data
Fanily
Friends
Health team members
Patient’s record or chart is what source of data
Secondary source
In depth assessment of the patients health status,,,, that usually takes place in the admission or transfer to a hospital or health care agency
Initial Comprehensive / Admission Assessment
Continuous assessment of the patients health status accompanied by monitoring and observation of specific problems identified in a mini, initial comprehensive or focused assessment
On-going time lapsed or partial assessment
An assessment of a specific condition, problems, identified risk or assessment of care
Focused Assessment/ Problem-oriented Assessment
A snapshot view of the patient based on a quick visual and physical assessment
Emergency Assessment
What is the first thing we get in emergency assessment?
ABC
Airway
Breathing
Circulation
Where do nurses gathers patient’s data?
Health history
Physical examination
It is used to analyze the patient data and develop hypotheses as to the patients problem
Clinical Reasoning Process
What are the foundation of clinical assessment?
Health history and Physical assessment
Is symptoms subjective or objective data?
Subjective
Is signs subjective or objective data?
Objective
This develops between the nurse and the patient and a mutual trust begins
Rapport
The use of this is beneficial as an instrument in assisting the new nurse to formulate relavant and interrelated questions
OLDCART
What is OLDCARTS
Onset
Location
Duration
Characteristics
Associated Manifestation
Relieving Factors
Treatment
Severity
Where the sign of symptom is located
Location
What the symptoms feels like, how it is described, and the severity
Characteristics
Anything that the patient has tried to relieve the signs or symptoms
Relieving Factors
When the sign or symptoms started
Onset
Any interventions the patient has previously tried
Treatment
What else is goin on when the patient experiences the signs and symptoms
Associated Manifestation
How long the sign has been going on
Duration
The use of pain scale or score
Severity
It is the subjective and objective data gathered duting the initial health history and physical examination
Assessment
This is essential to elicit pertinent information about the patient, family, and the community in order to provide the best care for the patient
Therapeutic Communication
A continuing process that determines if the goals or outcomes have been attained
Evaluation
The nurse uses clinical reasoning to formulate this base on the assessment data
Diagnosis
It is devising the best course of action to address the patient’s diagnosis
Planning
Indicated how well repeated measurements of the same relatively stable phenomenon will give the same result
Reliability
When observation or test is negative in people with the disease
Sensitivity
When observation or test is positive in people without the disease
Specificity
Indicated how closely a given observation agress with the “true state of affairs”
Validity
This is also knows as precision
Reliability
The best possible measure of reality
Validity
May be measured for one observer or for more than one observer
Reliability
