HEALTH ASSESSMENT EXAM 1
CHAPTER 2
FOUR TYPES OF ASSESSMENT DATABASES
O COMPLETE (TOTAL HEALTH)
COMPLETE HEALTH HISTORY AND FULL PHYSICAL EXAMINATION
DESCRIBES CURRENT AND PAST HEALTH STATE
FORMS A BASELINE AGAINST WHICH ALL FUTURE CHANGES CAN BE
MEASURED
THIS WOULD BE DONE IN A PHYSICIAN’S OFFICE/FIRST PATIENT
TAKES ABOUT HALF AN HOUR TO GET ALL THIS INFO
O FOCUSED OR PROBLEM-CENTERED DATABASE
USED FOR A LIMITED OR SHORT-TERM PROBLEM
COLLECT A MINI DATABASE
SMALLER IN SCOPE AND MORE TARGETED
COLLECT INFORMATION REGARDING THAT ACUTE INCIDENT
O FOLLOW-UP DATABASE
COMPLICATIONS?
ARE MEDICATIONS WORKING?
BLEEDING? STILL HURT? ANY BETTER?
O EMERGENCY DATABASE
URGENT, RAPID COLLECTION OF CRUCIAL INFORMATION
NAME?
, AS MUCH INFO AS YOU CAN?
CAB
O CIRCULATION – MOST IMPORTANT
O AIRWAY
O BREATHING
O WHAT’S HAPPENING?
CALL 911 AND EXPLAIN
EVIDENCE-BASED ASSESSMENT
O CLINICAL DECISION MAKING DEPENDS ON ALL FOUR FACTORS
BEST EVIDENCE FROM A CRITICAL REVIEW OF RESEARCH LITERATURE
THE PATIENT’S OWN PREFERENCES
THE CLINICIAN’S OWN EXPERIENCE AND EXPERTISE
PHYSICAL EXAMINATION AND ASSESSMENT
ASSESSMENT SKILLS MUST BE PRACTICED WITH HANDS ON
EXPERIENCE AND REFINED TO A HIGH LEVEL
CULTURAL COMPETENCY QUESTIONS
O WHEN MEETING A PATIENT FOR THE FIRST TIME
WHERE DOES THE PATIENT COME FROM?
WHAT IS HIS/HER HERITAGE?
WHAT IS HIS/HER CULTURAL BACKGROUND?
WHAT LANGUAGE IS THE PATIENT FAMILIAR WITH?
WHAT ARE HIS/HER HEALTH AND ILLNESS BELIEFS AND PRACTICES?
HEALTH
, O BALANCE OF A PERSON IS A COMPLEX, INTERRELATED PHENOMENON
WITH ONE’S BEING: PHYSICAL, MENTAL, AND SPIRITUAL
IN OUTSIDE WORLD: NATURAL, COMMUNAL, AND METAPHYSICAL
ILLNESS
O LOSS OF A PERSON’S BALANCE
ALMOST 40% OF US RESIDENTS IDENTIFY AS OTHER THAN NON-HISPANIC WHITES
EMERGING MINORITY GROUPS
O YOUNGER WITH LOWER MEDIAN AGES
O HIGHER PROPORTIONS UNDER 18 YEARS OLD
O HOUSEHOLDS WITH MULTIPLE GENERATIONS
O POVERTY LEVEL
TRANSPORTATION
ACCESS TO CARE
LITERACY
IMMIGRATION AND HEALTH CARE CONCERNS
O MANY NEW IMMIGRANTS HAVE ONLY MINIMAL UNDERSTANDING OF THE
FOLLOWING
MODERN HEALTH CARE DELIVERY SYSTEM
MODERN MEDICAL AND NURSING PRACTICES AND INTERVENTIONS
ENGLISH LANGUAGE
O IMPERATIVE THAT THE NURSE’S CARE IS TAILORED TO MEET THE PERSON’S
PERCEIVED NEEDS
NATIONAL CULTURAL AND LINGUISTIC STANDARDS
, O FIRST AND LANDMARK STANDARD
HEALTH CARE ORGANIZATIONS ARE LEGALLY REQUIRED TO ENSURE THAT
PATIENTS RECEIVE EFFECTIVE, UNDERSTANDABLE, AND RESPECTFUL CARE
THAT IS PROVIDED IN A MANNER COMPATIBLE WITH THEIR CULTURAL
HEALTH BELIEFS AND PRACTICES AND PREFERRED LANGUAGE
O EFFECTIVE CARE
POSITIVE OUTCOMES AND SATISFACTION FOR PATIENT
O RESPECTFUL CARE
CONSIDERS VALUES, PREFERENCES, AND EXPRESSED NEEDS OF PATIENT
O CULTURAL AND LINGUISTIC COMPETENCE
CONGRUENT BEHAVIORS, ATTITUDES, AND POLICIES THAT COME
TOGETHER IN A SYSTEM AMONG PROFESSIONALS THAT ENABLES WORK IN
CROSS-CULTURAL SITUATIONS
LINGUISTIC COMPETENCE
O TITLE VI OF CIVIL RIGHTS ACT OF 1964
SERVICES CANNOT BE DENIED TO PEOPLE OF LIMITED ENGLISH
PROFICIENCY
O MOST COMMON NON-ENGLISH LANGUAGE IS SPANISH
O PATIENTS WHO HAVE LIMITED ENGLISH PROFICIENCY (LEP) ARE AT RISK FOR
POOR HEALTH CARE OUTCOMES DUE TO THE BARRIER THAT LANGUAGE PRESENTS
DURING HEALTH CARE DELIVERY INTERACTIONS
CULTURAL COMPETENCE
O CULTURALLY SENSITIVE
CHAPTER 2
FOUR TYPES OF ASSESSMENT DATABASES
O COMPLETE (TOTAL HEALTH)
COMPLETE HEALTH HISTORY AND FULL PHYSICAL EXAMINATION
DESCRIBES CURRENT AND PAST HEALTH STATE
FORMS A BASELINE AGAINST WHICH ALL FUTURE CHANGES CAN BE
MEASURED
THIS WOULD BE DONE IN A PHYSICIAN’S OFFICE/FIRST PATIENT
TAKES ABOUT HALF AN HOUR TO GET ALL THIS INFO
O FOCUSED OR PROBLEM-CENTERED DATABASE
USED FOR A LIMITED OR SHORT-TERM PROBLEM
COLLECT A MINI DATABASE
SMALLER IN SCOPE AND MORE TARGETED
COLLECT INFORMATION REGARDING THAT ACUTE INCIDENT
O FOLLOW-UP DATABASE
COMPLICATIONS?
