NR 509 reading Notes. NR 509 Notes Overview of the Comprehensive heath History Advanced Physical Assessment

1. Assessment- point of entry in an ongoing a. Subjective data and objective data that is used to make a database for the purpose of judgment or diagnosis 2. Diagnostic reasoning applies the scientific method a. Data is prioritized by urgency of signs and symptoms b. Medical diagnosis are used to evaluate the cause or etiology of disease c. Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state. d. The process of analyzing health data and drawing conclusions to identify diagnoses i. Attending to cues ii. Formulating hypotheses iii. Gathering Data iv. Evaluating each hypothesis 3. EBP provides the best care with the most current treatment available. 4. Critical thinking and the diagnostic procedure a. First-level priority problems: life threatening and immediate needs b. Second level priority problems: requires prompt intervention to prevent further deterioration and may include a mental status change, acute pain or abnormal laboratory value c. Third Level priority problems: less urgent problems d. Collaborative problems: involves multiple disciplines 5. EVB Assessment 6. Collecting four types of Data a. Complete database b. Focused or problem centered c. Follow-up database d. Emergency database 7. Expanding the concept of health a. Holistic health model including mind, body, and spirit as interdependent and functioning as a whole. Defined as the absence of disease. b. Health promotion and disease prevention 8. Culture and genetics a. Obtaining a heritage assessment helps gather data that are accurate and meaningful and can guide culturally sensitive and appropriate care. Chapter 3: The interview 1. Data a. Subjective data- what the person says about themselves b. Objective data- what you obtain through physical exam 2. Communication a. Nonverbal vs verbal communication and body language are important in sending and receiving messages in the communication.