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HA- CH 1
Health Assessment
| Question | Answer |
|---|---|
| what are the 6 standards of practice for nursing? | 1. assessment2. diagnosis3. outcome identification4. planning5. implementation6. evaluation |
| collection of comprehensive data pertinent to pt health or situation | assessment |
| diaphoresis | exessive sweating |
| describe s/s experienced by the pt | clinical manifestation |
| clinical finding | sign or objective data |
| pt feels and communicates to professional | symptoms or subjective data |
| assessment that involves a detailed H & P in a primary care setting or on admission to hospital or long-term care facility | comprehensive assessment |
| assessment that involves a H & P that is limited in scope to a specific problem or complaint. this assessment is most commonly used in a walk in clinic or emergency department | problem-based/focused assessment |
| assessment that is usually done when a client is following up with health care provider for a previously id problem. | episodic/follow-up assessment |
| assessment that is usually short, unexpensive examination focused on disease detection | screening assessment |
| central component of nursing | promotion of health |
| is the behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness | health protection |
| is behavior motivated by the desire to > well-being and actualize human health potential | health promotion |
| preventing a disease from developing through the promotion of a healthy lifestyle | primary prevention |
| consists of screening efforts to promote early case finding of individuals with disease | secondary prevention |
| is directed toward minimizing the disability from acute or chronic disease or injury and jelping the client to live productively with limitations | tertiary prevention |
| the process of clustering data facilitates | data analysis |
| the formation of a plan of care for a client is initiated with | data collection |
| the RN collects comprehensive data pertinent to the patient's health or the situation | assessment; standard #1 |
| the RN analyzes the assessment data to determine the diagnosis or issues | diagnosis; standard #2 |
| the RN identifies expected outcomes for a plan individualized to the patient or the situation | outcome identification; standard #3 |
| the RN develops a plan that prescribes strategies and alternatives to attain expected outcomes | planning; standard #4 |
| the RN implements the ID plan | implenmentation; standard #5 |
| the RN evaluates progress toward attainment of outcomes | evaluation; standard #6 |
| what are 4 implenmentation practices for Standard #5 | coordination of care.health teaching and health promotion.consultation.prescriptive authority and tx |
| includes info provided by client when asked to describe their current state of health, their previous illnesses and surgeries, and their fam hx | history...subjective data |
| when subjective data is collected from another individual | secondary source of data |
| involves the collection of observable data by the nurse | examination...objective data |
| are data observed, felt, heard, or measured by the nurse | signs |
| are data the client or family tells the nurse | symptoms |
| detailed H & P performed at the onset of care in a primary care setting or on admission to hospital or long-term facility | comprehensive assessment |
| involves a H & P that is limited in scope to a specific problem or complaint; this assessment is more commonly used in walk-in clinics or the ER | problem-based/focused assessment |
| usually done when a client is following up with health care provider for a previously ID problem | episodic/follow-up assessment |
| type of episodic/follow-up assessment that a nurse performs in an acute care facility--IDs changes in condition from baseline | shift assessment |
| is short, usually inexpensive exam focused on disease detection; may be in a provider's office or a health fair | screening assessment |
| protection to prevent occurence of disease | primary prevention |
| ex- immunizations, pollution control, nutrition, exercise, etc | primary prevention |
| early ID of disease before it becomes symptomatic in order to halt the progression of the pathologic process | secondary prevention |
| ex- screening exam and self-exam practices | secondary prevention |
| minimize severity and disability from disease thru appropriate therapy for clinic disease | tertiary prevention |
| DM manageent, cardiac rehab, etc | tertiary prevention |
Created by:
TayBay15
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