HEALTH ASSESSMENT
EXAM 1
CHAPTER 1: EVIDENCE-BASED ASSESSMENT
1. Perform an assessment, evaluation, nursing diagnosis, planning, and identify outcomes while performing a health history
• ASSESSMENT
◦Subjective: What the patient says during history taking
‣ ex: pain, symptoms (‘I feel hot’)
◦Objective: What you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical
examination
‣ ex: vital signs (blood pressure, heart rate, pulse, respiration rate, or lung sounds)
◦Database: subjective data and objective data together with the patient’s record and laboratory studies
‣ From the database you make clinical judgement or diagnosis about the individual’s health state, response to actual or potential
health problems, and life process.
• DIAGNOSTIC REASONING
• Process of analyzing health data and drawing conclusions to identify diagnosis
◦Abductive Reasoning: thinking to determine the best explanation with information at hand
◦Deductive Reasoning: drawing on general principles from physiology and pathology
◦Inductive Reasoning: using signs and symptoms as a guide
◦Four major components:
‣ 1) attending to initially available cues
‣ 2) formulating diagnostic hypothesis
‣ 3) Gathering data relative to the tentative hypothesis
‣ 4) evaluating reach hypothesis with new data collected
◦Cluster/group assessment data that appear associated
• 5 STEPS OF THE NURSING PROCESS
◦Assessment: gather data from medical records and patient
◦Diagnosis: interpret clinical findings and use clinical judgement to determine diagnosis
◦Planning (plan of action): formulate goals and outcomes in
collaboration with patient
◦Implementation: implement the plan
◦Evaluation: evaluate the plan, reassessing, and/or change the
plan
,Using the CJ form, identify the cues in the following case study
knowwhat is
ineachbox
• CLINICAL JUDGEMENT PLAN: a way of structuring nursing education to enhance clinical judgement skills of novice practitioners.
• 3 LEVELS OF PRIORITY PROBLEMS
◦FIRST-LEVEL PRIORITY: emergent, life-threatening, and immediate
‣ ex: establishing an airway or support breathing
◦SECOND-LEVEL PRIORITY: are those that are next in urgency those requiring your prompt intervention to forestall further deterioration
‣ ex: mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of
infection, or risk to safety or security
◦THIRD-LEVEL PRIORITY: are those that are important to the patient’s health, but can be attended to after more urgent health problems are
addressed. Interventions to treat these problems are long-term and the response to treatment is expected to take more time.
‣ ex: lack of knowledge, mobility problems, and family coping Needhealth
promotioneducation
‣ these problems may require a collaborative effort between the patient and healthcare professionals.
◦COLLABORATIVE PROBLEMS: physical therapy, speech therapy, or occupational therapy
Recovery
hIr
• CLINICAL DECISION-MAKING DEPENDS ON THESE 4 FACTORS
‣ Evidence-Based practice is a holistic approach
◦1.) Best evidence from research literature
◦2.) Clinical experience
◦3.) Patient preference
◦4.) Physical exam and assessment
The primary barrier to evidence-based practice (EBP) is the LACK OF CONFIDENCE
, • FOUR TYPES OF DATABASES
◦COMPLETE (total health) DATABASE: complete health history and full physical examination (head-to-toe assessment)
‣ Describes the current and past health states, forms a baseline against all future changes
‣ Yields first diagnosis
‣ Often performed in primary care setting
• Pediatric/family practice clinic
• Independent or private practice
• Women’s healthcare agency
• Community health agency
◦FOCUSED OR PROBLEM-CENTERED DATABASE: limited or short-term problems
‣ Smaller in scope and more targeted
‣ Mainly one problem, one cue, or one body system
• ex: rash
‣ Collected in all settings
• Hospital
• Primary care
• Long-term care
◦FOLLOW-UP DATABASE: the status of any identified problems should be evaluated at regular and appropriate intervals.
‣ Collected in all settings to follow-up both short-term and chronic health problems
• ex: pt with heart failure
◦EMERGENCY DATABASE: urgent, rapid collection of crucial information and often complied concurrently with lifesaving measures
‣ Performed typically in emergency settings (ER)
• ex: overdose
• COMPREHENSIVE HEALTH CARE
Ptrequires all3
◦HOLISTIC MODEL OF HEALTH: views the mind, body, and spirit as interdependent and functioning as a whole within the environment
◦While genetics plays a role in health, the ENVIRONMENT A PERSON LIVES IN HAS A MORE SIGNIFICANT IMPACT ON HEALTH
◦SOCIAL DETERMINANT OF HEALTH (SDoH): factors that influence a person’s health and well-being
‣ Environment
‣ Access to healthcare
‣ Community
‣ Education
‣ Socioeconomic stability
EXAM 1
CHAPTER 1: EVIDENCE-BASED ASSESSMENT
1. Perform an assessment, evaluation, nursing diagnosis, planning, and identify outcomes while performing a health history
• ASSESSMENT
◦Subjective: What the patient says during history taking
‣ ex: pain, symptoms (‘I feel hot’)
◦Objective: What you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical
examination
‣ ex: vital signs (blood pressure, heart rate, pulse, respiration rate, or lung sounds)
◦Database: subjective data and objective data together with the patient’s record and laboratory studies
‣ From the database you make clinical judgement or diagnosis about the individual’s health state, response to actual or potential
health problems, and life process.
