M1_HA Flashcards
According to _____, Date? , a nurse’s scope of practice puts emphasis on diagnosis and treatment of human responses based on ______________________
ANA, 2010, ACCURATE CLIENT ASSESSMENTS
Role in health assessment: the standards
STANDARD 1: COLLECTS COMPREHENSIVE DATA PERTINENT TO THE PATIENT’S HEALTH OR SITUATION
STANDARD 2: Analyzes the assessment data to determine diagnoses or issues:
T or F
The most marketable nurses will continue to
be those with STRONG ASSESSMENT and
CLIENT TEACHING ABILITIES as well as those
who are TECHNOLOGICALLY SAVVY.
T
What trends should be keep in mind?
- Increased focus on primary care
- Increasing complexity of acute care
- Growing aging population
- Intensifying mental health issues
- Expanding service networks
The purpose of _______________ differs greatly from that of a medical or other type of health care assessment.
nursing assessment
PURPOSE: collect HOLISTIC. Subjective and
objective data to determine OVERALL LEVEL
OF FUNCTIONING in order to make a
PROFESSIONAL CLINICAL JUDGMENT
nursing assessment
In nursing assessment, the nurse collects these types of data about the clients
physiologic, psychological, sociocultural, developmental and spiritual
used to organize
information and promote the
collection of holistic data
Nursing Framework
Generic and basic Sections include in nursing framework for HA are:
History of Present Health Concern
Personal Health History
Family History
Lifestyle and Health Practices
PHYSICAL ASSESSMENT
Types of Health Assessment
- INITIAL COMPREHENSIVE ASSESSMENT
- ONGOING/ PARTIAL ASSESSMENT
- FOCUSED/ PROBLEM-ORIENTED ASSESSMENT
- EMERGENCY ASSESSMENT
A type of HA INCLUDES:
Subjective data about client’s perception of health
Initial Comprehensive Assessment
A type of HA INCLUDES:
Past health history
Initial Comprehensive Assessment
A type of HA INCLUDES:
Objective data gathered from Physical Examination
Initial Comprehensive Assessment
A type of HA INCLUDES:
Family history, lifestyle and health practices
Initial Comprehensive Assessment
A TOTAL health assessment is needed when the
client FIRST enters a health care system and
periodically thereafter
Initial Comprehensive Assessment
Depends on age, risk factors, health status , health
promotion and lifestyle
Initial Comprehensive Assessment
Consists of data collection that occurs after
the comprehensive database is established
ONGOING / PARTIAL ASSESSMENT
Mini-overview of the client’s body systems and
holistic patterns as a follow-up on health status
ONGOING / PARTIAL ASSESSMENT
Reassessment of health problems detected to
determine changes and detect any new
problems
ONGOING / PARTIAL ASSESSMENT
Performed whenever the nurse encounters a
client
ONGOING / PARTIAL ASSESSMENT
Determined by acuity of the client
ONGOING / PARTIAL ASSESSMENT
Performed when a comprehensive
database exists for a client who
comes to a healthcare facility with a
specific health concern
FOCUSED / PROBLEM-ORIENTED ASSESSMENT
Consists of thorough assessment of a
particular client problem and does not
address areas not related to the
problem
FOCUSED / PROBLEM-ORIENTED ASSESSMENT
Very rapid assessment performed
in life-threatening situations to
provide prompt treatment
EMERGENCY ASSESSMENT
Used to determine the status of
the client’s life-sustaining physical
functions
EMERGENCY ASSESSMENT
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted to the medical surgical ward for the first time in preparation for an abdominal surgery
Initial Comprehensive Assessment
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted due to gunshot wound and bleeding
profusely
EMERGENCY ASSESSMENT
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted 3 days ago for evaluation of anti-cancer medication side effects
ONGOING / PARTIAL ASSESSMENT
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted to the medical surgical ward for monitoring of respiratory status
FOCUSED / PROBLEM-ORIENTED ASSESSMENT
the first and most critical phase of
the nursing process.
Assessment
If _________________ is inadequate
or inaccurate, incorrect nursing judgments may be
made that adversely affect the remaining phases of
the process
data collection
Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
The steps of a nursing process are interrelated, forming a continuous circle of thought and action that is both dynamic and cyclic, according to?
Doenges and Moorhouse, 2008
In the nursing process, it’s the information collection or gathering data
assessment
In the nursing process, it’s the information interpretation or stating problems or strengths
diagnosis
In the nursing process, it’s settling nursing goals, desired outcomes and planning interventions
planning
In the nursing process, it’s the patient’s status and effectiveness of nursing interventions
evaluation
In the nursing process, it’s performing nursing interventions
Implementation
THE NURSE’S ROLE IN ASSESSMENT: Based on the __________, the nurse ___________________?
Nursing Scope of Practice, “collects comprehensive data
pertinent to the patient’s health or situation”
T or F
The nurse focuses on how the client’s health status
affects activities of daily living and how clients interact
within their family and community
T
proponents of HEALTH BELIEF MODEL
Becker & Rosenstock, 1987
Based on 3 concepts which is existence
of sufficient motivation, belief that one is
susceptible/ vulnerable to a serious
problem and the belief to change
following a health recommendation
HEALTH BELIEF MODEL
in HEALTH BELIEF MODEL these are the gender, class, age, etc.
demographic variables
in HEALTH BELIEF MODEL these are the personality, peer group pressure, etc.
