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HEALTH ASSESSMENT

CHAPTER 1-4

QuestionAnswer
Evidence-Based Assessment Evidence-based: denoting an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research Assessment:The collection of data about the individual’s health state.
Collecting Patient Data S/SAYS=SUBJECTIVES O/OBSERVED=OBJECTIVE Subjective data:What the patient says about themselves.Objective data:What you observe/assess about the patient.IPPADatabase:Combined subjective and objective data (plus other components)(EPIC)
Diagnostic Reasoning ANALYZING AND DRAWING CONCLUSION W/ QUESTION "WHY IS IT HAPPENING? Attending to initially available cuesFormulating diagnostic hypothesesGathering data relative to the tentative hypothesesEvaluating each hypothesis with the new data collected
Nursing Process-ADOPIE Assessment2.Diagnosis3.Outcome identification4.Planning5.Implementation6.Evaluation
ASSESSMENT SHORTNESS of breath WHile working
DIAGNOSIS ANALYZING WHATS GOING ON- OBSERVE THIGHNESS OF LUNGS IMPAIRED GASES EXCHANGE related to air pollution as evidenced by shortness of breath, low 02 sat, high rr
OUTCOME IDENTIFICATION WHAT DO I WANT TO HAPPEN AFTER TREATMENT? WANT THEM TO WALK W/O SOB for 5 mins by tonight
PLANNING HOW DO i ACCOMODATE THE PATIENT? PLAN
IMPLEMENTATION PUT CHAIR-AMBULATE-HELP THEM ANY SHORT-TERM GOAL
EVALUATION DID IT WORK ?
Critical Thinking and Prioritization NURSING SAFE GUARD
Critical Thinking: Assessing before thinking to promote effective diagnostic reasoning and clinical judgment
Prioritization: First-level priority problemsEmergent, life-threateningSecond-level priority problemsNext in urgencyThird-level priority problemsLeast urgent
First-level priority problems Emergent, life-threatening AIRWAY-BREATHING-CIRCULATION
Second-level priority problems Next in urgency NO URINE IN 8 HOURS? CLAMP URINE CATHETHER? DEHYDRATION? SEPTIC SHOCK KIDNEY FAILure ACUTE PAIN-MENTAL STATUS CHANGE RISK FOR SAFETY OR SECURITY
Third-level priority problems Least urgent ORAL CARE-VENTILATOR ACQUIRED PNEUMONIA-LEADING TO SECOND OR FIRST PRIORITY
Evidence-Based Practice-FLORENCE NIGHTGALE Developed” in the 1800s, “defined” in the 1970s. Encompasses:Research evidenceClinical expertiseClinical knowledgePatient values/preferencesBarriers delay or prevent evidence-based changes to practice PPL WHO WANT THINGS TO BE TRADITIONALLY DONE-
Collecting Patient Data
Complete (Total Health) Database Includes complete health history and full physical exam FIRST ADMISSION ASSESSMENT- HEALTH-HX,HEAD-TOE ASSESSMENT
Focused (Problem-centered) Database History and exam focuses on one primary problem
Follow-up Database Reevaluation of a previously identified problem/intervention WELLCARE-COME BACK TO SEE IF TEACHING AND INTERVENTION WORK
Emergency Database Urgent collection of most crucial information to prevent further deterioration CRITICAL INFORMATION COLLECTION WHEN DID IT STARTED? DID SOMETHING CHANGE WITH HER LIFESTYLE? MED, FOODS?
Health Expansion
Holistic health Expanded care to include cultures/values, family, life factors, etc.
Health promotion Push to practice healthier lifestyles
Disease prevention CHEMOPROPHYLASIS-TAKING A DRUG TO AVOID SUPERINFECTION(COMPLICATION) Making alterations in current lifestyle choices to prevent chronic disease developmentExamples: Thorough history screening, complete physical exam, prevention counseling, depression/mental health screening, chemoprophylaxis(PRENATAL VITAMINS)
Cultural UNITED STATES CULTURE IS CHARACTERIZED AS THE MELTING POT-SALAD BOWL-GINSENG INTERACTS W/ DIGOXIN
genetic considerations
CHAPTER 2 CULTURAL ASSESSMENT-WHATS IS IMPORTANT TO YOU? HOW WOULD YOU LIKE ME TO DO THIS AND THAT? BE AWARE OF OWN VALUES AND BIASES...
