Health Assessment Reviewer for Prelims PDF

HEALTH ASSESSMENT REVIEWER FOR PRELIMS UNIT 1 THE NURSE’S ROLE IN HEALTH ​ The purpose of a nursing health ASSESSMENT assessment is to collect holistic subjective and obje...

HEALTH ASSESSMENT REVIEWER FOR PRELIMS UNIT 1 THE NURSE’S ROLE IN HEALTH ​ The purpose of a nursing health ASSESSMENT assessment is to collect holistic subjective and objective data to ASSESSMENT: STEP 1 OF THE NURSING determine a client’s overall level of PROCESS functioning in order to make a professional clinical judgment Assessment - is the first and most critical phase of the nursing process Framework for Health Assessment in Nursing - is ongoing and continuous throughout all ​ A nursing framework helps to organize phases of the nursing process. information and promotes the collection - It is analyzing and synthesizing those data, of holistic data making judgments about the effectiveness of ​ The questions asked in each physical nursing interventions, and evaluating client care system’s chapter focus on that particular outcomes. body system and are broken down into four sections: -History of present health concern -Personal health history -Family history - Lifestyle and health practices ​ Thus the end result of a nursing assessment is the identification of client problems that require nursing care. Types of Health Assessment 1.Initial Comprehensive Assessment- involves collection of subjective data about the client’s perception of their health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client’s overall functioning) as well as objective data gathered during a step by-step physical examination. -a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system. 2.Ongoing or Partial Assessment - consists of Focus of Health Assessment in Nursing data collection that occurs after the ​ A comprehensive health assessment comprehensive database is established. consists of both a health history and -Consists of data collection that occurs after the physical examination. comprehensive database is established. This consists of a mini overview of the client’s body HEALTH ASSESSMENT REVIEWER FOR PRELIMS systems and holistic health patterns as a ​ Results of laboratory testing (e.g., follow-up on health status. platelet count, x-ray findings) -usually performed whenever and wherever the -obtained by general observation and by using nurse or another health care professional has an the four physical examination techniques: encounter with the client, whether in the inspection, palpation, percussion, and hospital, community, or home setting. auscultation. -client’s medical/health record 3.Focused or Problem-Oriented Assessment - -may also be observations noted by the family or does not replace the comprehensive health significant others about the client. assessment. - It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. 4.Emergency Assessment - is a very rapid assessment performed in life-threatening situations. -an immediate assessment is needed to provide prompt treatment. Steps of Health Assessment 1.Collecting Subjective Data- are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, 3.Validating Assessment Data- is a crucial part preferences, beliefs, ideas, values, and personal of assessment that often occurs along with information that can be elicited and verified only collection of subjective and objective data. by the client. -It serves to ensure that the assessment process ​ Biographical information is not ended before all relevant data have been ​ History of present health concern collected and helps to prevent documentation of ​ Personal health history inaccurate data. ​ Family history ​ Health and lifestyle practices 4.Documenting Data- is an important step of ​ Review of systems assessment because it forms the database for the entire nursing process and provides data for all 2. Collecting objective Data- The examiner other members of the health care team. directly observes objective data -ensure that valid conclusions are made when ​ Physical characteristics (e.g., skin color, the data are analyzed in the second step of the posture) nursing process. ​ Body functions (e.g., heart rate, respiratory rate) ANALYZING CUES TO IDENTIFY CLIENT ​ Appearance (e.g., dress, hygiene) CONCERNS: STEP 2 OF THE NURSING ​ Behavior (e.g., mood, affect) PROCESS ​ Measurements (e.g., blood pressure, temperature, height, weight) HEALTH ASSESSMENT REVIEWER FOR PRELIMS Analysis of cues- (the second phase of the -provide clues to possible physiological, nursing process) requires the nurse to use psychological, and sociologic problems. clinical judgment. -They also provide the nurse with information client concern- problem of a client who may be that may reveal a client’s risk for a problem as an individual, family, group, or community. well as areas of strengths for the client. -These concerns are identified and prioritized by -obtained through interviewing nurses to plan nursing interventions to treat and evaluate the client's concern. Interviewing - Obtaining a valid nursing health Collaborative problems- defined as certain history requires professional, interpersonal, and “physiological complications that nurses interviewing skills. The nursing interview is a monitor to detect their onset or changes in communication process that has two focuses: status”. ​ Establishing rapport and a trusting Process of Data Analysis- This process requires relationship with the client to elicit diagnostic reasoning skills, often called critical accurate and meaningful information. thinking. The process can be divided into six ​ Gathering information on the client’s major steps: developmental, psychological, ​ Identify abnormal cues and supportive physiological, sociocultural, and cues. spiritual status to identify deviations that ​ Cluster cues. can be treated with nursing and ​ Draw inferences and identify and collaborative interventions or strengths prioritize client concerns. that can be enhanced through ​ Propose possible collaborative problems nurse–client collaboration. to notify primary care providers. ​ Identify the need for referral to a Phases of the Interview primary care provider. Pre Introductory Phase - The nurse reviews the ​ Document