Health Assessment and The Nurse
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| What does primary preventative care focus on? | Health promotion and illness prevention
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| What does secondary preventative care focus on? | Early detection, prompt intervention, and health maintenance.
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| What does tertiary preventative care focus on? | Rehabilitation and extended care.
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| What are the five steps of the nursing process? | Assessment
Diagnosis (nursing)
Plan
Implementation
Evaluation
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| What is a nursing assessment? | A wholistic approach to collecting data. Allows judgments to be made about the clients current state of health.
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| 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.
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| What are the four types of assessments? | Complete assessment
Focused assessment
Episodic assessment
Emergency assessment
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| 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
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| What special considerations would you need to take into consideration when assessing a child? | physiological differences
developmental stage
caregiver involvement
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| 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
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| What are the three parts of the nursing assessment? | Observation
Interviewing
Physical examination
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| 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.
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| What are the four parts of the interviewing phase? | Prepatory
Introductory
Working
Termination
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| What are the four techniques used in the physical examination phase? | Inspection
Palpation
Percussion
Auscultation
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| What are the two types of data collection? | Objective and Subjective
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| What is objective data? What is it also known as? | Objective data is anything that you directly observe or measure. Also known as signs.
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| What is subjective data? What is it also known as? | Subjective data is what the patient is telling you. Also known as symptoms.
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| What are the two types of data sources? | Primary data source is the patient
Secondary data source is everything else
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| What are some of the pitfalls of data collection? | Omission of data
Hasty/misinterpretation
Irrelevant data
Failure to follow up
Poor communication
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| 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
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| What is a medical diagnosis? | Made by physician
Refers to the disease process
Somewhat uniform between clients
Remains the same during disease process
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| What is a nursing diagnosis? | Describes client's response
Responses vary between individuals
Changes as client's response changes
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| What are the three parts of the nursing diagnosis? | Problem
Etiology- the "related to" factor
Symptom- "as evidenced by"
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| What are the four types of nursing diagnosis? | Actual
Potential (risk)
Wellness (health promotion)
Syndrome
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| What are some systems of documentation? | Narrative charting
Source oriented charting
Problem oriented charting
Focus charting
Charting by exception
Computerized documentation
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| 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
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| 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
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| Identify the level of Preventative Care when the nurse focuses on rehabilitation and extended care | Tertiary
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| Identify the 5 steps of the nursing process: | Assessment, Diagnosis, Plan, Implement, and Evaluate
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| 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?"
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| 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.
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Created by:
MEPN 2013
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