Demographic Profile CONSIDER GENERATION WHILE CARING FOR PATIENTS
Immigration and Health Disparities CONSIDERING THOSE FACTORS LISTED ABOVE, TO PREVENT ERRORS AND PROVIDE QUALITY CARE
IMMIGRATION Those not US citizens at birthOften experience language barriers and access to care that affect health outcomes
HEALTH DISPARITIES Preventable differences that can lead to suboptimal health outcomes LOW SOCIOECONOMIC-HEALTH LITERACY-SEXUAL ORIENTATION-BUILT ENVIRONMENT
Social determinants of health (SDOH): Can affect health outcomes: ethnicity, socioeconomic status, gender/gender identity, age, mental health, religion, disabilities, sexual orientation, etc
Culture-related Concepts Four characteristics:Learned from birthShared by members of cultural groupAdapted to certain environmental conditionsDYNAMIC & Continually changing
Consists of subcultural groups Race – physical characteristics (skin color, hair texture, etc)Ethnicity – a social group W/common geographical origin, religion, language, values, traditions, food etc. Acculturation – adopting the culture and behavior of the majority culture
Religion and Spirituality DOCUMENT IF PATIENT REFUSES TO TELL Religion:Specific set of organized beliefs and practices shared by a group Spirituality:Individual’s practice having to do with a sense of peace and purpose
Health-related Beliefs/Practices DIMENSIONS OFACCULTURALIVE STRESS INSTRUMENTAL/ENVIRONMENTAL:FINANCE-LANGUAGE BARRIER-LACK OF EDUCATION-ACCESS TO HEALTHCARE SOCIAL/INTERPERSONAL: CHANGING GENDER-FAMILY CONFLICT-LOSS SOCIAL STATUS SOCIETAL:STIGMA-LEVEL OF ACCULTURATION-POLITICAL FORCE
BALANCE HEALTH IS the balance of the person Physical, mental, and spiritual and outside world(natural, communal or metaphysical)
ILLNESS BELIEFS Biomedical/scientific-caused by foreign microorganisms, such as :viruses -bacteria; physical and psychological illnes Naturalistic/holistic Magicoreligious-supernatural forces dominate.
Healing beliefs and practices: Homeopathy(MAKING THEY OWN MEDECINE) acupuncture, chiropractic manipulation, hypnosis, meditation, massage, biofeedback, herbal remediATION
Increased awareness for childrenAcknowledge cultural expression of pain UNDERSTAND THE DIFFERENCE BETWEEN CULTURE AND SITUATION WITH CHILDREN TRACE ON A CHILD BACK, IS IT CULTURE OR ABUSE? RESPECT PATIENT CARE
Providing Culturally Competent Care RESPECT CULTURE AND INCORPORATE IN CARE ASK QUESTION WHILE PERFORMING SKILLS UPON ADMISSION TO PROVIDE HOLISTIC CARE I.E hot/cold theory, where the four humors of the body-blood, phlegm, black and yellow bile regulate bodily functions. Treatment of disease is adding or substracting cold, heat, dryness or wetness to restore the balance of the humors
Culturally sensitive Awareness of cultural differences and similarities that exist among you and your patients
Culturally appropriate Knowing when, where, and how to provide specific culture-related care
Culturally competent Ability to view your patients as unique individuals and able to understand that your patient’s culture affects their beliefs, values, and behaviors so that trusting relationships are developed
Completing a Cultural Assessment cultural knowledge related to language, food preferences, religion, and health care beliefs-spiritually assessment
Cultural Self-Assessment To ensure self-awareness
Assess: health practices, heritage, language, method of communication, family, nutrition, pregnancy/birth beliefs, spirituality/religion, death practices, etc
Spiritual Assessment How should I address your health care needs? FICA spiritual history tool:Faith – Do you consider yourself spiritual or religious?Importance/influence – What importance does your faith have in your life?Community – Are you part of a spiritual/religious group?Address/action –
CHAPTER 3 THE INTERVIEW
Data Collection: SubjectiveObjective
Interview components to consider: Location and timeExplanation of your rolePurpose of the interviewTime frameParticipationConfidentialityCost
Process of Communication SendingVerbal communicationNonverbal communicationReceiving Ability to take in information
Factors affecting communication: INTERNAL AND EXTERNAL FACTORS traps: false assurance-unwanted advice-using authority-avoidance language-distancing-using professional jargon-using leading or biased questions-talking too much-interrupting- using why questions
Internal factors: Liking other (genuine) EmpathyAbility to listenSelf-awareness
External factors: Ensuring privacy Avoiding interruptionsComfortable physical environmentDress/appearanceMinimal note-taking/EHR use
Techniques of Communication Introduction – introduce self and purpose, set the tone, build rapportWorking phase – collection of the needed dataOpen-ended questions – allows for a narrative responseClosed (direct) questions – limited to one-word/brief response (yes or no)
