Mod 1 pt2 Flashcards
the first and most critical phase of
the nursing process.
NURSING ASSESSMENT
Please study the ppt as well due to the fact that it is mostly graphs
STEPS OF
HEALTH
ASSESSMENT 4
- COLLECTIONOF SUBJECTIVEDATA
2.COLLECTION OF OBJECTIVEDATA
3.VALIDATIONOFDATA
4.DOCUMENTATIONOFDATA
sensations/ symptoms,
perceptions, desires,
preferences, beliefs,
ideas, values and
personal information
that can be elicited and
verified only by the
client
SUBJECTIVE DATA
provides a focus for the
physical exam and identify potential
nursing diagnoses
Health History
- Assists the client in focusing on the most significant health concern
- May be termed as chief complaint during initial physician interview
MAJOR HEALTH PROBLEM
Meaning of cold spa
Character onset location duration severity pattern associated factors affects the client
Describe the sign of symptoms feeling appearance sound smell or taste if applicable for example what does the pain feel like
Character
When did it begin when the pain start
Onset
Where is it does it radiate does it occur anywhere else
Location
How long does it last does it recur
Duration
How bad is it how much does it bother you
Severity
Better or worse
Pattern
What other symptoms occur with it how does it affect you
Associated factors how it affects the client
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
Females are indicated by a ___ while males are a
Circle and square
Deals with human responses, which includes nutritional habits, activity
and exercise patterns, sleep and rest patterns, self-concept and selfcare activities, social and community activities, relationships, values and
beliefs system, education and work, stress level and coping style and
environment
LIFESTYLE AND HEALTH
PRACTICES PROFILE
assessment of how the
client view herself including sexual responsibility, basic hygiene practices,
regularity of health care checkups, breast/testicular self-exam, and
accident and hazard protection
Self-Concept and Self-Care Responsibilities
helps the nurse discover outlets the client has for
support and relaxation and if the client in involved in the community
beyond the family and work
Social Activities
client describes the composition of the family into
which they were born and about past and current relationships with
these family members
Relationships
assesses the client’s values, philosophical,
religious and spiritual beliefs. Note that note all clients are comfortable
discussing their feelings and should be respected
Values and Belief System
identify areas of stress and satisfaction in the
client’s life, should bring about kind and amount of education the client
has, did the client enjoyed school or what he/she perceives his/her
education
Education and Work
investigate amount of stress the
clients perceive they are under and how they cope, how they address
events and how they usually respond
Stress Levels and Coping Styles
assess health hazards unique to the
client’s living situation and lifestyle.
Environment
