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Exam (elaborations)

Exam 1: Review

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Exam of 21 pages for the course Transcript/subjective data at Transcript/subjective data (EXAM 1: REVIEW)

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EXAM 1: REVIEW


Definehbthehbtermhbassessmenthbinhbthehbcontexthbofhbthehbnursinghbprocess.hb-hbanswers--
Thehbfirsthbandhbfoundationalhbstephbishbassessment,hbdefinedhbashbahbcollectionhbofhb"comprehensiveh
bdatahbpertinenthbtohbthehbpatient'shbhealthhband/
orhbsituation."hbThehbassessmenthbandhbsubsequenthbanalysishbofhbdatahbarehbpreformedhbbyhbnursesh
binhballhbsettings.




Describehbthehbcomponentshbofhbahbhealthhbassessment.hb-hbanswers--
Conductinghbahbhealthhbhistoryhb(collectinghbsubjectivehbdata),hbperforminghbahbphysicalhbexaminationh
b(collectinghbobjectivehbdata),hbandhbdocumentinghbfindings.hbThehbamounthbofhbinformationhbcollecte
dhbbyhbthehbnursehbduringhbahbhealthhbhistoryhbandhbthehbextenthbofhbthehbphysicalhbexaminationhbdep
endhbonhbsetting,hbsituation,hbpatient'shbneeds.hbandhbnursehbexperience.



Distinguishhbbetweenhbobjectivehbandhbsubjectivehbdata.hb-hbanswers--
Subjectivehbdatahb=hbhealthhbhistoryhbcollectedhbduringhbinterview;hbinfohbabouthbpatient'shbcurrenthbst
atehbofhbhealth,hbmedications,hbprevioushbillnesseshbandhbsurgeries,hbfamilyhbhistory,hbandhbreviewhbofh
bsystems.

hbSymptomshb=hbprimaryhbsourcehbdata




Objectivehbdatahb=hbsigns;hbahbphysicalhbexaminationhbinvolvinghbthehbcollectionhbofhbobjectivehbdata;h
bpalpation,hbinspection,hbpercussion,hbauscultation;hbheight,hbweight,hbBP,hbtemp,hbpulse,hbrespiratoryh
brate




Identifyhbsituationshbinhbwhichhbappropriatenesshbofhbthehbchosenhbhealthhbassessmenthbapproachhbva
ries.hb-hbanswers--
Thehbtermhbcontexthbrefershbtohbcircumstanceshborhbsituationshbassociatedhbwithhbandhbeventhborhbeve
nts.hbThehbphrasehbcontexthbofhbcarehbrefershbtohbthehbcircumstanceshborhbsituationshbrelatedhbtohbthe
hbhealthhbcarehbdelivery;hbSetting,hbenvironment,hbphysical,hbpsychological




Comprehensivehbhealthhbassessment:hbhospitalhbadmission

Problem-basedhbfocusedhbassessment:hbER,hbsorehbthroat

Episodichbassessment:hbFollowhbuphbscreening,hbmammogram

,Differentiatehbbetweenhbhealthhbpromotionhbandhbhealthhbprotection.hb-hbanswers--
Healthhbpromotion:hbbehaviorhbmotivatedhbbyhbthehbdesirehbtohbincreasehbwell-
beinghbandhbactualizehbhumanhbhealthhbpotential;hbcentralhbcomponenthbofhbhealthhbcare;hbbeginshbwi
thhbhealthhbassessment,hbnursehbassesshbpatientshbhealthhbstatus,hbhealthhbpractices,hbandhbrisks



Healthhbprotection:hbbehaviorhbmotivatedhbbyhbdesirehbtohbavoidhbillness,hbdetecthbillnesseshbearly,hban
dhbmaintainhbfunctioninghbwhenhbill.



Statehbthehbpurposeshbofhbahbhealthhbhistory.hb-hbanswers--Healthhbhistoryhb=hbsubjectivehbdata



Databasehbusedhbtohbcreatehbahbplan,hbpreventhbdisease,hbresolvehbproblems,hbandhbminimizehblimitati
ons.



