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Dillon Ch 1

Health Assessment and The Nurse

What does primary preventative care focus on? Health promotion and illness prevention
What does secondary preventative care focus on? Early detection, prompt intervention, and health maintenance.
What does tertiary preventative care focus on? Rehabilitation and extended care.
What are the five steps of the nursing process? Assessment Diagnosis (nursing) Plan Implementation Evaluation
What is a nursing assessment? A wholistic approach to collecting data. Allows judgments to be made about the clients current state of health.
What are some things determined by the nursing assessment? The patient's baseline and normal function as well as any dysfunction or risky for dysfunction. Also determines strenghts.
What are the four types of assessments? Complete assessment Focused assessment Episodic assessment Emergency assessment
What kind of assessment you do is dependent on... condition of client, knowledge base and experience of examiner, constraints of cilinical setting, intent of interaction, expectation of patient
What special considerations would you need to take into consideration when assessing a child? physiological differences developmental stage caregiver involvement
What special considerations would you need to take into consideration when assessing an elderly adult? The impact of their illness/injury on activities of daily living Sensory defects Cognitive defects Mistreatment
What are the three parts of the nursing assessment? Observation Interviewing Physical examination
What are some things you might look for during the general survey? general appearance, grooming and personal hygiene, apparent state of health, level of consciousness, signs of distress, posture, gait and motor activity.
What are the four parts of the interviewing phase? Prepatory Introductory Working Termination
What are the four techniques used in the physical examination phase? Inspection Palpation Percussion Auscultation
What are the two types of data collection? Objective and Subjective
What is objective data? What is it also known as? Objective data is anything that you directly observe or measure. Also known as signs.
What is subjective data? What is it also known as? Subjective data is what the patient is telling you. Also known as symptoms.
What are the two types of data sources? Primary data source is the patient Secondary data source is everything else
What are some of the pitfalls of data collection? Omission of data Hasty/misinterpretation Irrelevant data Failure to follow up Poor communication
Organizing data in clusters helps to... Recognize patters of response/ behavior Distinguish between relevant & irrelevant Identify patterns of cause and effect Determine if there are gaps in the data and where they exist
What is a medical diagnosis? Made by physician Refers to the disease process Somewhat uniform between clients Remains the same during disease process
What is a nursing diagnosis? Describes client's response Responses vary between individuals Changes as client's response changes
What are the three parts of the nursing diagnosis? Problem Etiology- the "related to" factor Symptom- "as evidenced by"
What are the four types of nursing diagnosis? Actual Potential (risk) Wellness (health promotion) Syndrome
What are some systems of documentation? Narrative charting Source oriented charting Problem oriented charting Focus charting Charting by exception Computerized documentation
Identify the level of Preventative Care when the nurse focuses on health promotion and illness prevention. The focus is not only on wellness, but also to minimize risk of health problems. Primary
Identify the level of Preventative Care when the nurse focuses on early detection, prompt intervention, and health maintenance for pt.s with health problems; addresses acute problems seen with inpatient hospitalization. Secondary
Identify the level of Preventative Care when the nurse focuses on rehabilitation and extended care Tertiary
Identify the 5 steps of the nursing process: Assessment, Diagnosis, Plan, Implement, and Evaluate
Define Critical Thinking Critical Thinking is reflective, reasonable thinking, it involves inquiry, interpretation, analysis and synthesis; a mindset that enables you to use your cognitive skills to critically think. It is not just doing, it is asking "why?"
What is Restating? Restating the pt's main idea shows him that you are listening, allows you to acknowledge your pt's feelings, and encourages further discussion. It also helps clarify and validate what your pt has said and may help identify teaching needs.
Created by: MEPN 2013