NURSING 275 HOLISTIC ASSESSMENT EXAM 1 STUDY GUIDE

HOLISTIC ASSESSMENT EXAM 1 STUDY GUIDE Assessment is the collection of subjective and objective data about a patient’s health. • Subjective data consist of information provided by the affected individual. • Objective data include information obtained by the health care provider through observation and inspecting, percussing, palpating, and auscultating during the physical examination. The holistic health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together. Health assessment also should consider the cultural beliefs and practices of different people. Obtaining a heritage assessment helps gather data that are accurate and meaningful and can guide culturally sensitive and appropriate care. The nursing process includes six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It is a dynamic, interactive process in which practitioners move back and forth within the steps. • Nurses apply the process differently depending on their level of time and experience. • The novice nurse has no experience with specific patient populations and uses rules to guide performance. • The proficient nurse understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it. • The expert nurse has an intuitive grasp of a clinical situation and zeroes in on the accurate solution Critical thinking is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment. The process includes identifying relevant information, gathering clinical cues, completing an assessment, and setting priorities. • First-level priority problems are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. • Second-level priority problems are next in urgency. They require prompt intervention to prevent further deterioration and may include a mental status change, acute pain, or abnormal laboratory values. • Third-level priority problems are important to the patient’s health but can be addressed after more urgent problems. Examples include lack of knowledge or family coping. • Collaborative problems are certain physiologic conditions in which the approach to treatment involves multiple disciplines • Evidence-based practice is a systematic approach to practice that uses the best evidence, the clinician’s experience, and the patient’s preferences and values to make decisions about care and treatment. • An individual’s health status is influenced by a group of personal, social, economical, and environmental factors, collectively known as determinants of health. • Cultural care is professional health care that is culturally sensitive, appropriate, and competent. To develop cultural care, you must have knowledge of your personal heritage and the heritage of the nursing profession, the health care system, and the patient. • Culture has four characteristics. First, it is learned from birth through language acquisition and socialization. Second, it is shared by all members of the same cultural group. Third, it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. Fourth, it is dynamic and ever changing. • Ethnicity pertains to membership in a social group that claims to possess a common geographic origin, migratory status, religion, race, and language and shared values, traditions or symbols, and food preferences. One’s cultural background is a fundamental component of one’s ethnic background. • Religion is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator or ruler of the universe. •Spirituality is borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. • Socialization is the process of being raised within a culture and acquiring the characteristics of the group. Education is a form of socialization. -In times of illness, religion and spirituality may be a source of comfort for patients and their significant others. -Religion and spiritual leaders may strongly influence the perception of health, illness, and practices. Spirituality may be used to find meaning and purpose for illnesses. The process of communication includes sending and receiving information. When exchanging information, both individuals engage in verbal and nonverbal communication, which can affect the communication process. “IMPLICIT BIAS” refers to the attitudes, beliefs, or stereotypes that inform and affect our understanding, Actions, and Decisions. • operates at a Level below our conscious Awareness as opposed to “explicit Bias” which refers to beliefs and attitudes that one endorses at a conscious Level. • can be Positive or negative • Not limited to Race, can include gender, Religion, socioeconomic status, sexual orientation, age, size, etc… • Present in every Facet of Life and institution in our country (Education, Healthcare, criminal justice, hiring practices) How to approach implicit biases: • Confront your biases when they arise • Challenge others to do the same • Make connections with people that are different • Internal factors are specific to the examiner. Four internal factors promote good communication: liking others, expressing empathy, the ability to listen, and self-awareness. • External factors relate mainly to the physical setting. You can foster good communication with certain external factors, such as by ensuring privacy, preventing interruptions, creating a conducive environment, arranging equal status seating, wearing appropriate attire, and documenting responses via note-taking or an electronic health record without interfering with the conversation. • The interview has three phases: an introduction, a working phase, and a closing. • During the first phase, begin the interview by introducing yourself and your role. • During the working phase, gather data. Start with open-ended questions, which ask for narrative information. •Then use closed or direct questions, which ask for specific information in short, one- or two- word answers. • Nonverbal communication is important in establishing rapport and conveying information while providing clues to understanding feelings. No matter what form is used to record the health history, plan to gather data in eight categories. • First, collect biographical data, such as the patient’s name, date of birth, occupation, primary language, and communication needs. • Second, note the source of the history, which is usually the patient but may be someone else, such as a relative or interpreter. • Third, obtain the reason for seeking care, formerly known as the chief complaint. In the patient’s own words, briefly describe the reason for the visit stating one or two symptoms or signs and their duration. • Fourth, record the present health or history of present illness. For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care. When a patient reports a symptom, perform a symptom analysis including location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, and patient’s perception. • Fifth, investigate past health events, such as illnesses, injuries, hospitalizations, surgeries, and allergies, and current prescribed and herbal medications. • Sixth, gather a family history to help detect health risks for the patient, and assist with early screening and periodic surveillance. Several questions should be added to assess spiritual resources or religion, nutritional status, and immigration status as applicable. • Seventh, perform a review of systems to evaluate the past and present health of each body system, doublecheck for significant data that may have been omitted, and assess health promotion practices. • Eighth, perform a functional assessment, including activities of daily living, measuring a person’s self-care ability. • Mental status is a person’s emotional (feeling) and cognitive (knowing) function. Functioning related to mental status is inferred by assessing the individual’s consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, and perceptions. • The full mental status examination is a systematic check of emotional and cognitive functioning. Its purpose is to determine mental health strengths and coping skills and to screen for dysfunction. • The four main components of the mental status assessment are appearance, behavior, cognition, and thought processes. Think of the initials A, B, C, and T to help remember these categories. • To assess appearance, observe the patient’s posture, body movements, dress, grooming, and hygiene.