Howhbdoeshbthehbnursehbfacilitatehbthehbdiscussionhbtohbdeterminehbthehbpatient'shbbeliefs?hb-
hbanswers--
Howhbdoeshbthehbpatienthbdefinehbhealth;hbbeliefshbabouthbattaininghbandhbmaintaininghbhealth;hbview
hbofhbresponsibilityhbforhbhealth,hbhealthhbbehaviorshbcurrentlyhbpracticed,hbandhbunhealthyhbbehaviors
hbpatientshbarehbwillinghbtohbchange;hbhealthhbexpectationshbbasedhbonhblifehbexperiences:hbself,hbfamil
y,hbfriends,hbandhbculture



Distinguishhbthehbpurposeshbofhbcomprehensivehbandhbfocusedhbhealthhbassessments.hb-hbanswers--
Comprehensivehbhealthhbhistory:hbperformedhbduringhbahbhospitalhbadmission,hbwithhbanhbinitialhbclinic
hborhbhomehbvisit,hborhbwhenhbthehbpatient'shbreasonhbforhbseekinghbcarehbishbforhbreliefhbofhbgeneraliz
edhbsymptomshbsuchhbashbweighthblosshborhbfatigue;hbrequireshbmorehbtimehbbecausehbahbcompletehbd
atabasehbishbbeinghbestablished;hbbiographichbdata-
initialhbvisit,hbreasonhbforhbseekinghbcare,hbpresenthbhealthhbstatus,hbpasthbmedicalhbhistory,hbfamilyhbhi
story,hbpersonalhbandhbpsychosocialhbhistory,hbandhbreviewhbofhbbodyhbsystems.



Focusedhbhealthhbassessmentshb(problem-
basedhbassessment):hbincludeshbdatahbthathbarehblimitedhbinhbscopehbtohbahbspecifichbproblem;hbmusthb
behbdetailedhbenoughhbthathbthehbnursehbishbawarehbofhbotherhbhealth-
relatedhbdatahbthathbmighthbaffecthbthehbcurrenthbproblem.



Describehbwhenhbtohbusehbopen-ended,hbclose-ended,hbandhbdirectivehbquestioning.hb-hbanswers--
Beginhbwithhbopen-endedhbquestionshbtohbencouragehbahbfree-

, flowing,hbopenhbresponse:hbfocushbonhbquestionshbabouthbpatient'shbhealth;hbmayhbneedhbtohbrefocush
bquestionshbifhbpatienthbishbunablehbtohbfocushbonhbtopichborhbtakeshbexcessivehbtime.




Close-endedhbquestionshbyieldhbmorehbprecisehbdata;hbgivehbpatienthboptionshbforhbresponse.



Directivehbquestionshbleadhbpatienthbtohbfocushbonhbonehbsethbofhbthoughts;hbmosthboftenhbusedhbinhbr
eviewinghbsystemshbandhbevaluatinghbfunctionalhbstatus.



Listhbstepshbofhbsymptomhbanalysis.hb-hbanswers--
Symptomhbanalysis:hbahbsystematichbwayhbtohbcollecthbdatahbabouthbthehbhistoryhbandhbstatushbofhbsy
mptoms;hbnothballhbindividualshbseekinghbhealthhbcarehbhavehbahbspecifichbproblemhborhbillness,hbthush
brecordinghbahbhistoryhbofhbpresenthbillnesshborhbahbsymptomhbanalysishbishbnothbalwayshbindicated.




Onset:hbwhenhbdidhbthehbsymptomshbbegin?

Location:hbWherehbarehbthehbsymptoms?

Duration:hbHowhblonghbdohbthehbsymptomshblast?

Characteristics:hbDescribehbthehbcharacteristicshbofhbthehbsymptoms.

AggravatinghbandhbAlleviatinghbfactors:hbWhathbaffectshbthehbsymptoms?

RelatedhbSymptoms:hbArehbotherhbsymptomshbpresent?

Treatment:hbDescribehbself-treatmenthbbeforehbseekinghbcare.

Severity:hbDescribehbthehbseverityhbofhbthehbsymptom.



Describehbcommunicationhbtechniqueshbthathbenhancehbdatahbcollection.hb-hbanswers--
Activehblisteninghbconcentrateshbonhbpatienthbresponseshbandhbsubtleties;hbavoidhbformulatinghbthehbn
exthbquestionhbduringhbresponses,hbavoidhbmakinghbassumptionshbabouthbpatienthbresponses.



Facilitationhbuseshbverbalhbandhbnonverbalhbphraseshbtohbencouragehbpatientshbtohbcontinuehbtalkinghbf
urtherhb(uhhbhuh,hbgohbon).



Clarificationhbishbusedhbtohbgatherhbmorehbinformation.hb



Restatementhbishbrepeatinghbwhathbpatientshbsayshbinhbdifferenthbwordshbtohbconfirmhbinterpretation.

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