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Health Assess. Ch. 1

Why learn health assessment?

What are the six standards of practice? Assessment, Diagnosis, Outcomes, Identification, Planning, Implementation, and Evaluation.
What is assessment? The collection of "comprehensive data pertinent to the patient's health or the situation."
What refers to a systematic method of collecting all types of data that identify the client's strengths, weaknesses, physiologic status, knowledge, motivation, support systems, and coping ability that may influence the client's health either positively or Health Assessment
What are the 2 primary components of health assessment? History and physical examination
The collection of subjective data. History
The collection of objective data. Physical exam
What a patient feels and communicates to the nurse (i.e. pain, itching, nausea). Symptom
What the nurse observes, feels, hears or measures (i.e. excessive sweating or diaphoresis, fever, rash, swelling). Sign
What is the term often used to describe signs and symptoms experienced by a client? Clinical Manifestations
When the RN collects comprehensive data pertinent to the patient's health or the situation. Assessment
The RN analyzes the assessment data to determine the issues. Diagnosis
Theh RN recognizes expected outcomes for a plan individualized to the patient or the situation. Outcome Identification
The RN develops a method that prescribes strategies and alternative to attain expected outcomes. Planning
The RN puts the plan into effect: Coordination of Care, Health Teaching and Promotion, Consultation, Prescriptive Authority and Treatment. Implementation
The RN monitors progress toward attainment of outcomes. Evaluation
What is the first and most foundational aspect of health assessment? Correctly assessing a patient.
Types of health assessment Comprehensive, Problem-based/Focused, Episodic/Follow-up, and Screening
This involves a detailed history and physical examination performed at the onset of care in a primary care setting or on admission to hopital or long-term care facility. Encompasses health problems the client experienced as well as health promotion, disea Comprehensive Assessment
This involves a history and examination that is limited in scope to a specific probme or complaint (i.e. sprained ankle). This type of assessment is most commonly used in walk-in clinics or emergency departments. Problem-based/Focused Assessment
This type of assessment is performed when a client is re-visiting a facility to be re-evaluated after their symptoms have been treated. This visit is to determine if any further action should be taken, or if the patient is cured. Episodic/Follow-up Assessment
This is a short, usually inexpensive examination focused on disease detection. Usually performed in a health care provider's office as part of a comprehensive examination (i.e. BP screening, glucose screening, etc.). Screening Assessment
When should data be documented so as to be used by other health care professionals? ALWAYS
How is the effectiveness of documentation improved? If the nurse has documented completely, accurately, and descriptively.
A legal document, as well as a permanent record of health status, that is used as a baseline to monitor for changes. Health care record
How should data be recorded? Accurately, concisely, legibly, and without bias or opinion.
What are the 3 levels of prevention? Primary, Secondary, and Tertiary
What is Primary Prevention? Protection to prevent occurrence of disease (i.e. immunizations, pollution control, nutrition exercise). Routine check-ups.
What is Secondary Prevention? Early identification of disease before it becomes symptomatic in order to halt the progression of the pathologic process (i.e. screening & self exams-mammogram, BP screening).
What is Tertiary Prevention? It minimizes severity and disability from disease through appropriate therapy for chronic disease (i.e. cardiac rehabilitation). Try to get back to greatest potential.
Healthy People 2010 Document that contains the national health objectives that address the most significant preventable threats to health, and national goals to reduce such threats.
What are the 2 main goals of Healthy People 2010? Increase the years of healthy life and eliminate health care disparities.
Created by: shanhaup
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