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Terms in this set (48)
What is Health Assessment? Requires the use of: hearing,seeing,smelling,and touching
Nursing is a practice profession
Health assessment is an essential skill to nursing practice
A key goal of health assessment is to identify patient cure for
normal and abnormal findings
Person-centered care is the ultimate goal of health
assessment
What is the definition of Health? Health has different meaning for each individual, family,
community, and population
Nurse should have an understanding of each patient's
definition of health
Cultural practices influence an individual's behavior to
promote, maintain, and restore health
Primary Prevention Health promotion strategies limits exposure to hazards,and
risks and to make healthy lifestyle choices
Ex: annual physical exam, immunizations
Secondary Prevention Early screenings, detection, and treatment of diseases the
ability to access early treatments
Ex: Colonoscopy to screen for colon cancer
Tertiary Prevention Restoration of health after illness or disease to prevent death
and disability
Ex:Rehabilitation programs
Health Assessment is a Skill Requires each nurse to be a detective, to investigate
everything reported by the patient
Need to be able to recognize and analyze cues, formulate
hypotheses, generate solutions and a plan of action
Assessing a patient requires using perceptual senses
, Characteristics of Health Assessment Collects, validates, and clusters data to assess the whole
patient.
Must be organized
Utilizes patient resources (pasta medical history, diagnostics,
verbal, and written reports)
Establish baseline information about the patient.
Identifies factors influencing health and well-being
Identifies normal and abnormal findings, relevant and
irrelevant
Assessment Is the first steps and requires the nurse collect and analyze
data
(Physiological, psychological, psychosocial, economical,
spiritual and cultural practices and beliefs)
Diagnosis Includes analyzing potential or actual health problems or
needs for the patient
Subjective & Objective data
Planning/Outcome This involves working with the patient in care to meet the
needs incorporating short term and long term goals of the
patient
SMART GOALS:Specific, Measurable, Achievable, Realistic,
Timing
Implementation (Intervention) Includes nursing and patient actions to meet the goals of
Evaluation This is ongoing process that assesses whether short or long
term goals have been met
Reevaluate and modifications if necessary
Critical Thinking (Reflective Thinking) Involves collecting and analyzing information and carefully
considering options for action
Clinical Reasoning Uses patient's history, physical signs, symptoms, laboratory
data, and diagnostic imaging.
Arrives at a diagnosis and formulates a treatment plan based
on that information.
Clinical Judgment Interpretation or conclusion about a patients needs, concerns
or health problems, and/or the decision to take action ( or
not) use or modify standard approaches, or improvise as one
deems appropriate to the patients response
Intuitive Thinking "Gut feeling" about what may be occurring in a patient
situation
Psychomotor the "doing" process of assessment
Inspect
Percussion
Palpitation
Auscultation
The 4 techniques for physical assessment Inspection
Palpation
Percussion
Auscultation