HEALTH ASSESSMENT PRACTICE TEST REVIEW

HEALTH ASSESSMENT PRACTICE TEST REVIEW Identify the role of the professional nurse in health assessment. - CORRECT ANSWER1. Promotes health (state of optimal functioning or well-being with physical, social and mental components) 2. Prevents illness (primary, secondary and tertiary) 3. Treat human responses to health or illness 4. Advocate for individuals, families, communities and populations. From lecture--Direct and indirect caregiving-advocacy--scholarship and researchState the purpose of health assessment. - CORRECT ANSWER-Gathering info about health status of the patient, analyzing and synthesizing those data, making judgements about nursing interventions based on findings, and evaluating patient care outcomes. Includes both hx and physical. Helps you collect pt's past medical and surgical histories, risk factors and current symptoms. May also gain further info into pts. current condition and establish a database against which subsequent assessments can be measured. ID patterns and trends to tell whether pt is getting better or worse. Lecture: Assess overall health of client. Analyze physical findings, lab, health history, ets & come up with care plan based on this data the nurse will make judgements about interventions then evaluate outcomes. Identify the roles of the nursing process, critical thinking, and diagnostic reasoning in nursing care. - CORRECT ANSWER-Serve as a framework for providing individualized care not only to individuals but also for families and communities. It is patient centeredfocused on solving probs and enhancing strengths. Parts include ASSESSING the pt, analyzing the data and making a DIAGNOSES, determining pt. outcomes or PLANNING care, IMPLEMENTIGN and then EVALUATING the pts. status to determine whether interventions were effective. Continue to evaluate and revise as required. So assess, diagnose, ID the formulation of measurable, realistic, patient-centered outcomes (goals), Make a care plan that includes resources targeting nursing interventions and write care plan, implement and evaluate. Nursing Process--ADPIE - CORRECT ANSWER-Assess Diagnose Plan Implement Evaluate Recognize differences in the types and frequencies of assessments - CORRECT ANSWER-*Emergency Assessment-involves a life-threatening or unstable situation such as pt in ED who has experienced a traumatic injury. Use triage to determining level of urgency with A-airway, B- Breathing, C-Circulation, D-Disability, E-Exposure. Life threatening problems require initiation of critical interventions. *Comprehensive- includes a complete health history and physical assessment. Would be part of annual physical and actually rarely happens. Is done annually on an outpatient basis, following admission to a hospital of long term care facility, or every 8 hrs. for pts. in ICU *Focused Assessment- is based on the pt's health issues, Focused usually at urgent care and focuses on the illness/condition that brought the pt into the clinic. Occur in all settings including the clinic, hospital and home health setting. Frequency of assessment depends on the seriousness of pts condition which is related to the setting for care. Hospitalized pts. may be assessed every shift change. LTC pts. may only be assessed once per month. ICU pts can be assessed hourly. Also periodic (annual) well visits Identify the components of comprehensive health assessment - CORRECT ANSWERDemographic data, complete description of he reason for seeking healthcare, history of present illness (where it hurts, duration/frequency of problem, intensity of pain, description of pain, what makes the pain better or worse, pain goal, functional goal). Current meds and indication, family history, functional health assessment (ADLs). In pediatrics ask growth and development questions. Review systems about all body systems (include objective data/vital signs) Describe the frameworks for collecting health assessment data - CORRECT ANSWER3 major frameworks for organizing assessment data: Functional systems, head-to-toe system and body systems. Helps you stay organized so you don't skip anything. Functional = How does pt's health affect their ability to function in daily life. (handle their ADLs). Ex: Want to be able to drive to the grocery but has a health problem that prevents them from driving. Head-to-Toe-Most organized system for gathering comprehensive physical data. Not done on every single pt but following the head-to-toe route is a good way to organize your assessment. Body systems - Organized and completed by system: Gastro, urinary, pulmonary, cardiac, etc. Because all systems are interrelated, it's hard to isolate and assess only one at a time. Most commonly followed by specialists such as cardiologists only looking at CV system. Differentiate between subjective and objective data - CORRECT ANSWER-Subjective data = WHAT THE PATIENT TELLS YOU. ANY DATA YOU CAN'T OR DON'T SEE,HEAR OR FEEL.Feelings, sensations, experiences and perceptions. Objective is measurements Data the RN sees, hears or feels. Also includes measurements such as lab reports, & standard measurements such as vital signs, weight, etc.. Apply effective communication skills - CORRECT ANSWER-Pg 22-26 Keep in mind a pts' cultural beliefs. Assess the patient's perceptions of the health care system. Focus on the pt and their concerns. Assist pt to work through feelings and explore options related to the situation, outcomes and treatments. Be empathetic. (seeing situation from pt's perspective). Use verbal and nonverbal communication skills and use active