ARE MEDICATIONS WORKING?
BLEEDING? STILL HURT? ANY BETTER?
O EMERGENCY DATABASE
URGENT, RAPID COLLECTION OF CRUCIAL INFORMATION
NAME?
, AS MUCH INFO AS YOU CAN?
CAB
O CIRCULATION – MOST IMPORTANT
O AIRWAY
O BREATHING
O WHAT’S HAPPENING?
CALL 911 AND EXPLAIN
EVIDENCE-BASED ASSESSMENT
O CLINICAL DECISION MAKING DEPENDS ON ALL FOUR FACTORS
BEST EVIDENCE FROM A CRITICAL REVIEW OF RESEARCH LITERATURE
THE PATIENT’S OWN PREFERENCES
THE CLINICIAN’S OWN EXPERIENCE AND EXPERTISE
PHYSICAL EXAMINATION AND ASSESSMENT
ASSESSMENT SKILLS MUST BE PRACTICED WITH HANDS ON
EXPERIENCE AND REFINED TO A HIGH LEVEL
CULTURAL COMPETENCY QUESTIONS
O WHEN MEETING A PATIENT FOR THE FIRST TIME
WHERE DOES THE PATIENT COME FROM?
WHAT IS HIS/HER HERITAGE?
WHAT IS HIS/HER CULTURAL BACKGROUND?
WHAT LANGUAGE IS THE PATIENT FAMILIAR WITH?
WHAT ARE HIS/HER HEALTH AND ILLNESS BELIEFS AND PRACTICES?
HEALTH
, O BALANCE OF A PERSON IS A COMPLEX, INTERRELATED PHENOMENON
WITH ONE’S BEING: PHYSICAL, MENTAL, AND SPIRITUAL
IN OUTSIDE WORLD: NATURAL, COMMUNAL, AND METAPHYSICAL
ILLNESS
O LOSS OF A PERSON’S BALANCE
ALMOST 40% OF US RESIDENTS IDENTIFY AS OTHER THAN NON-HISPANIC WHITES
EMERGING MINORITY GROUPS
O YOUNGER WITH LOWER MEDIAN AGES
O HIGHER PROPORTIONS UNDER 18 YEARS OLD
O HOUSEHOLDS WITH MULTIPLE GENERATIONS
O POVERTY LEVEL
TRANSPORTATION
ACCESS TO CARE
LITERACY
IMMIGRATION AND HEALTH CARE CONCERNS
O MANY NEW IMMIGRANTS HAVE ONLY MINIMAL UNDERSTANDING OF THE
FOLLOWING
MODERN HEALTH CARE DELIVERY SYSTEM
MODERN MEDICAL AND NURSING PRACTICES AND INTERVENTIONS
ENGLISH LANGUAGE
O IMPERATIVE THAT THE NURSE’S CARE IS TAILORED TO MEET THE PERSON’S
PERCEIVED NEEDS
NATIONAL CULTURAL AND LINGUISTIC STANDARDS
, O FIRST AND LANDMARK STANDARD
HEALTH CARE ORGANIZATIONS ARE LEGALLY REQUIRED TO ENSURE THAT
PATIENTS RECEIVE EFFECTIVE, UNDERSTANDABLE, AND RESPECTFUL CARE
THAT IS PROVIDED IN A MANNER COMPATIBLE WITH THEIR CULTURAL
HEALTH BELIEFS AND PRACTICES AND PREFERRED LANGUAGE
O EFFECTIVE CARE
POSITIVE OUTCOMES AND SATISFACTION FOR PATIENT
O RESPECTFUL CARE
CONSIDERS VALUES, PREFERENCES, AND EXPRESSED NEEDS OF PATIENT
O CULTURAL AND LINGUISTIC COMPETENCE
CONGRUENT BEHAVIORS, ATTITUDES, AND POLICIES THAT COME
TOGETHER IN A SYSTEM AMONG PROFESSIONALS THAT ENABLES WORK IN
CROSS-CULTURAL SITUATIONS
LINGUISTIC COMPETENCE
O TITLE VI OF CIVIL RIGHTS ACT OF 1964
SERVICES CANNOT BE DENIED TO PEOPLE OF LIMITED ENGLISH
PROFICIENCY
O MOST COMMON NON-ENGLISH LANGUAGE IS SPANISH
O PATIENTS WHO HAVE LIMITED ENGLISH PROFICIENCY (LEP) ARE AT RISK FOR
POOR HEALTH CARE OUTCOMES DUE TO THE BARRIER THAT LANGUAGE PRESENTS
DURING HEALTH CARE DELIVERY INTERACTIONS
CULTURAL COMPETENCE
O CULTURALLY SENSITIVE
