Health Assessment Exam 1 (ch. 1-4)

Health Assessment Exam 1 (ch. 1-4) health assessment ans: term in nursing used to include health history and physical exam health history ans: - info from patient and medical records - gathered data about patient through guided questions/pkt to fill out - provide dates whenever possible - pt telling their story (subjective) - beginning of the nursing POC physical exam ans: - completed by nurse/provider - be systematic **do the same every time** - trend findings - DOCUMENT assessment ans: term used by PROVIDERS to include the medical diagnosis plan ans: term used by PROVIDERS to include how they will tx the dx primary, secondary, and tertiary ans: 3 levels of prevention primary ans: prior to onset of problems secondary ans: screening tertiary ans: rehab assessment, diagnosis, planning, implementation, and evaluation ans: steps of the nursing process (patient is the focus!!) assessment ans: - subjective data (symptoms) - objective data = measurable (signs) - clump data to SUPPORT DX diagnosis ans: - what is the problem or potential problem? - subjective and objective data MUST support nursing dx planning ans: - what is the goal of care? - what interventions are needed to get to the goal? - how long should this take? implementation ans: - now do what you planned (update changes) evaluation ans: - was the goal achieved? onset, location, duration, characteristics of symptoms, associated characteristics, relieving factors, treatment, severity/scale ans: OLD CARTS - for questioning onset, provoking factors, quality, region/radiation, severity, time/treatment, understanding/impact ans: OPQRSTU - for questioning feelings, ideas, function, expectations ans: FIFE - explore pt's perspective mutual agreement, pt empowerment, and achievable POC ans: Why FIFE/explore pt's perspective? feelings ans: FIFE - fears or concerns about problem ideas ans: FIFE - about nature and cause of problem function ans: FIFE - effect on pt's life expectations ans: FIFE - of disease, health care team, or health care based on prior experiences therapeutic communication ans: the act of developing pt rapport nonverbal, active listening, accepting, exploring, reflecting, restating, and guiding ans: characteristics of therapeutic communication active listening ans: listening more than talking accepting ans: never using "why?" exploring ans: "tell me more..."; "go on.." reflecting ans: validation within therapeutic communication restating ans: making sure you heard the pt correctly and emphasize important points guiding ans: using open vs. closed ended questions the silent patient ans: - active listening - nonverbal cues - do not try to fill silence with words the confusing patient ans: - multiple symptoms, positive review of symptoms, provider should focus on context of symptoms, emphasize patient's perspective, and guide the interview into a psychosocial assessment - assess mental status - **know the law** - check responses against chart or seek permission to speak with family members the patient with AMS ans: - power of attorney or next of kin - **know the law** - always seek the best-informed source the talkative patient ans: - utilize guiding, reflecting, and restating - give free reign for first 5-10 minutes - set limits where needed - may need to schedule 2nd meeting the crying patient ans: - use reflecting, active listening, and showing support - accept displays of emotions and support the angry patient ans: - use reflecting, active listening, and safety precautions - validate their feeling without agreeing with their reasons - stay calm, do not get angry in return - move to a more private location ESL/non-english speaking patient ans: - use QUALIFIED translator - all written info should be in pt's native language ethics ans: set of principles crafted through reflection and discussion to define what is right and wrong - medical = guide professional behavior confidentiality ans: - key quality that fosters a nurse-patient relationship - info. may on be shared with appropriate health care team members - nurse's obligation to protect pt info - HIPPA interviewing process ans: - demands effective communication and relation skills - need ability to elicit accurate info - need interpersonal skills to respond to pt's feeling and concerns - *** always be aware of your affect on the pt... you may need to adjust your tone, posture, facial expressions, or simply slow the conversation down and address any OVERT issues/concerns *** pre-interview, intro, working, termination ans: interview phases pre-interview ans: setting the stage, plan for the interview, make goals introduction ans: - put patient at ease, establish trust/rapport - confidentiality; nonjudgmental approach, mutual trust; professional boundaries; cultural competency (respect/spiritual needs) working ans: - obtain patient information - make sure to take notes but do not be consumed by notetaking - learn to write/type without looking - use therapeutic communication termination ans: - summarize important info - discuss plan of care health history format ans: - structured framework for organizing pt info in written or verbal form - focuses on specific kinds of info comprehensive health assessment ans: admission of new patient in ALL settings focused assessment ans: - returning patient - chief complaint follow-up history ans: problem or treatment evaluation