• DIAGNOSTIC REASONING
• Process of analyzing health data and drawing conclusions to identify diagnosis
◦Abductive Reasoning: thinking to determine the best explanation with information at hand
◦Deductive Reasoning: drawing on general principles from physiology and pathology
◦Inductive Reasoning: using signs and symptoms as a guide
◦Four major components:
‣ 1) attending to initially available cues
‣ 2) formulating diagnostic hypothesis
‣ 3) Gathering data relative to the tentative hypothesis
‣ 4) evaluating reach hypothesis with new data collected
◦Cluster/group assessment data that appear associated
• 5 STEPS OF THE NURSING PROCESS
◦Assessment: gather data from medical records and patient
◦Diagnosis: interpret clinical findings and use clinical judgement to determine diagnosis
◦Planning (plan of action): formulate goals and outcomes in
collaboration with patient
◦Implementation: implement the plan
◦Evaluation: evaluate the plan, reassessing, and/or change the
plan
,Using the CJ form, identify the cues in the following case study
knowwhat is
ineachbox
• CLINICAL JUDGEMENT PLAN: a way of structuring nursing education to enhance clinical judgement skills of novice practitioners.
• 3 LEVELS OF PRIORITY PROBLEMS
◦FIRST-LEVEL PRIORITY: emergent, life-threatening, and immediate
‣ ex: establishing an airway or support breathing
◦SECOND-LEVEL PRIORITY: are those that are next in urgency those requiring your prompt intervention to forestall further deterioration
‣ ex: mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of
infection, or risk to safety or security
◦THIRD-LEVEL PRIORITY: are those that are important to the patient’s health, but can be attended to after more urgent health problems are
addressed. Interventions to treat these problems are long-term and the response to treatment is expected to take more time.
‣ ex: lack of knowledge, mobility problems, and family coping Needhealth
promotioneducation
‣ these problems may require a collaborative effort between the patient and healthcare professionals.
◦COLLABORATIVE PROBLEMS: physical therapy, speech therapy, or occupational therapy
Recovery
hIr
• CLINICAL DECISION-MAKING DEPENDS ON THESE 4 FACTORS
‣ Evidence-Based practice is a holistic approach
◦1.) Best evidence from research literature
◦2.) Clinical experience
◦3.) Patient preference
◦4.) Physical exam and assessment
The primary barrier to evidence-based practice (EBP) is the LACK OF CONFIDENCE
, • FOUR TYPES OF DATABASES
◦COMPLETE (total health) DATABASE: complete health history and full physical examination (head-to-toe assessment)
‣ Describes the current and past health states, forms a baseline against all future changes
‣ Yields first diagnosis
‣ Often performed in primary care setting
• Pediatric/family practice clinic
• Independent or private practice
• Women’s healthcare agency
• Community health agency
◦FOCUSED OR PROBLEM-CENTERED DATABASE: limited or short-term problems
‣ Smaller in scope and more targeted
‣ Mainly one problem, one cue, or one body system
• ex: rash
‣ Collected in all settings
• Hospital
• Primary care
• Long-term care
◦FOLLOW-UP DATABASE: the status of any identified problems should be evaluated at regular and appropriate intervals.
‣ Collected in all settings to follow-up both short-term and chronic health problems
• ex: pt with heart failure
◦EMERGENCY DATABASE: urgent, rapid collection of crucial information and often complied concurrently with lifesaving measures
‣ Performed typically in emergency settings (ER)
• ex: overdose
• COMPREHENSIVE HEALTH CARE
Ptrequires all3
◦HOLISTIC MODEL OF HEALTH: views the mind, body, and spirit as interdependent and functioning as a whole within the environment
◦While genetics plays a role in health, the ENVIRONMENT A PERSON LIVES IN HAS A MORE SIGNIFICANT IMPACT ON HEALTH
◦SOCIAL DETERMINANT OF HEALTH (SDoH): factors that influence a person’s health and well-being
‣ Environment
‣ Access to healthcare
‣ Community
‣ Education
‣ Socioeconomic stability
