Health Assesment Exam 1
what does health assessment serve as the foundation for subsequent standards (assessment, diagnosis, outcome,
identification, planning, implementation, and evaluation)
health assessment is the core competency with what person centered care
what is the cycle of the components of a health collect health history (Subjective)
assessment perform physical exam (objective)
document data
analyze and interpret data
dev plan of care
(main points are HH, phys exam, document)
subjective data (Symptoms) what patient reports
objective data (Signs) what you observe/measure (vitals, inspection, labs, imaging)
documentation must be -accurate, concise, no bias, at point of care
-interpreted, organized, synthesized
-complete, accurate, descriptive
documentation serves as the baseline for eval of changes and decisions related to care
types of assessments comprehensive, problem-focused, follow-up (episodic), shift assessment, screening
comprehensive assessment -detailed history where learning everything about them
-new admissions (prim care/LTC/Hospital
-baseline; full HH + head to toe exam at onset of care
what does a comprehensive assessment encompass health problems, health promotion, disease prevention, assessment for probs
related w known risk factor of patient
problem focused assessment -where history and phys exam targeted to specific complaint or system (Ed or walk
in)
-consider potential impact of patient's underlying health status
ex. sore throat fracture
follow up (episodic) assessment re evaluation of identified problems and treatment efficacy
ex getting cast off
shift assessment -nurse conduct assessments each shift on hospitalized patients.
-focuses mostly about condition or prob patient is experiencing
what is the purpose of a shift assessment identify changes in a patient's condition from baseline
, Health Assesment Exam 1
screening assessment focused on disease detection (blood pressure screening, glucose screening,
cholesterol screening)
types of assessments are determine by -context of care (circumstances related to health care delivery)
-patient need (adaptive)
-health asses. skills
what is clinical judgement decision or conclusion reached by nurse which then drives action
clinical judgement depends on accurate collection/asses. of data and interpretation of data guides actions
what is clinical reasoning process to make sense of data collected
what does clinical reasoning involve analysis and interpretation of data based on nursing knowledge, current evidence
and best practice.
a problem list in clinical reasoning is what a key outcome of data analysis and interpretation that is a summary of health probs
identified from health assessment.
what factors go into a nurses expectations and clinical nurse's knowledge, experience/attitudes, ethical perspective, knowing the patient
judgement
what is noticing in a nurse's clinical judgement recog. a sit. is/isn't consistent w what is anticipated/expect to see
perpetual grasp of the situation
what is reflecting used for knowledge for future encounters
what is reflection IN action reflecting in midst of another situation
what is reflection ON action thinking abt prev situation and developing a better understanding of what happened
what is health promotion behavior motivated by desire to increase well-being and actualize human health
potential
what is health protection behavior motivated by desire to actively avoid illness, detect illnesses early, and
maintain functioning when ill w/in its constraints
what is primary prevention protection to prevent occurrence of disease (before it starts
through promotion of healthy lifestyles
ex. immunization, nutrition, exercise
, Health Assesment Exam 1
what is secondary prevention early identification of disease (before it becomes symptomatic) to halt the
progression of the pathologic process
ex. screening exams and self exam practices (bp screening, mammography)
what is tertiary prevention minimize severity and disability from disease through appropriate therapy for
chronic disease (managing disease) (and helping patient maximize health)
ex. diabetes mellitus management, cardiac rehab, hypertension management.
components of an interview -facilitating discussion to collect data
-reveal patient's story and provide foundation for personalized, safe, and effective
HC for each individual.
what does a successful patient interview include? selecting an appropriate physical setting, using a patient-centered approach, and
creating a positive rapport with the patient
-everyone is unique
The key parts of the physical setting of an interview are privacy, comfort, quiet without disctractions
- address everyone in room (See if need to leave or stay)
-sit eye to eye
-consider cultural norms
-personal space may vary
what is the premise of patient centered approach patients, families, and HC providers engage in shared decision making for all health
decisions
what factors play a role in the interview age, culture, gender identity and expression, language, physical or emotional
distress, sensory impairment, cognitive impairment
establishing rapport with a patient depends on what -professional behavior (ID badge, knocking, introducing self, dress)
-effective communication (interest, nonverbal cues, posture, eye contact, body
language)
during the introduction phase of the interview you should -greet the patient; introduce self (determine role of guests as well)
-establish purpose of visit from patient (set timeline)
-describe purpose and process of the interview (what you need from them)
during the discussion phase of the interview you should -facilitate and maintain patient centered discussion
what -use various communication skills and techniques to collect data (health history)
during the summary phase of the interview you should -summarize data with patient (that has implications for HP, disease prevention)
-allow patient to clarify data
-create a shared understanding of problems with the patient (validated patient)
-plan for next steps and end interview
what do open ended questions do encourage an open response, allow patients to describe in their own words
what are directive questions more specific, used to gather precise detail (1 or 2 word answers)
what are some techniques to enhance that interview active listening, facilitation, clarification, reflection (restate phrase), address
inconsistencies (btwn what reported what observed), interpretation, summarization
what does health assessment serve as the foundation for subsequent standards (assessment, diagnosis, outcome,
identification, planning, implementation, and evaluation)
health assessment is the core competency with what person centered care
what is the cycle of the components of a health collect health history (Subjective)
assessment perform physical exam (objective)
document data
analyze and interpret data
dev plan of care
(main points are HH, phys exam, document)
subjective data (Symptoms) what patient reports
objective data (Signs) what you observe/measure (vitals, inspection, labs, imaging)
documentation must be -accurate, concise, no bias, at point of care
-interpreted, organized, synthesized
-complete, accurate, descriptive
documentation serves as the baseline for eval of changes and decisions related to care
types of assessments comprehensive, problem-focused, follow-up (episodic), shift assessment, screening
comprehensive assessment -detailed history where learning everything about them
-new admissions (prim care/LTC/Hospital
-baseline; full HH + head to toe exam at onset of care
what does a comprehensive assessment encompass health problems, health promotion, disease prevention, assessment for probs
related w known risk factor of patient
problem focused assessment -where history and phys exam targeted to specific complaint or system (Ed or walk
in)
-consider potential impact of patient's underlying health status
ex. sore throat fracture
follow up (episodic) assessment re evaluation of identified problems and treatment efficacy
ex getting cast off
shift assessment -nurse conduct assessments each shift on hospitalized patients.
