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Health Assessment
Batt Exam
| Question | Answer |
|---|---|
| state of complete physical, mental, and social well-being, not merely the absence of disease. | Health |
| Health as a process and state of becoming whole, reflecting mutuality between the person and environment. | Roy & Andrews (1999): |
| Health characterized by wholeness, developed human structures, and bodily function, requiring therapeutic self-care. | Orem (1971): |
| A culturally defined, valued, and practiced state of well-being, enabling individuals to perform role activities. | Leininger (1991): |
| Health as a state of well-being and the full utilization of personal power. | Nightingale (1860): |
| Ecological Model: Examines the interaction between agent, host, and environment. | Leavell & Clark (1965) |
| Defines health as the absence of disease or injury. | Clinical Model: |
| Views health as the actualization of a person’s potential. | Eudemonistic Model: |
| Defines health as the realization of inherent and acquired human potential. | Health Promotion Model: |
| Identifying patient needs and corresponding interventions. | Plan of Care: |
| Systematic gathering of patient health information to determine status, risks, and health-promoting activities. | Data Collection: |
| Interview, physical assessment, documentation, and interpretation of findings. | Components: |
| Gathering subjective and objective data, including medical history and psychosocial factors. | Assessment: |
| Identifying patient issues using clinical judgment. | Diagnosis: |
| Developing a care plan with goals, outcomes, and interventions. | Planning: |
| Executing the planned intervention. | Implementation: |
| Assessing the effectiveness of interventions. | Evaluation: |
| Holistic evaluation, forming a baseline reference. | Initial Comprehensive Assessment: |
| Follow-up assessments after a comprehensive evaluation. | Ongoing/Partial Assessment: |
| Addresses specific health concerns. | Focused/Problem-Oriented Assessment: |
| Rapid assessment for life-threatening conditions, focusing on Airway, Breathing, Circulation (ABCs). | Emergency Assessment: |
| Are there external clues to explain the patient’s condition? | Exposure |
| What is the level of consciousness? | Disability |
| nurses collect comprehensive health information from the client to establish an accurate assessment. | Working Phase |
| This phase ensures clarity and patient involvement by summarizing and validating gathered data. | Summary and Closing Phase |
| essential for establishing rapport and ensuring patient-centered care. It can be categorized into verbal and non-verbal communication. | Communication |
| Used for gathering specific details | Close-ended Questions |
| Encourages elaboration | Open-ended Questions |
| Helps patients describe symptoms by providing predefined choices. | Laundry List Technique |
| Clarifies patient responses for greater understanding. | Rephrasing |
| Recognizing subtle cues from verbal and non-verbal - behaviors. | Inferring |
| unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. It is subjective and highly individualized, | Pain |
| Pain is classified based on: | 1. Duration (Acute vs. Chronic) 2. Location (Localized vs. Generalized) 3. Intensity (Mild, Moderate, Severe) 4. Etiology (Origin or cause) |
| refer to diagnoses or critical conditions that require immediate medical attention within the first 24 hours of hospital admission. | Clinical alerts |
| Indicating potential hemorrhage or coagulation disorders. | Bleeding Alerts |
| Flagging signs of sepsis, systemic infection, or localized infections requiring urgent care. | Infection Alerts |
| Notifying healthcare teams of pre-existing conditions such as - diabetes, cardiac disorders, or respiratory diseases. | Medical Alerts |
| Highlighting adverse drug interactions, allergies, or sensitivities. | Drug Alerts |
| Warning about complications related to anaesthesia administration. | Anaesthetic Alerts |
| one of the most urgent clinical alerts, | Bleeding |
| Can occur immediately after surgery (primary bleeding), within 24 hours (reactive bleeding), or up to 10 days later (secondary bleeding). | 1. Post-Operative Bleeding |
| Includes epistaxis (nosebleeds) or gum bleeding, often related to systemic conditions. | Mucosal Bleeding |
| Unexplained or excessive bruising may indicate an underlying bleeding disorder. | Skin Bruising |
| May occur in cases of coagulation defects and require specialized evaluation. | Deep Muscle Hematomas |
| Help maintain consistent communication of clinical alerts. | Patient Administration Systems (PAS) |
| Healthcare professionals receive training on identifying, responding to, and managing alerts to minimize adverse events. | Training & Education Programs |
| Alerts are integrated into digital systems for real-time monitoring. | Electronic Health Records (EHR) |
| A systematic method for evaluating critically unwell patients: | ABCDE Approach: |
| Severe or undiagnosed cases may require referral to a hematologist for further assessment and treatment. | Consultation & Specialized Care: |
| Establish rapport and a trusting relationship. | Nursing Interview |
| Gather information on developmental, psychological, physiologic, sociocultural, and spiritual status. | Nursing Interview |
| involves reviewing medical records to identify sensitive information before conducting interviews. | Pre-Introductory Phase |
| essential for establishing rapport and ensuring patient-centered care. It can be categorized into verbal and non-verbal communication. | Effective communication |
| Maintain a neutral yet compassionate expression, adjusting appropriately to patient cues. | Facial Expression |
| Exhibit a non-judgmental approach, respecting all backgrounds, beliefs, and identities. | Attitude |
| Active listening ensures critical information is understood. | Listening |
| Educate the patient throughout interactions to empower their involvement in care decisions. | roviding Information |
| Lasts through the expected recovery period. - Protective in nature, with a clear cause. - Short duration and limited tissue damage. | Acute Pain |
| - Persists beyond 6 months, varying in intensity. - May have an identifiable or unknown cause, leading to significant personal suffering | . Chronic Pain |
| Mild pain | 1 to 3 |
| Moderate pain | 4 to 6 |
| Severe pain | - 7 to 10: |
| - What causes the pain? What worsens or relieves it? - Effectiveness of past medications or treatments. | - P – Precipitating/Alleviating Factors |
| - How does the pain feel? (sharp, dull, stabbing, burning) | - Q – Quality of Pain |
| - Is the pain localized or spreading? | - R – Radiation |
| - Pain intensity measured using a descriptive, numeric, or visual scale. | - S – Severity |
| - Onset and duration: Is the pain constant or intermittent? | - T – Timing |
| Previous diagnoses, treatments, surgeries, and hospitalizations. | Past Medical History |
| he current health concern, symptoms, and relevant medical details. | History of Present Illness |
| Systematic evaluation of each bodily system for any abnormalities. | . Review of Systems |
| Daily routines, dietary habits, exercise, and stress management. | Lifestyle and Health Practices |
| Poor circulation leading to cold extremities. | Cool Peripheries: |
| Indicating active bleeding or clotting disorders. | Swelling & Bruising: |
| Linked to reduced oxygen supply to the brain. | Confusion or Agitation: |
| Low blood pressure following significant bleeding. | Hypotension: |
| Increased heart rate due to blood loss. | Tachycardia |
| Rapid breathing as the body compensates for blood loss. | - Tachypnea: |
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mtchamngo