Notes from textbook reading Flashcards
ADPIE
Assessment, diagnosis, Planning, implementation, evaluation
types of health assessment
- initial comprehensive assessment
- ongoing or partial assessment
- focused or problem-oriented assessment
- emergency assessment
Steps of health assessment
- collection of subjective data
- collection of objective data
- validation of data
- documentation of data
Initial Comprehensive Assessment
involves collection of subjective data about the client’s perception of their health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client’s overall functioning) as well as objective data gathered during a step-by-step physical examination.
Ongoing or Partial Assessment
consists of data collection that occurs after the comprehensive database is established. This consists of a mini overview of the client’s body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data
Focused or Problem-Oriented Assessment
does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not address areas not related to the problem.
Emergency Assessment
very rapid assessment performed in life-threatening situations (Fig. 1-4). In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.
What are types of subjective data?
- Biographical information (name, age, religion, occupation, etc.)
- History of present health concern: physical symptoms related to each body part or system (e.g., eyes and ears, abdomen)
- Personal health history
- Family history
- Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment)
- Review of systems
- Physical characteristics (e.g., skin color, posture)
- Body functions (e.g., heart rate, respiratory rate)
- Appearance (e.g., dress, hygiene)
- Behavior (e.g., mood, affect)
- Measurements (e.g., blood pressure, temperature, height, weight)
- Results of laboratory testing (e.g., platelet count, x-ray findings)
Process of Data Analysis
- Identify abnormal cues and supportive cues.
- Cluster cues.
- Draw inferences and identify and prioritize client concerns.
- Propose possible collaborative problems to notify primary care provider.
- Identify need for referral to primary care provider.
- Document conclusions.
Nonverbal communication to avoid during interviews
- excessive or insufficient eye contact
- distraction and distance
- standing
Verbal communication to avoid during interviews
- biased or leading questions
- rushing through the interview
- reading the questions
What are open-ended questions?
Open-ended questions are used to elicit the client’s feelings and perceptions. They typically begin with the words “how” or “what.” An example of this type of question is: “How have you been feeling lately?”
Closed-Ended Questions
Use closed-ended questions to obtain facts and to focus on specific information. The client can respond with one or two words. Closed-ended questions typically begin with the words “when” or “did.” An example of this type of question is: “When did your headache start?”
When interacting with an anxious client
- Provide the client with simple, organized information in a structured format.
- Explain who you are, along with your role and purpose.
- Ask simple, concise questions.
- Avoid becoming anxious like the client.
- Do not hurry, and decrease any external stimuli.
