Assessment Correct Answer-systematically collecting data where
registered nurse collects comprehensive data pertinent to the patient's
health and or situation
Health assessment process Correct Answer-nurse incorporates the
patient's knowledge, motivation, support systems, coping ability, and
preferences to develop a plan of care to better the patient to maximize
health
Components of a health assessment Correct Answer-1. Health history
2. Physical examination
3. Documentation of data
Subjective data Correct Answer-things a person tells you about that you
cannot observe through your senses; symptoms. the patient tells you
what's wrong or you collect it from health history
Objective data Correct Answer-information that is seen for yourself and
collected by you (the nurse)
Comprehensive assessment Correct Answer-takes place in a primary
care, admission to hospital, or long term care facility. involves a detailed
history and physical examination performed at the onset of care
,Problem based/focus assessment Correct Answer-Takes place at a walk
in clinic or emergency department that involves a history and
examination that are limited to a specific problem or complaint
episodic/follow-up assessment Correct Answer-usually done when the
patient is following up with a health care provider for a previously stated
problem
Shift assessment Correct Answer-nurses conduct assessment each shift
to make identifying changes to a patient's condition easier and also can
allow nurses to determine the changes in patient's care
screening assessment/examination Correct Answer-short examination
focused on disease detection. (BP, glucose screening, etc)
Purposes for obtaining a written medical record Correct Answer--
prevents the patient from having to explain same information to another
health care provider
-includes information about the patient such as med allergies and past
disease/surgeries
health promotion Correct Answer-the process of motivating the patient
to increase their well being and actualize health potential
health protection Correct Answer-the process of motivating the patient
to prevent illness, detecting it early, getting require vaccinations, and
maintain function
, primary prevention Correct Answer-preventing a sides before it starts by
living healthy lifestyle or receiving vacs
secondary prevention Correct Answer-early detection of disease (self
exams or screenings)
tertiary prevention Correct Answer-minimizing the disability from acute
or chronic disease. living and managing your disease well in order to
maximize health
motivations for learning health assessment Correct Answer--better
quality of life
-better patient center plan of care
-more experience for nurses
purpose of a health history Correct Answer-To obtain subjective data
from patients so the nurse and patient can create a plan to promote
health, prevent disease, resolve acute health problems and minimize
limitations related to chronic health problems
comprehensive health history Correct Answer-may be performed during
a hospital admission with an initial clinic or home visit or when the
patient's reason for seeking care is for the relief of generalized symptoms
such as weight loss or fatigue.