conclusions. medical record before meeting with the client. -The nurse will then need to rely on interviewing 2 COLLECTING SUBJECTIVE DATA: THE skills to elicit valid and reliable data from the INTERVIEW AND HEALTH HISTORY client and the client’s family or significant other. -an integral part of interviewing the client to obtain a nursing health history. Subjective data Introductory Phase - After introducing herself to consist of: the client, the nurse explains the purpose of the ​ Sensations or symptoms interview, discusses the types of questions that ​ Feelings will be asked, explains the reason for taking ​ Perceptions notes, and assures the client that confidential ​ Desires information will remain confidential. ​ Preferences -Conducting the interview at eye level with the ​ Beliefs client demonstrates respect and places the nurse ​ Ideas and the client at equal levels. ​ Values -it is also essential for nurses to develop trust ​ Personal information and rapport. -These types of data can be elicited and verified -The nurse can begin this process by conveying only by the client. a sense of priority and interest in the client. HEALTH ASSESSMENT REVIEWER FOR PRELIMS Working Phase - The nurse then listens, observes describing symptoms, conditions, or cues, and uses critical thinking skills to interpret feelings. and validate information received from the ​ Rephrasing - helps you to clarify client. The nurse and client collaborate to information the client has stated; it also identify the client’s problems and goals. enables you and the client to reflect on what was said. Summary and Closing Phase - the nurse ​ Well-Placed Phrases - Listen closely to summarizes information obtained during the the client during their description and working phase and validates problems and goals use phrases such as “uh-huh,” “yes,” or with the client. “I agree” to encourage the client to - also identifies and discusses possible plans to continue. resolve the problem. ​ Inferring- Inferring information from -nurse makes sure to ask if anything else what the client tells you and what you concerns the client and if there are any further observe in the client’s behavior may questions. elicit more data or verify existing data. ​ Providing Information - to provide the Communication During the Interview client with information as questions and concerns arise. Make sure that you Nonverbal Communication - is as important as answer every question as thoroughly as verbal communication. Your appearance, you can. If you do not know the answer, demeanor, posture, facial expressions, and explain that you will find out. attitude strongly influence how the client perceives the questions you ask. Facilitate eye COMPLETE HEALTH HISTORY level contact. Never overlook the importance of - it provides the foundation for clinical communication or take it for granted. judgments in identifying nursing problems, where to focus, and areas where a more detailed Verbal Communication - essential to a client physical examination may be needed. interview. The goal of the interview process is to -also provide the nurse with specific cues to elicit as much data about the client’s health health problems that are most apparent to the status as possible. Several types of questions and client. techniques to use during the interview are -The health history has eight sections: discussed in the following sections. ​ Biographical data - usually include information that identifies the client ​ Open-Ended Questions - are used to ​ Reasons for seeking health care - “What elicit the client’s feelings and is your major health problem or concern perceptions; begin with the words at this time?” and “How do you feel “how” or “what.” about having to seek health care?” ​ Closed-Ended Questions - obtain facts ​ History of present health concern - and to focus on specific information; encourage the client to explain the client can respond with one or two health problem or symptom in as much words; “when” or “did.” detail as possible by focusing on the ​ Laundry List - to provide the client with onset, progression, and duration of the a list of words to choose from in problem; signs and symptoms and HEALTH ASSESSMENT REVIEWER FOR PRELIMS related problems; and what the client -Firm examination table or bed at a height that perceives as causing the problem prevents stooping ​ Personal health history - focuses on -A bedside table/tray to hold the equipment questions related to the client’s personal needed for the examination. history, from the earliest beginnings to the present. Ask the client about any Preparing Oneself - as an examiner is essential childhood illnesses and immunizations to be able to gather objective data to elicit sound to date. clinical judgments. ​ Family health history - it is also helpful -it is helpful to assess your own feelings and to be aware of other health problems anxieties before examining the client. that may have affected the client by -preventing the transmission of infectious virtue of having grown up in the family agents. and being exposed to these problems. -Wash your hands before beginning the ​ ROS for current health problems - each examination body system is addressed and the client -Always wear gloves; Wear a mask and is asked specific questions to elicit protective eye goggles. further details of current health problems or problems from the recent Physical Examination Techniques past that may still affect the client or that are recurring. 1.Inspection - involves using the senses of ​ Lifestyle and health practices profile - vision, smell, and hearing to observe and detect Here clients describe how they are any normal or abnormal findings. managing their lives, their awareness of -This technique is used from the moment that healthy versus toxic living patterns, and you meet the client and continues throughout the the strengths and supports they have or examination. use. ​ Developmental level 2.Palpation- using parts of the hand to touch and feel. 3 COLLECTING OBJECTIVE DATA: ​ Light palpation - place your dominant PHYSICAL EXAM TECHNIQUES hand lightly on the surface of the structure. There should be very little or Objective data - include information about the no depression (