-focuses mostly about condition or prob patient is experiencing
what is the purpose of a shift assessment identify changes in a patient's condition from baseline
, Health Assesment Exam 1
screening assessment focused on disease detection (blood pressure screening, glucose screening,
cholesterol screening)
types of assessments are determine by -context of care (circumstances related to health care delivery)
-patient need (adaptive)
-health asses. skills
what is clinical judgement decision or conclusion reached by nurse which then drives action
clinical judgement depends on accurate collection/asses. of data and interpretation of data guides actions
what is clinical reasoning process to make sense of data collected
what does clinical reasoning involve analysis and interpretation of data based on nursing knowledge, current evidence
and best practice.
a problem list in clinical reasoning is what a key outcome of data analysis and interpretation that is a summary of health probs
identified from health assessment.
what factors go into a nurses expectations and clinical nurse's knowledge, experience/attitudes, ethical perspective, knowing the patient
judgement
what is noticing in a nurse's clinical judgement recog. a sit. is/isn't consistent w what is anticipated/expect to see
perpetual grasp of the situation
what is reflecting used for knowledge for future encounters
what is reflection IN action reflecting in midst of another situation
what is reflection ON action thinking abt prev situation and developing a better understanding of what happened
what is health promotion behavior motivated by desire to increase well-being and actualize human health
potential
what is health protection behavior motivated by desire to actively avoid illness, detect illnesses early, and
maintain functioning when ill w/in its constraints
what is primary prevention protection to prevent occurrence of disease (before it starts
through promotion of healthy lifestyles
ex. immunization, nutrition, exercise
, Health Assesment Exam 1
what is secondary prevention early identification of disease (before it becomes symptomatic) to halt the
progression of the pathologic process
ex. screening exams and self exam practices (bp screening, mammography)
what is tertiary prevention minimize severity and disability from disease through appropriate therapy for
chronic disease (managing disease) (and helping patient maximize health)
ex. diabetes mellitus management, cardiac rehab, hypertension management.
components of an interview -facilitating discussion to collect data
-reveal patient's story and provide foundation for personalized, safe, and effective
HC for each individual.
what does a successful patient interview include? selecting an appropriate physical setting, using a patient-centered approach, and
creating a positive rapport with the patient
-everyone is unique
The key parts of the physical setting of an interview are privacy, comfort, quiet without disctractions
- address everyone in room (See if need to leave or stay)
-sit eye to eye
-consider cultural norms
-personal space may vary
what is the premise of patient centered approach patients, families, and HC providers engage in shared decision making for all health
decisions
what factors play a role in the interview age, culture, gender identity and expression, language, physical or emotional
distress, sensory impairment, cognitive impairment
establishing rapport with a patient depends on what -professional behavior (ID badge, knocking, introducing self, dress)
-effective communication (interest, nonverbal cues, posture, eye contact, body
language)
during the introduction phase of the interview you should -greet the patient; introduce self (determine role of guests as well)
-establish purpose of visit from patient (set timeline)
-describe purpose and process of the interview (what you need from them)
during the discussion phase of the interview you should -facilitate and maintain patient centered discussion
what -use various communication skills and techniques to collect data (health history)
during the summary phase of the interview you should -summarize data with patient (that has implications for HP, disease prevention)
-allow patient to clarify data
-create a shared understanding of problems with the patient (validated patient)
-plan for next steps and end interview
what do open ended questions do encourage an open response, allow patients to describe in their own words
what are directive questions more specific, used to gather precise detail (1 or 2 word answers)
what are some techniques to enhance that interview active listening, facilitation, clarification, reflection (restate phrase), address
inconsistencies (btwn what reported what observed), interpretation, summarization
