Study Guide for Health Assessment Exam 1

Study Guide for Health Assessment Exam 1 Ch. 1-7 Concepts to know CH. 1 Evidence-Based Practice Types of Data • Objective – visibly able to measure on a patient o Vital signs, (BP, Pulse) Redness o Observed when inspecting, percussing, palpating and auscultating patient during physical exam • Subjective – aspects that the patient say o Must be in quotations o It is what they say it is o Examples – pain level • Database o Formed from these elements plus patients record and labs Data bases: Complete Database: includes a complete health history and a full physical examination. o collected in a primary care setting such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency Focused or Problem centered: limited or short-term problem. Here you collect a “mini” database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system o used in all settings—hospital, primary care, or long-term care Follow up: status of any identified problems should be evaluated at regular and appropriate intervals. What change has occurred? Is the problem getting better or worse? Which coping strategies are used? o type of database is used in all settings to follow up both short-term and chronic health Emergency: urgent, rapid collection of crucial information o Life saving measures-- What did you take?” “How much did you take?” and “When?” Evidence based practice • What is this? • Systematic approach to practice that emphasizes the use of best evidence in combination with the clinician's experience, as well as the patient preferences and values, to make decisions about care and treatment • the best evidence from a critical review of research literature; the patient's own preferences; the clinician's own experience and expertise; and finally physical examination and assessment Prioritizing Patients • First-level priority o EMERGENCY, Life threatening, and immediate. o Examples: establishing an airway or supporting breathing. o ABC plus V – Airway, Breathing, Circulation, Vital Sign Change (high fever) • Second-level priority o Next in urgency, requiring attention to avoid further deterioration. o Examples: mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security • Third-level priority o Important to patient’s health but can be addressed after more urgent problems are addressed o to treat these problems are more long term, and the response to treatment is expected to take more time. o Examples: Problems with lack of knowledge, activity, rest, or family-coping • Collaborative Problems o Approach to treatment involving multiple disciplines. o Examples: Alcohol withdrawal patients and pregnant mothers. Using critical thinking and nursing process Nursing Process ADPIE – Assessment, Diagnosis, Planning, Implementation, Evaluation 1. Assessment • Collection of Data to make clusters of cues to make infrences • Can be acquired from: Clinical record, interview, health history, physical exam, functional assessment, cultural and spiritual exam, consultation, and research 2. Diagnosis • Interpretation of data • Identify and compare clusters of cues with definitions and defining characteristics • Validation of inferences • Document the diagnoses 3. Outcome Identification • Identify expected outcomes related to patient individualization • Ensuring outcomes are realistic and measurable • Specify short and long term goals 4. Planning • Establish prioritize • Develop outcomes and set time frames for meeting outcomes • Identify relevant interventions and utilize health care team members in the care of the pt • Document plan of care 5. Implementation • Determine patient readiness and involve the patient in health care process ………………………………………………..CONTINUED……………………………….