NURS 301 Health Assessment Exam 1 Focused Review

To establish a baseline, build a rapport with patients, create a baseline and collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgement. Compare and contrast medical assessment from nursing health assessment. Medical assessment – focuses primarily on the client’s physiologic status. Example: pain, airway, vital signs, ECG, labs, medication, discharge education Nursing health assessment- its sub and objective data collection and is ongoing and continuous to get the overall patients physical level of functioning Describe the phases of the nursing process involved in health assessment by the nurse. Assessment: collecting objective and subjective data Diagnosis: analyzing sub and obj to make a professional nursing judgment Planning: determine outcome criteria and developing a plan Implementation: carrying out the plan Evaluation: assessing whether outcome criteria have been met and revision of the plan if needed. Compare and contrast subjective from objective data Compare and contrast the four basic types of nursing assessment: Subjective data is what the patient tells us, things we can’t confirm. Objective are what we evaluate and see and do. Ex: vital signs, rashes. (a) initial comprehensive is the full physical assessment usually done the first time the pt is seen. Full physical health history review of systems and head to toe. (b) ongoing or partial -after comprehensive is database is established. Ex: pt admitted to hx required frequent assessments of o2, lungs or abdomen. Etc... (c) focused/problem oriented Is a brief individualized examination mainly on what the problem is leading to ex. Appendicitis=abdominal assessment. (d) emergency is a physical examination done when time is a factor treatment must begin immediately. Describe the three phases of a client interview process. Give examples on what occurs in each phase. Introductory: introduction, explaining the purpose, types of questions that will be asked, assuring confidentiality, making sure the client is comfortable and privacy. Developing trust and rapport Working: bio data, reason for seeking care, past health history and family history, review of body systems. Lifestyle and health practices. Summary and closing-summarizing information validating problems and goals, identifying and discussing plans to resolve problems with clients, is there anything else the client needs or any questions. Describe effective verbal and nonverbal communication techniques to collect subjective client data. Identify verbal communication to avoid during a client interview. Describe ways to adapt the interview for the older client. Verbal: open-ended questions “how or “what” Ex: how have you been feeling today? Closed ended questions “when or did” only can answer to that question Ex: when did the nausea start? rephrasing, providing information. Non-verbal- appearance, demeanor, facial expressions, silence, listening, posture and attitude. Things to AVOID: biased or leading questions, rushing, reading the questions. Too much or too little eye contact, distraction, or standing. Describe the purpose of performing genogram. Helps organize and illustrates the client’s family history. It helps us see if there are health problems that run in the family and those of genetic predisposition. .............................................CONTINUED................................