Glossary of Health Assessment Quiz 1
- Tamara Marin
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- The registered nurse collects comprehensive data pertinent to the patient's health or the situation.
- The RN analyzes the assessment data to determine the diagnoses or issues.
- The RN identifies expected outcomes for a plan individualized to the patient or the situation.
- Outcome Identification
- The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes.
- The RN implements the identified plan through coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment.
- The RN evaluates progress toward attainment of outcomes.
- Information provided by clients when asked to describe their current state of health, previous illnesses and surgeries, and their family background.
- History (subjective data)
- Subjective data acquired by another individual (such as a family member)
- Secondary source of history data
- Collection of observable data by the nurse. Data obtained using techniques of inspection, palpation, percussion, and auscultation.
- Objective Data - Examination
- Data observed, felt, heard, or measured by the nurse. Include fever, rash, enlarged lymph nodes, and swelling.
- Data that the client or family tells the nurse. Pain, itching, nausea.
- Detailed history and physical examination performed at the onset of care. Encompasses health problems of the client as well as health promotion, disease prevention, and assessment for problems with known risk factors.
- Comprehensive assessment
- History and examination that is limited in scope to a specific problem or complaint (ie sprained ankle).
- Problem based/focused assessment.
- Usually done when client is seeking additional care with a provider after a previous visit. 2 weeks after antibiotics, etc.
- Follow-up/Episodic assessment
- Short, usually inexpensive exam focused on disease detection.
- Screening assessment
- 5 data sources
- Client, Significant Others, Records, Consultations, Lab/Diagnostic studies
- Data collection methods
health history interview
- Health History Interview 4 components
- Purpose, Preparation, Plan-Skills, Parts
- Health History Purpose
- I - involve client
C - collect subjective data
E - establish a baseline
- Health History Preparation
- S - self (build trust, skills, knowledge, appearance)
S - setting (privacy, quiet, comfort)
- Health History Plan
- Health History Parts
- Health History Physical Examination
- Physical Exam Purpose
- V - validate subjective data
C - collect objective data
E - establish a baseline
- Physical Exam Preparation
- Hands, equipment, client positioning
- Physical Exam Plan - Skill
- KNOW IN ORDER:
Except abdominal exam, out of order - auscultation before palpation/percussion
- Diagnosis - Purpose
- Direct plan of care
PPM - predict, prevent, manage
decrease costs, increase efficiency
- Diagnosis - Process
- Analyze - normal, risk, impaired
Synthesize - signs/symp, evidence
- Normal Temperature
- Normal Oral Temperature
- Normal axillary temperature
- Normal rectal temperature
- Normal Heart rate
- 60-100 BPM
- Normal respirations
- 12-20 RPM
- Normal Blood Pressure
- Systolic 110-140/
- Risk potential diagnosis
- 2 parts -
Risk of "x"
- Actual diagnosis
- 3 parts -
AEB (as evidenced by) "x"
- Symptom Analysis
- O - onset
L - location
D - duration
C - characteristics
A - aggravating and alleviating factors
R - related symptoms
T - treatment
S - severity
- When did symptoms begin?
- Where are the symptoms?
- How long do the symptoms last?
- Describe the characteristics of the symptom
- Aggravating and Alleviating Factors
- What affects the symptoms?
- Related Symptoms
- What other symptoms are present?
- Describe self treatment tried before seeking care
- Describe the severity of the symptom
- older adult vital sign changes
- 97.2 F average temp
arteriosclerosis - higher BP
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