Nursing Assesment Exam 1 Flashcards
What is Health Assessment?
The process of gathering, verifying, analyzing, communicating data about a patient
Purpose of a Health Assessment
To establish a database about the patient’s level of wellness, health practices, past illness, related experiences, health care goals
Basis for the patient’s individualized plan of care
Complete or comprehensive data
Total health data base- includes complete health history, full physical examination, laboratory and diagnostic test results, documentation of data. Describes current and past health state and forms baseline to measure all future changes, yields first diagnoses
Episodic or focused data
Problem-centered data base. For mimited or short-term problem, collect “mini” data base, smaller scope and more focused than complete data base, concerns mainly one problem, one cue complex, or one body system;History and exam follow direction of presenting concern:acute or chronic onset, as located with fever, local or generalized
followup database
Status of all identified problems should be evaluated at regular and appropriate intervals, note changes that have occurred , evaluate whether problem is getting better or worse, identity coping strategies being used.
Emergency data base
Rapid collection of data, often compiled concurrently with life saving measures, diagnosis must be swift and sure: person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness and disability are being assessed
Nursing Process
Assessment, diagnosis, outcome identification, planning, implementation, Evaluation
Collect data
Review of clinical record, interview, health history, physical exam, functional assessment, cultural and spiritual assessment, consultation, review of the literature
three levels of health promotion
Primary, secondary and Tertiary
Primary
Preventing disease from developing through promoting healthy lifestyle
secondary
Screening efforts to promote early detection of disease
tertiary
Treating to minimize disability from acute or chronic illness or injury and allowing for most productive life within limitations
Critical thinking
disciplined thinking that is clear, rational, open-minded and informed by evidence
critical thinking components
Scientific knowledge base, experience, competencies, attitudes, standards.