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507 Assessment-intro
intro to health assessment
Question | Answer |
---|---|
levels of care - primary, secondary, tertiary | primary - promote health/prevent illness*****secondary - early detection/prompt intervention/health maint----tertiary - rehab/extended care |
Nursing process ADPIE | A-assessment-----D-diagnosis(nursing)-----P-plan----I-implementation----E-evaluation |
nursing assessment is a holistic approach to collect data (unique to nursing) - first step is | ongoing and continuous throughout nursing process |
assessment determines the clients | baseline,normal fx, presence/risk of dysfxn, strengths----allows nurse to make judgements about state of health |
two types of assessment | complete-----focused/episodic/emergency--------these are dependent upon intent of interaction, condition of client, examiner knowledge, clinical setting, patient expectation |
pediatric considerations | physiological differences----developmental stage---caregiver involvement |
elderly considerations | impact of illness on ADLs---sensory/cognitive dificits----mistreatment |
assessment is a thinking-doing-feeling-process utilizing "OIP" | o-observation/general survey with senses-----I=interviewing-------P= physical exam |
general survey includes | general appearance---grooming/hygiene----apparent state of health---LOC---mental status---signs of distress---posture---gait/motor |
interviewing phases | preparatory---introductory---working---termination |
physical exam phase - IPPA | inspection---palpation---percussion---auscultation |
types of data | objective = signs-----subjective = symptoms |
data sources | primary = pt----secondary = all other sources |
data validation comparisions betw subjective/objective by looking for | look for discrepancies---abn findings---data reliability |
methods to validate data | confirm accuracy abn findings---clarify w/ pt---verify with colleagues, family, records, etc |
pitfalls of data collections | omission---misinterpretation/hasty---irrelevant data---failure to follow up---poor communication |
organize data in cluster/concept mapping -----framework systems (name 4) | ***Gordon's functional health patterns ***Maslow's hieerarchy of human needs ***Roy's Adaptation theory ***NANDA unitary person framework |
interpretation - clustering helps recognize | ****patterns of response/behavior ***relevant/irrelevant ***gaps in data ***patterns of cause/effect |
concept map centers around client using these 4 catagories | problem---potential problem---identified areas for enhanced wellnes---strengths |
Nursing diagnosis PES |