Health Assessment Exam 1 (ch. 1-4)
health assessment ans: term in nursing used to include health history and physical exam
health history ans: - info from patient and medical records
- gathered data about patient through guided questions/pkt to fill out
- provide dates whenever possible
- ...
Health Assessment Exam 1 (ch. 1-4)
health assessment ans: term in nursing used to include health history and physical exam
health history ans: - info from patient and medical records
- gathered data about patient through guided questions/pkt to fill out
- provide dates whenever possible
- pt telling their story (subjective)
- beginning of the nursing POC
physical exam ans: - completed by nurse/provider
- be systematic **do the same every time**
- trend findings
- DOCUMENT
assessment ans: term used by PROVIDERS to include the medical diagnosis
plan ans: term used by PROVIDERS to include how they will tx the dx
primary, secondary, and tertiary ans: 3 levels of prevention
primary ans: prior to onset of problems
secondary ans: screening
tertiary ans: rehab
assessment, diagnosis, planning, implementation, and evaluation ans: steps of the nursing process
(patient is the focus!!)
assessment ans: - subjective data (symptoms)
- objective data = measurable (signs)
- clump data to SUPPORT DX
diagnosis ans: - what is the problem or potential problem?
- subjective and objective data MUST support nursing dx
planning ans: - what is the goal of care?
- what interventions are needed to get to the goal?
- how long should this take?
implementation ans: - now do what you planned (update changes)
evaluation ans: - was the goal achieved?
onset, location, duration, characteristics of symptoms, associated characteristics, relieving factors,
treatment, severity/scale ans: OLD CARTS - for questioning
feelings ans: FIFE - fears or concerns about problem
ideas ans: FIFE - about nature and cause of problem
function ans: FIFE - effect on pt's life
expectations ans: FIFE - of disease, health care team, or health care based on prior experiences
therapeutic communication ans: the act of developing pt rapport
nonverbal, active listening, accepting, exploring, reflecting, restating, and guiding ans: characteristics of
therapeutic communication
active listening ans: listening more than talking
accepting ans: never using "why?"
exploring ans: "tell me more..."; "go on.."
reflecting ans: validation within therapeutic communication
restating ans: making sure you heard the pt correctly and emphasize important points
guiding ans: using open vs. closed ended questions
the silent patient ans: - active listening
- nonverbal cues
- do not try to fill silence with words
the confusing patient ans: - multiple symptoms, positive review of symptoms, provider should focus on
context of symptoms, emphasize patient's perspective, and guide the interview into a psychosocial
assessment
- assess mental status
- **know the law**
- check responses against chart or seek permission to speak with family members
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