Techniques of Communication Verbal responsesinterviewer response should help move conversation forward9 types: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
Nonverbal Communication Physical appearanceGrooming, dress, etcPostureClosed position (crossed arms and legs looks defensive) TELL ME MORE ABOUT YOUR SMOKE GesturesNodding head, picking nails, tapping a pen Facial expressionBoredom, annoyed, distracted, overly inappropriately happyEye contactAvoid lack of and avoid fixed gazeVoiceTone, rate of speechTouchRefrain from unless the patient appears accepting
Age-specific Communication Interviewing the parent or caregiverDual focus – patient and parent/caregiverCommunication regression can occur during times of stress/crisis
SPECIFIC AGES Infant (birth – 12 months)Toddler (12 – 36 months)Preschooler (3 – 6 years)School-age (7-12 years)Adolescent (12+)Older Adult
Special Needs Interviews Hearing-impaired patientsAcutely ill patientsPatients under the influencePersonal questions to interviewerSexually aggressive patientsCryingAngerThreats of violenceAnxiety
Cultural Considerations is your love one out there/ ask for preferred name GenderMale/female accompany Gender identification Sexual orientationLGBTQInterpretersFamily memberEmployeesLanguage linesHealth literacyOral teaching, written materials, teach-back method
Healthcare Professional Communication Interprofessional communicationCommunication between two or more healthcare professionalsStandardized communication reportSBARSituationBackgroundAssessment Recommendation
CHAPTER4 Health History Sequence
Biographic data Name, address, # number, age, birthdate, relationship status, occupation, etc Source of History Self, caregiver, parent, interpreter, etc Reason for Seeking CareChief complaint, main symptom/sign requiring care Present Health or History of Present Illness Location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, patient’s perception
Past Health HistoryChildhood illnesses, injuries, chronic illnesses, hospitalizations, surgeries, OB history, immunizations, allergies, exams, home meds Family HistoryCancer, obesity, cardiac disease, diabetes, stroke, kidney disease, mental health disease, etc Functional Assessment of ADLsAbility to care for oneself
Review of Systems General overall health stateSkin, hair, nailsHead:Eyes and earsNose and sinusesMouth and throatNeckBreasts and axilla Neurological systemTREMORRespiratory systemCardiovascular system SOB-COUGHPeripheral vascular systemGastrointestinal systemUrinary system Male/female genitalia; sexual healthMusculoskeletal systemEndocrine; Hematologic
Functional Assessment Self-esteem, self-conceptActivity, exercise, ADLsSleep, restNutrition, eliminationRelationships, resourcesSpiritual resourcesCoping, stress managementPersonal habits (smoking, alcohol, drugs)Intimate partner violenceOccupational health
Self-esteem, self-concept- Relationships, resources-CAUSING STRESS Personal habits (smoking, alcohol, drugs)- Coping, stress management- Activity, exercise, ADLs- Nutrition, elimination-24H DIET ECALL Sleep, rest- NOT SLEEPING ENOUGH
Occupational health-WHERE DOES PT WORKS? Spiritual resources-WHO TO CALL Intimate partner violence-
Perception of Health How do you define health?How do you view your situation now?What are your concerns?What do you think will happen in the future?What are your health goals?What do you expect from us as nurses, physicians, or other health care providers?
Child-specific Health History Biographic data Name, address, phone number, age, birthdate, relationship status, occupation, etc Source of History Self, caregiver, parent, interpreter, etcReason for Seeking CareChief complaint, main symptom/sign requiring care
Present Health or History of Present IllnessLocation, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, patient’s perception Past Health HistoryPrenatal status, L&D, postnatal status, childhood illnesses, serious injuries, chronic illnesses, surgeries, immunizations, allergies, home meds
Developmental History Growth, milestones, developmentNutritional History Family HistoryCancer, obesity, cardiac disease, diabetes, stroke, kidney disease, mental health disease, etc
Child-specific Data Review of Systems: Same as adult except focused questioning on child-specific issues Functional Assessment:Relationships, activity/rest, economic status, home environment, environmental hazards, coping/stress management, habits, health promotion
Adolescents PRE-TEEN SEXUALITY -PT NEEDS TO BE ALONE HEEADSSS - method of interviewing focuses on assessment of:Home environment Education and employment Eating Activities (peer related) DrugsSexuality Suicide and depression Safety from injury and violence
Created by: Seka_nurse
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