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HEALTH ASSESSMENT
CHAPTER 1-4
| Question | Answer |
|---|---|
| Evidence-Based Assessment | Evidence-based: denoting an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research Assessment:The collection of data about the individual’s health state. |
| Collecting Patient Data S/SAYS=SUBJECTIVES O/OBSERVED=OBJECTIVE | Subjective data:What the patient says about themselves.Objective data:What you observe/assess about the patient.IPPADatabase:Combined subjective and objective data (plus other components)(EPIC) |
| Diagnostic Reasoning ANALYZING AND DRAWING CONCLUSION W/ QUESTION "WHY IS IT HAPPENING? | Attending to initially available cuesFormulating diagnostic hypothesesGathering data relative to the tentative hypothesesEvaluating each hypothesis with the new data collected |
| Nursing Process-ADOPIE | Assessment2.Diagnosis3.Outcome identification4.Planning5.Implementation6.Evaluation |
| ASSESSMENT | SHORTNESS of breath WHile working |
| DIAGNOSIS | ANALYZING WHATS GOING ON- OBSERVE THIGHNESS OF LUNGS IMPAIRED GASES EXCHANGE related to air pollution as evidenced by shortness of breath, low 02 sat, high rr |
| OUTCOME IDENTIFICATION | WHAT DO I WANT TO HAPPEN AFTER TREATMENT? WANT THEM TO WALK W/O SOB for 5 mins by tonight |
| PLANNING | HOW DO i ACCOMODATE THE PATIENT? PLAN |
| IMPLEMENTATION | PUT CHAIR-AMBULATE-HELP THEM ANY SHORT-TERM GOAL |
| EVALUATION | DID IT WORK ? |
| Critical Thinking and Prioritization | NURSING SAFE GUARD |
| Critical Thinking: | Assessing before thinking to promote effective diagnostic reasoning and clinical judgment |
| Prioritization: | First-level priority problemsEmergent, life-threateningSecond-level priority problemsNext in urgencyThird-level priority problemsLeast urgent |
| First-level priority problems | Emergent, life-threatening AIRWAY-BREATHING-CIRCULATION |
| Second-level priority problems | Next in urgency NO URINE IN 8 HOURS? CLAMP URINE CATHETHER? DEHYDRATION? SEPTIC SHOCK KIDNEY FAILure ACUTE PAIN-MENTAL STATUS CHANGE RISK FOR SAFETY OR SECURITY |
| Third-level priority problems | Least urgent ORAL CARE-VENTILATOR ACQUIRED PNEUMONIA-LEADING TO SECOND OR FIRST PRIORITY |
| Evidence-Based Practice-FLORENCE NIGHTGALE | Developed” in the 1800s, “defined” in the 1970s. Encompasses:Research evidenceClinical expertiseClinical knowledgePatient values/preferencesBarriers delay or prevent evidence-based changes to practice PPL WHO WANT THINGS TO BE TRADITIONALLY DONE- |
| Collecting Patient Data | |
| Complete (Total Health) Database | Includes complete health history and full physical exam FIRST ADMISSION ASSESSMENT- HEALTH-HX,HEAD-TOE ASSESSMENT |
| Focused (Problem-centered) Database | History and exam focuses on one primary problem |
| Follow-up Database | Reevaluation of a previously identified problem/intervention WELLCARE-COME BACK TO SEE IF TEACHING AND INTERVENTION WORK |
| Emergency Database | Urgent collection of most crucial information to prevent further deterioration CRITICAL INFORMATION COLLECTION WHEN DID IT STARTED? DID SOMETHING CHANGE WITH HER LIFESTYLE? MED, FOODS? |
| Health Expansion | |
| Holistic health | Expanded care to include cultures/values, family, life factors, etc. |
| Health promotion | Push to practice healthier lifestyles |
| Disease prevention CHEMOPROPHYLASIS-TAKING A DRUG TO AVOID SUPERINFECTION(COMPLICATION) | Making alterations in current lifestyle choices to prevent chronic disease developmentExamples: Thorough history screening, complete physical exam, prevention counseling, depression/mental health screening, chemoprophylaxis(PRENATAL VITAMINS) |
| Cultural | UNITED STATES CULTURE IS CHARACTERIZED AS THE MELTING POT-SALAD BOWL-GINSENG INTERACTS W/ DIGOXIN |
| genetic considerations | |
| CHAPTER 2 | CULTURAL ASSESSMENT-WHATS IS IMPORTANT TO YOU? HOW WOULD YOU LIKE ME TO DO THIS AND THAT? BE AWARE OF OWN VALUES AND BIASES... |
| Demographic Profile | CONSIDER GENERATION WHILE CARING FOR PATIENTS |
| Immigration and Health Disparities | CONSIDERING THOSE FACTORS LISTED ABOVE, TO PREVENT ERRORS AND PROVIDE QUALITY CARE |
| IMMIGRATION | Those not US citizens at birthOften experience language barriers and access to care that affect health outcomes |
| HEALTH DISPARITIES | Preventable differences that can lead to suboptimal health outcomes LOW SOCIOECONOMIC-HEALTH LITERACY-SEXUAL ORIENTATION-BUILT ENVIRONMENT |
| Social determinants of health (SDOH): | Can affect health outcomes: ethnicity, socioeconomic status, gender/gender identity, age, mental health, religion, disabilities, sexual orientation, etc |