Psychological characteristics
the 5 variables in HEALTH BELIEF MODEL
perceived susceptibility
perceived severity
health motivation
perceived benefits
perceived barriers
proponents of HEALTH PROMOTION MODEL
Pender, 1996
in HEALTH PROMOTION MODEL these are the individual characteristics and experiences
- prior related behavior
- personal factors: biological, psychological, sociocultural
in HEALTH PROMOTION MODEL these are the behavior-specific cognitions and affect
- perceived benefits of action
- perceived barriers to action
- perceived self-efficacy
- activity-related affect
interpersonal influences (family, peers, providers), norms, supports, models - situational influences: options, demand characteristics, aesthetics
STEPS OF HEALTH ASSESSMENT
- COLLECTION OF SUBJECTIVE DATA
2.COLLECTION OF OBJECTIVE DATA
3.VALIDATION OF DATA
4.DOCUMENTATION OF DATA
provides basic biographical data, chronic illness and clues on how present illness affects patient’s ADL.
medical record and other members of the health team
sensations/ symptoms, perceptions, desires, preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the client
SUBJECTIVE DATA
considered a primary source and all others are secondary sources
Patient
provides a focus for the physical exam and identify potential
nursing diagnoses
Health History
It should begin with an explanation to
the client of why the information is
being requested
COMPLETE HEALTH HISTORY
When students are collecting information and sharing in a form of academic discussion, ___________ must be deleted, and ______ are used to protect the client’s privacy
identifiable information, initials
REASONS FOR SEEKING HEALTH CARE May be termed as this during initial physician interview
chief complaint
Question that Assists the client in focusing on the most significant health concern
WHAT IS YOUR MAJOR HEALTH PROBLEM OR CONCERNS AT THIS TIME?
question that Encourages the client to discuss fears or other feelings about having to see a health care
provider
HOW DO YOU FEEL ABOUT HAVING TO SEEK HEALTH CARE?
Encourage the client to explain the health problem or symptom in as much
detail as possible and what the client perceives as causing the problem
HISTORY OF PRESENT HEALTH
CONCERN
he information gathered here will help the nurse evaluate the client’s insight
into the problem and the client’s plans for managing it
HISTORY OF PRESENT HEALTH
CONCERN
In HISTORY OF PRESENT HEALTH CONCERN Ask the client to?
- Evaluate what makes the problem worse
- what makes it better
- previous management/treatment done
- what effect the problem has had with daily life and ability to provide self-care
MNEMONICS FOR SYMPTOM ANALYSIS
C - character
O - onset
L - location
D - duration
S - severity
P - pattern
A - associated factors / how it affects the client
In symptom analysis, it gives the time or it questions when did it begin?
onset
In symptom analysis, it describes the sign or symptom
character
In symptom analysis, it questions, where is it? Does it radiate? Does it occur anywhere else?
location with radiation
In symptom analysis, it questions, how long does it last? Does it recur?
duration
In symptom analysis, it questions, how bad is it? How much does it bother you?
severity
In symptom analysis, it questions, what makes it better or worse?
pattern
In symptom analysis, it questions, what other symptoms occur with it? How does it affect you?
associated factor / how it affects the client
example of characteristics in symptom analysis
feeling
appearance
sound
smell
taste
Other MNEMONICS FOR SYMPTOM ANALYSIS
L - location
O - onset
C - character
S - severity
T - timing
A - associated symptoms
A - aggravating / alleviating factors
M - meaning
&
P - provoking / relieving
Q - quality
R - region and radiation
S - severity
T - time
on the PQRST, it questions,
1. what brings the pain on?
2. what makes it better?
3. what makes it worse?
4. what medications are you using at the moment?
5. how often are you taking them?
6. do they help?
7. do they cause any side effects?
8. have you taken anything else in the past for this pain?
9. what was the effect of that?
provoking / relieving
on the PQRST, it questions,
1. Describe the pain.
2. what does it feel like (stabbing, burning, sharp, aching)?
quality
on the PQRST, it questions,
1. where is the pain?
2. does it spread anywhere else?
region and radiation
on the PQRST, it questions,
1. how severe is the pain? Now? at its worst? at its least? most of the time?
2. how does the pain affects your daily activities?
severity
on the PQRST, it questions,
1. when did the pain start?
2. is it constant or intermittent?
3. how often does it occur?
4. how long does it last?
time
This portion focuses on questions related to:
* Childhood illnesses and immunizations
* Adult co-morbidities
* Past surgeries/ accidents
* Prolonged episodes of pain, allergies and prescription medications
PERSONAL HEALTH HISTORY
T or F
in PERSONAL HEALTH HISTORY, you should Note client’s perception about themselves during discussion.
T
T or F
in PERSONAL HEALTH HISTORY, you should Use open-ended questions as much as possible.
T
what basic or general section of NURSING FRAMEWORK FOR HEALTH ASSESSMENT include maternal and paternal grandparents, aunts and uncles, parents, siblings and children?
FAMILY HISTORY
what basic or general section of NURSING FRAMEWORK FOR HEALTH ASSESSMENT you Should include many genetic relatives as the client can recall?
FAMILY HISTORY