Health Assessment Ch. 1
Terms
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- Health assessment
- a systematic method of collecting data about a client for the purpose of determining the client's current and ongoing health status, predicting risks to health, and identifying health-promoting activities.
- interview
- in which subjective data are gathered, includes the health history and focused interview.
- primary source
- the client is considered to be the direct source.
- secondary source
- indirect source would include family members, caregivers, other members of the health team, and medical records.
- Subjective data
- information that the client experiences and communicates the nurse.
- health history
- is to obtain information about the client's health in his or her own words and based on the client's own perceptions.
- focused interview
- enables the nurse to clarify points, to obtain missing information, and to follow up on verbal and nonverbal cues identified in the health history.
- physical assessment
- is hands in examination of the client.
- objective data
- are observed or measured by the professional nurse.
- client record
- is a legal document used to plan care, to communicate information between and among health care providers.
- confidentiality
- information sharing is limited to those directly involved in client care.
- HIPAA
- Health Insurance Potability and Accountability Act protects an individual's health information.
- narrative notes
- the nurse utilizes words, phrases, sentences, and paragraphs to record information.
- SOAP
-
S= Subjective data
O= Objective data
A= Assessment
P= Planning
- APIE
-
A= Assessment
P= Problem
I= Intervention
E= Evaluation - Interpretation of finings
- making determinations about all the data collected in the health assessment.
- Communication
- refers to the exchange of information, feelings, thoughts, and ideas.
- Holism
- considering more than the physiologic health status of a client.
- nursing process
- is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client.
- Nursing Process Steps
-
1) ASSESSMENT is the collection, organization, and validation of subjective and objective data.
2) DIAGNOSIS is using critical thinking and applies to knowledge to the sciences and other disciplines to analyze and synthesize data.
3) PLANNING involves setting priorities; stating client goals or outcomes; and selecting nursing
strategies, orders to deal with the health status of a client
4) IMPLEMENTATION is put the plan in action.
5)EVALUATION refers to the determination that the goal has been achieved within the states time frame. - critical thinking
- a process of purposeful and creative thinking about resolutions of problems or the development of ways to manage situations.
- informal teaching
- generally occurs as a natural part of a client encounter.
- formal teaching
- occurs in response to an identified learning need of an individual.