Health Assessment Exam 1 Study Guide PDF

lOMoARcPSD|28287070 Health Assessment Exam 1 Study Guide Health Assessment (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by a...

lOMoARcPSD|28287070 Health Assessment Exam 1 Study Guide Health Assessment (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by angel agramont ([email protected])  lOMoARcPSD|28287070 Exam 1 NUR 216 Module 1 (Ch 1, 2, 3) Major Concepts  Understanding Health Assessment  Interviewing the Patient for a Health History  Taking Health History Content Outline  Definition of Health o Different for everyone, family, community, and population. WHO Def: State of complete physical, social, and mental well-being and not merely the absence of disease and infirmity. Balance of body, mind spirit. Influenced by the external environment, physiological biological, behavioral, and economic political factors.  Levels of Health Prevention o Primary- prevention of disease and disability strives to help limit exposure to hazards and risks and make healthy lifestyle choices. (Immunizations, health, and safety education) o Secondary- early screenings to detect diseases in early stages while the patient is asymptomatic, identification of risk factors for diseases, and ability to access early treatment. The goal is to prevent future disability. (Colonoscopy to screen for colon cancer, testing for glaucoma, identifying risk factors for substance abuse) o Tertiary- Restoration of health after illness or disease had occurred to prevent death and disability. (Rehab program for stroke patients, inpatient treatment for patient with severe depression)  The Nursing Process and Clinical Judgement Model o Nursing Process- ADPIE A- assessment: collect, analyze data about whole individual. Includes physiological, psychological, psychosocial, economical, spiritual, and cultural practices and beliefs. D- Diagnosis: analyzing potential or actual health problems using both subjective and objective data. Uses clinical judgment and critical thinking to analyze all information. Synthesize and cluster information to hypothesize about patients health status. P- Planning: Working with patient to meet needs in short or long term goals. Must be measurable (SMART goals) and nursing care plan is developed to meet goals. Plan is shared with other health care members. I- Implementation: Interventions include nursing and patient actions and plan of care to meet goals. Not time limited and can vary from hours, days to months. E- Evaluation: Ongoing process that assess the short and long term goals have been met or unmet. Invloves clinical judgement to analyze the plan of care is effective or needs to be re-evaluated and modified. Downloaded by angel agramont ([email protected])  lOMoARcPSD|28287070 o Clinical Judgement Model- Recognizing cues: what matters most. Analyze cues: what does it mean. Prioritize hypothesis: where do I start. Generate solutions: what can I do. Take action: what will I do. Eveluate outcomes: did I help.  Cognitive Skills: Critical Thinking, Clinical Judgement/reasoning, and Intuitive Thinking o CT: think, recall knowledge, recognize differences or deviations between normal and abnormal. Rational and intuitive judgement, problem solving, reflective process. CJ: Interpretation or conclusion about patients needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones. CR: use of history, physical signs, symptoms, lab data, and imaging to diagnose, assess, and formulate a treatment plan. IT: Feeling that guides an individual in a specific direction although individual cannot understand its exact reason. “gut feeling”  Introduction to Psychomotor Skills o Doing process. Inspection-looking. Percussion-tapping diff areas to assess underlying structures. Palpation-using hands to feel surface characteristics. Auscultation-listening for sounds.  Therapeutic Communication o Holistic approach, empathy and compassion, unconditional regard (respect/accept individual), genuineness (being honest), respect, caring. CLEAR (center yourself, listen, empathize, attention, respect)  Special Needs Patients o Hearing loss, visually, aphasiac, cognitively, aggressive/challenging, language, low health literacy  Cultural Considerations o Can influence interview, health is expressed differently based on values, beleifs, attitudes, behaviors, and ability to meet basic needs.  Interviewing the Patient o Open ended questions, closed ended are more focused. Phase one-introductory, phase two-working, phase three-summarize  Completing the Health History o Comprehensive-whole patients and all body systems (head to toe), focused/problem based- focused on acute problem or symptom, Follow up-after patient has been seen and concentrates on new date seen last seen. o Primary source- patient, secondary source-family members o LMNOPQRSTUVW (Subjective data gathering) L-location (where is pain), M- mechanism (what do you think is causing it), N-new (Is it new), O-onset (start), P-palliative (what makes it better), provocative (makes it worse), Q-quality (describe pain), R-radiation (pain go to other areas), S-severity (1-10), T-timing (pain changed over time, diff during certain times of day), U-unusual (unusual symptoms not related to your pain), V-valid (symptoms seem real), W-work (prevent you to work). o OLDCARTS O-onset, L-location, D-duration, C-characteristics, A-aggravating or alleviating factors, R-related symptoms, T- treatment, S-severity o Biographical data (demographics) -name, address, DOB, age, gender, occupation, language, allergies, insurance Downloaded by angel agramont ([email protected])  lOMoARcPSD|28287070 o Military history o Medications o Immunizations o Health prevention/promotion o Past history o Family history o Psychosocial assessment (behavioral, environmental, social, financial, economic)  Education  Occupation  Housing/environment  Exercise  Sleep/rest  Safety  Support system/home life  Stress/coping mechanisms  Domestic violence  Substance abuse  Sexuality o Cultural assessment- identifies cultural factors that affect a patient health o Spiritual assessment-beliefs systems of patients o Review of systems (head to toe)  General status,  Skin  Hair on body  Nails  Head  Eyes  Ears  Nose/sinuses  Mouth/throat  Respiratory  Breasts  Cardiac  Hematological  Gastrointestinal  Urinary  Musculoskeletal  Peripheral vascular  Neurological  Women’s health  OB history  Male genital o Mental health assessment  Appearance, emotional reaction, speech pattern, memory/cognition, behavior/mood o Cognitive assessment Downloaded by angel agramont ([email protected])  lOMoARcPSD|28287070  Thinking skills, language, calculation, perceptions, memory, awareness, social skills, learning, reasoning, judgement (Orientation to time (what is the date, registration (I say three words, repeat them back to me, naming (what is this, reading (can you read this to me) o Patient Education o Documentation Module 2 (Ch 6, 7) Major Concepts  General Survey  Assessing Vital Signs  Assessing Plans  Inclusive Approaches to Health Assessment Content outline  Preparation and Equipment for Assessment  Focused Assessment  Vital Signs  Orthostatic vital signs  Pain o Definition of Pain o Physiology of Pain o Types of Pain o Pain Assessment o Pain Assessment Tools  Inclusive Health Assessment o Concepts/span> o Key principles o Anti-oppressive approach Module 3 (Ch 4, 5) Major Concepts  Assessing Nutritional Status  Anthropometric Measurements  Assessment Techniques Content Outline  Definition of Nutrition  Nutritional Diagnostics  Nutritional Health History Downloaded by angel agramont ([email protected])  lOMoARcPSD|28287070  Nutritional Assessment  Anthropometric Measurements  Patient Nutritional Education  Assessment Techniques  Preparation for Assessment  Standard Precautions  Focused Assessment  Inspection, palpation, percussion, auscultation Downloaded by angel agramont ([email protected])