| Culture-related Concepts | Four characteristics:Learned from birthShared by members of cultural groupAdapted to certain environmental conditionsDYNAMIC & Continually changing |
| Consists of subcultural groups | Race – physical characteristics (skin color, hair texture, etc)Ethnicity – a social group W/common geographical origin, religion, language, values, traditions, food etc. Acculturation – adopting the culture and behavior of the majority culture |
| Religion and Spirituality DOCUMENT IF PATIENT REFUSES TO TELL | Religion:Specific set of organized beliefs and practices shared by a group Spirituality:Individual’s practice having to do with a sense of peace and purpose |
| Health-related Beliefs/Practices | DIMENSIONS OFACCULTURALIVE STRESS INSTRUMENTAL/ENVIRONMENTAL:FINANCE-LANGUAGE BARRIER-LACK OF EDUCATION-ACCESS TO HEALTHCARE SOCIAL/INTERPERSONAL: CHANGING GENDER-FAMILY CONFLICT-LOSS SOCIAL STATUS SOCIETAL:STIGMA-LEVEL OF ACCULTURATION-POLITICAL FORCE |
| BALANCE | HEALTH IS the balance of the person Physical, mental, and spiritual and outside world(natural, communal or metaphysical) |
| ILLNESS BELIEFS | Biomedical/scientific-caused by foreign microorganisms, such as :viruses -bacteria; physical and psychological illnes Naturalistic/holistic Magicoreligious-supernatural forces dominate. |
| Healing beliefs and practices: | Homeopathy(MAKING THEY OWN MEDECINE) acupuncture, chiropractic manipulation, hypnosis, meditation, massage, biofeedback, herbal remediATION |
| Increased awareness for childrenAcknowledge cultural expression of pain | UNDERSTAND THE DIFFERENCE BETWEEN CULTURE AND SITUATION WITH CHILDREN TRACE ON A CHILD BACK, IS IT CULTURE OR ABUSE? RESPECT PATIENT CARE |
| Providing Culturally Competent Care RESPECT CULTURE AND INCORPORATE IN CARE ASK QUESTION WHILE PERFORMING SKILLS UPON ADMISSION TO PROVIDE HOLISTIC CARE | I.E hot/cold theory, where the four humors of the body-blood, phlegm, black and yellow bile regulate bodily functions. Treatment of disease is adding or substracting cold, heat, dryness or wetness to restore the balance of the humors |
| Culturally sensitive | Awareness of cultural differences and similarities that exist among you and your patients |
| Culturally appropriate | Knowing when, where, and how to provide specific culture-related care |
| Culturally competent | Ability to view your patients as unique individuals and able to understand that your patient’s culture affects their beliefs, values, and behaviors so that trusting relationships are developed |
| Completing a Cultural Assessment | cultural knowledge related to language, food preferences, religion, and health care beliefs-spiritually assessment |
| Cultural Self-Assessment | To ensure self-awareness |
| Assess: health practices, heritage, language, method of communication, family, nutrition, pregnancy/birth beliefs, spirituality/religion, death practices, etc | |
| Spiritual Assessment How should I address your health care needs? | FICA spiritual history tool:Faith – Do you consider yourself spiritual or religious?Importance/influence – What importance does your faith have in your life?Community – Are you part of a spiritual/religious group?Address/action – |
| CHAPTER 3 | THE INTERVIEW |
| Data Collection: | SubjectiveObjective |
| Interview components to consider: | Location and timeExplanation of your rolePurpose of the interviewTime frameParticipationConfidentialityCost |
| Process of Communication | SendingVerbal communicationNonverbal communicationReceiving Ability to take in information |
| Factors affecting communication: | INTERNAL AND EXTERNAL FACTORS traps: false assurance-unwanted advice-using authority-avoidance language-distancing-using professional jargon-using leading or biased questions-talking too much-interrupting- using why questions |
| Internal factors: | Liking other (genuine) EmpathyAbility to listenSelf-awareness |
| External factors: | Ensuring privacy Avoiding interruptionsComfortable physical environmentDress/appearanceMinimal note-taking/EHR use |
| Techniques of Communication | Introduction – introduce self and purpose, set the tone, build rapportWorking phase – collection of the needed dataOpen-ended questions – allows for a narrative responseClosed (direct) questions – limited to one-word/brief response (yes or no) |
| Techniques of Communication | Verbal responsesinterviewer response should help move conversation forward9 types: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary |
| Nonverbal Communication Physical appearanceGrooming, dress, etcPostureClosed position (crossed arms and legs looks defensive) TELL ME MORE ABOUT YOUR SMOKE GesturesNodding head, picking nails, tapping a pen | Facial expressionBoredom, annoyed, distracted, overly inappropriately happyEye contactAvoid lack of and avoid fixed gazeVoiceTone, rate of speechTouchRefrain from unless the patient appears accepting |
| Age-specific Communication | Interviewing the parent or caregiverDual focus – patient and parent/caregiverCommunication regression can occur during times of stress/crisis |
| SPECIFIC AGES | Infant (birth – 12 months)Toddler (12 – 36 months)Preschooler (3 – 6 years)School-age (7-12 years)Adolescent (12+)Older Adult |
| Special Needs Interviews | Hearing-impaired patientsAcutely ill patientsPatients under the influencePersonal questions to interviewerSexually aggressive patientsCryingAngerThreats of violenceAnxiety |
| Cultural Considerations is your love one out there/ ask for preferred name | GenderMale/female accompany Gender identification Sexual orientationLGBTQInterpretersFamily memberEmployeesLanguage linesHealth literacyOral teaching, written materials, teach-back method |
| Healthcare Professional Communication | Interprofessional communicationCommunication between two or more healthcare professionalsStandardized communication reportSBARSituationBackgroundAssessment Recommendation |
| CHAPTER4 | Health History Sequence |
| Biographic data Name, address, # number, age, birthdate, relationship status, occupation, etc Source of History Self, caregiver, parent, interpreter, etc Reason for Seeking CareChief complaint, main symptom/sign requiring care | Present Health or History of Present Illness Location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, patient’s perception |
| Past Health HistoryChildhood illnesses, injuries, chronic illnesses, hospitalizations, surgeries, OB history, immunizations, allergies, exams, home meds | Family HistoryCancer, obesity, cardiac disease, diabetes, stroke, kidney disease, mental health disease, etc Functional Assessment of ADLsAbility to care for oneself |
| Review of Systems General overall health stateSkin, hair, nailsHead:Eyes and earsNose and sinusesMouth and throatNeckBreasts and axilla | Neurological systemTREMORRespiratory systemCardiovascular system SOB-COUGHPeripheral vascular systemGastrointestinal systemUrinary system Male/female genitalia; sexual healthMusculoskeletal systemEndocrine; Hematologic |
| Functional Assessment | Self-esteem, self-conceptActivity, exercise, ADLsSleep, restNutrition, eliminationRelationships, resourcesSpiritual resourcesCoping, stress managementPersonal habits (smoking, alcohol, drugs)Intimate partner violenceOccupational health |
| Self-esteem, self-concept- Relationships, resources-CAUSING STRESS Personal habits (smoking, alcohol, drugs)- | Coping, stress management- Activity, exercise, ADLs- Nutrition, elimination-24H DIET ECALL Sleep, rest- NOT SLEEPING ENOUGH |
| Occupational health-WHERE DOES PT WORKS? Spiritual resources-WHO TO CALL Intimate partner violence- | |
| Perception of Health | How do you define health?How do you view your situation now?What are your concerns?What do you think will happen in the future?What are your health goals?What do you expect from us as nurses, physicians, or other health care providers? |
| Child-specific Health History | Biographic data Name, address, phone number, age, birthdate, relationship status, occupation, etc Source of History Self, caregiver, parent, interpreter, etcReason for Seeking CareChief complaint, main symptom/sign requiring care |
| Present Health or History of Present IllnessLocation, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, patient’s perception | Past Health HistoryPrenatal status, L&D, postnatal status, childhood illnesses, serious injuries, chronic illnesses, surgeries, immunizations, allergies, home meds |
| Developmental History Growth, milestones, developmentNutritional History Family HistoryCancer, obesity, cardiac disease, diabetes, stroke, kidney disease, mental health disease, etc | |
| Child-specific Data | Review of Systems: Same as adult except focused questioning on child-specific issues Functional Assessment:Relationships, activity/rest, economic status, home environment, environmental hazards, coping/stress management, habits, health promotion |
| Adolescents PRE-TEEN SEXUALITY -PT NEEDS TO BE ALONE | HEEADSSS - method of interviewing focuses on assessment of:Home environment Education and employment Eating Activities (peer related) DrugsSexuality Suicide and depression Safety from injury and violence |
Created by:
Seka_nurse
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