Health Assessment and Promotion Midterm Study Guide_ Latest updated 2021/2022,100% CORRECT
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NURSE-UN 239
Institution
NURSE-UN 239
Health Assessment and Promotion Midterm Study Guide_ Latest updated 2021/2022
Introduction
- Health is specific to the individual and based on experience, upbringing, race/ ethnicity, sexual identity, culture, values
o Health: a state of complete physical, mental, and social well-being and not...
health assessment and promotion midterm study guide latest updated 20212022
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Health Assessment and Promotion Midterm
Study Guide_ Latest updated 2021/2022
Introduction
- Health is specific to the individual and based on experience, upbringing, race/ ethnicity, sexual identity,
culture, values
o Health: a state of complete physical, mental, and social well-being and not merely the absence
of disease and infirmity (WHO)
o Biomedical health: absence of disease
o Holistic health: the view that the mind, body, and spirit are interdependent and function as a
whole within the environment
o Wellness: a dynamic process and view of health; a move toward optimal functioning; a
“positive” state of health
- Role of the professional nurse:
o To promotes health
o To prevent illness
o To treat human responses to health or illness
o To advocate for individuals, families, communities, and populations
- Health assessment: a systemic method of collecting and analyzing data
o Utilizes the American Nurses Association’s (ANA) Standards of practice, which incorporates the
nursing process
- Nursing Process: the traditional critical thinking competency that allows nurses to make clinical
judgments and take actions based on reason
o Supports nurses to continually examine what they are doing and to study how it can be done
better
o Benefits of the nursing process
▪ Diagnose both actual and potential problems
▪ Provide a blueprint or plan for patient care
▪ Systemic
▪ Dynamic
▪ Humanistic
▪ Outcome-focused
o Assessment → Diagnosis → Planning → Implementation → Evaluation
o Assessment: health history (subjective data), physical assessment (objective data),
psychological, sociocultural, spiritual, economic, lifestyle, documentation of date
▪ Subjective data: symptoms, history
● Information the patient or their family tells you
● “I have a headache”; “My husband says he has a headache”
▪ Objective data: signs, physical examination
● The findings resulting from direct observation using all of your senses (sight,
sound, touch, smell)
● Uses techniques of inspection, palpation, percussion, and auscultation
o BP 120/80; patient is restless; WBC 12,000; lungs crackles bilaterally
▪ Documentation: legal document of patient’s health status
● Baseline for evaluation; changes and decisions related to care
● Confidentiality: keeping patient health information private
o (HIPAA): requires protection of specific health information
● Accuracy and completeness: must precisely reflect assessment data without bias;
legally accepted abbreviation use; correction
, ● Narrative: SOAP, PIE, DAR, CBE
o SOAP: subjective, objective, assessment, plan
o PIE: plan, implement, evaluate
o DAR: data, action, response
o CBE: charting by exception (abnormal signs lead to additional
assessments)
● Verbal: SBAR
o SBAR: situation, background, assessment, recommendation
▪ Types of Assessments:
● First level priority problems, second level priority problems, third level priority
problems, collaborative problems
- Critical Thinking: an active organized, cognitive process used to carefully examine one’s thinking and
the thinking of others
o Basic critical thinking: concrete and based on a set of rules, early step in developing reasoning,
not enough experience to individualize; weak competencies
o Complex critical thinking: analyze and examine choices independently; look beyond expert
opinion; thinkers separate self from experts; each solution has benefits and risks
- Data analysis, interpretation, and clinical judgment include:
o Identifying abnormal findings
o Correctly interpreting findings to select appropriate plan of care
o Applying clinical judgment to interpret or make conclusions regarding patient needs, concerns,
or health problems
o After understanding the situation, the nurse responds by determining appropriate interventions
- Diagnostic Reasoning:
o Attending to initially available cues
o Formulating diagnostic hypothesis
o Gathering date relative to the tentative hypothesis
o Evaluating each hypothesis with the new data collected, thus arriving to at a final diagnosis
- Diagnosis: formulating using PES statement
o Problem
o Etiology
o S: defining characteristics
o Diagnosis (P) is related to (r/t) etiology (E) as evidenced by (aeb) characteristics (S)
▪ Diagnosis and etiology is not a medical diagnosis; characteristics is the assessment data
o Types of Diagnoses
▪ Medical: disease condition based on specific evaluation of signs and symptoms
▪ Nursing: judgment about the patient in response to an actual or potential health problem
▪ Collaborative: an actual or potential physiological complication that nurses monitor to
