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507 Assessment-intro

intro to health assessment

levels of care - primary, secondary, tertiary primary - promote health/prevent illness*****secondary - early detection/prompt intervention/health maint----tertiary - rehab/extended care
Nursing process ADPIE A-assessment-----D-diagnosis(nursing)-----P-plan----I-implementation----E-evaluation
nursing assessment is a holistic approach to collect data (unique to nursing) - first step is ongoing and continuous throughout nursing process
assessment determines the clients baseline,normal fx, presence/risk of dysfxn, strengths----allows nurse to make judgements about state of health
two types of assessment complete-----focused/episodic/emergency--------these are dependent upon intent of interaction, condition of client, examiner knowledge, clinical setting, patient expectation
pediatric considerations physiological differences----developmental stage---caregiver involvement
elderly considerations impact of illness on ADLs---sensory/cognitive dificits----mistreatment
assessment is a thinking-doing-feeling-process utilizing "OIP" o-observation/general survey with senses-----I=interviewing-------P= physical exam
general survey includes general appearance---grooming/hygiene----apparent state of health---LOC---mental status---signs of distress---posture---gait/motor
interviewing phases preparatory---introductory---working---termination
physical exam phase - IPPA inspection---palpation---percussion---auscultation
types of data objective = signs-----subjective = symptoms
data sources primary = pt----secondary = all other sources
data validation comparisions betw subjective/objective by looking for look for discrepancies---abn findings---data reliability
methods to validate data confirm accuracy abn findings---clarify w/ pt---verify with colleagues, family, records, etc
pitfalls of data collections omission---misinterpretation/hasty---irrelevant data---failure to follow up---poor communication
organize data in cluster/concept mapping -----framework systems (name 4) ***Gordon's functional health patterns ***Maslow's hieerarchy of human needs ***Roy's Adaptation theory ***NANDA unitary person framework
interpretation - clustering helps recognize ****patterns of response/behavior ***relevant/irrelevant ***gaps in data ***patterns of cause/effect
concept map centers around client using these 4 catagories problem---potential problem---identified areas for enhanced wellnes---strengths
Nursing diagnosis PES
Created by: lorrelaws