Assessment - ANSWER-systematically collecting data where registered nurse
collects comprehensive data pertinent to the patient's health and or situation
Health assessment process - ANSWER-nurse incorporates the patient's
knowledge, motivation, support systems, coping ability, and preferences to
develop a plan of care to better the patient to maximize health
Components of a health assessment - ANSWER-1. Health history
2. Physical examination
3. Documentation of data
Subjective data - ANSWER-things a person tells you about that you cannot
observe through your senses; symptoms. the patient tells you what's wrong or
you collect it from health history
Objective data - ANSWER-information that is seen for yourself and collected by
you (the nurse)
Comprehensive assessment - ANSWER-takes place in a primary care, admission
to hospital, or long term care facility. involves a detailed history and physical
examination performed at the onset of care
,Problem based/focus assessment - ANSWER-Takes place at a walk in clinic or
emergency department that involves a history and examination that are limited
to a specific problem or complaint
episodic/follow-up assessment - ANSWER-usually done when the patient is
following up with a health care provider for a previously stated problem
Shift assessment - ANSWER-nurses conduct assessment each shift to make
identifying changes to a patient's condition easier and also can allow nurses to
determine the changes in patient's care
screening assessment/examination - ANSWER-short examination focused on
disease detection. (BP, glucose screening, etc)
Purposes for obtaining a written medical record - ANSWER--prevents the patient
from having to explain same information to another health care provider
-includes information about the patient such as med allergies and past
disease/surgeries
health promotion - ANSWER-the process of motivating the patient to increase
their well being and actualize health potential
health protection - ANSWER-the process of motivating the patient to prevent
illness, detecting it early, getting require vaccinations, and maintain function
, primary prevention - ANSWER-preventing a sides before it starts by living
healthy lifestyle or receiving vacs
secondary prevention - ANSWER-early detection of disease (self exams or
screenings)
tertiary prevention - ANSWER-minimizing the disability from acute or chronic
disease. living and managing your disease well in order to maximize health
motivations for learning health assessment - ANSWER--better quality of life
-better patient center plan of care
-more experience for nurses
purpose of a health history - ANSWER-To obtain subjective data from patients so
the nurse and patient can create a plan to promote health, prevent disease,
resolve acute health problems and minimize limitations related to chronic health
problems
comprehensive health history - ANSWER-may be performed during a hospital
admission with an initial clinic or home visit or when the patient's reason for
seeking care is for the relief of generalized symptoms such as weight loss or
fatigue.
problem based/problem focused - ANSWER-includes data limited to a specific
problem