detect the onset of changes in patient’s status
Medical vs. Nursing Diagnoses
Pneumonia Impaired gas exchange;
ineffective breathing pattern
Acute Myocardial Chest pain; decreased
Infarction cardiac output
o Types of Nursing Diagnoses
, ▪ Actual: describes human responses to health conditions or life processes that exist in an
individual, family, or community
▪ Risk (potential): describes human responses to health conditions/ life processes that may
develop in a vulnerable individual, family, or community
▪ Wellness: describes human responses to levels of wellness in an individual, family, or
community
- Evidence Based Practice: systematic approach to practice that emphasizes the use of best evidence in
combination with the clinician’s experience, as well as the patient preference and values, to make
decisions about care and treatment
- Complete Health History:
o Biographic Data
o Source of History
o Reason for seeking care
o Present Health/History of present illness
o Past Health
o Family History
o Review of Systems
o Functional Assessment
o Perception of Health
- Health promotion: behavior motivated by desire to increase well-being and actualize health potential;
the process of enabling people to increase control over, and to improve, their health
o Disease prevention
o Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning
when ill
o Central component of nursing
o Begins with health assessment—data to identify patient’s health status, practices, and risk factors
o Interpretation of data allows the nurse to target health promotion needs
- Three levels of health promotion/protection:
o Primary prevention: optimize health and disease prevention through promotion of healthy
lifestyles
o Secondary prevention: identify at an early stage to initiate prompt treatment; screening efforts
o Tertiary prevention: minimizing the effects of the disease or illness and allowing for the most
productive life within limitations
- Health People 2020: objectives address most significant preventable threats to health with goals to
reduce threats
o Four overarching goals:
▪ Attain high quality, longer lives, free from preventable diseases
▪ Achieve health equity, eliminate disparities, and improve the health of all groups
▪ Create social and physical environments that promote health for all
▪ Promote quality of life, healthy development, and healthy behaviors across all life stages
Interviewing & Health History Cultural Considerations
- Health Assessment: health history and physical examination
- The Interview
, o Subjective Data: patient knows everything and you know nothing
▪ Primary data: from the patient
▪ Secondary data: from family, caregivers, chart
o Identify: areas of concern that should be addressed during the physical examination; topics for
teaching and health promotion
o Goals: Record a COMPLETE health history
▪ Create a database used to create a plan, prevent disease, resolve problems, and
minimize limitations
o Keys: gather complete and accurate data, including chronology and symptoms of illness;
establish rapport and trust; teach about health state
o “Contract” between nurse and patient
▪ Consists of spoken and unspoken rules for behavior (verbal and nonverbal)
▪ Sending and receiving communication
o Verbal Communication: talking/ interacting
o Nonverbal Communication: appearance, sitting/standing, posture, facial expression, gestures,
eye contact, touch
o Pre-interaction
o Beginning the interview:
▪ “Mr. Craig, I want to ask you some questions about your health and your usual daily
activities so that we can plan your care here in the hospital.”
o The working phase: process by helping them to describe and clarify their experiences, to plan
courses of action and try out the plans, and to begin to evaluate the effectiveness of their new
behavior
o Closing the interview:
▪ “Are there any questions you would like to ask?”
o Therapeutic Communication: single-most important factor for successful interviewing is the
communication skill of the nurse; professional communication gains the patient’s trust
o The Interview is Affected by numerous factors:
▪ Physical setting
▪ Nurse behaviors
▪ Type of questions asked
▪ How questions are asked
▪ Personality and behavior of patients
▪ How patient is feeling at the time of interview
▪ Nature of information being discussed or problem being confronted
o Physical setting: private, quiet, comfortable room without distractions; privacy is essential for
sensitive issues
o Patient-related Variables:
▪ Consider patient age and physical, mental, and emotional status
▪ Ideally, the patient will be alert and in no physical or emotional discomfort
▪ If in distress, limit the number and nature of necessary questions. Save additional
questions for later
o Asking Questions:
▪ The art of obtaining information and listening carefully is an essential competency of
nurses
▪ Some areas of questioning are sensitive, and sensitivity varies
▪ Seek clarification
Open-Ended Questions Closed (Direct) Questions
Narrative Information Specific Information
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