Health assessment Review Sheet for Exam 1
CHAPTER 1: EVIDENCE-BASED ASSESSMENT
Assessment is a point of entry and it's an ongoing process.
It starts with Subjective data ( this is the data collected from the Patient) and Objective
data ( this is the data the nurse sees, hears, and smells) plus any medical history.
The Data collected is what the nurse uses to make clinical judgments and make a
nursing diagnosis.
The 5 steps of the Nursing Process (ADPIE)
Assessment, Diagnosis, Planning, Implementation, and Evaluate
Critical thinking and the nursing process go hand in hand.
Novice: Starting out in an area of learning. Uses rules to guide performance
Competent: Building on 2 to 3 years of clinical experience. See actions in the context of
patient goals or plans
Proficient: Adding to time and experience. Understands the patient situation as a whole
rather than individual parts—apply long term goals
Expert: Attained mastery of an area of learning. Performs clinical
judgment using intuitive analysis
There are 3 priority problem levels.
First level priority: This is Emergent, life-threatening, and immediate.
Second level priority: Next in urgency, requiring attention so as to avoid further
deterioration.
Third level priority: important to patient health, but can be addressed after more
urgent problems are addressed.
Collaborative problems: approach to treatment involves multiple disciplines.
There are 4 types of Data
1. Complete total health database:
, 2. Episodic or problem-centered database
3. Follow-up database
4. Emergency database
CHAPTER 2: CULTURE AWARENESS
The importance of cultural awareness: it increases understanding of cultural diversity by
being self-aware and knowledgeable about one’s own culture
Culture plays a major role in patients’ attitudes, behaviors, and beliefs related to health
care practices. The nurse should practice cultural competence in caring for every
patient, recognizing that cultural differences exist and should be respected. Culture has
an impact on nearly every aspect of a patient’s life, from food to beliefs about death.
The nurse must assess the patients’ cultural food preferences, preferences regarding
eye contact and personal space, and the need for a medical interpreter. Using culturally
competent nursing care facilitates a thorough, accurate assessment and helps ensure
clear communication, development of a culturally appropriate plan of care, and overall
patient satisfaction
Key Points
● Culture has a major impact on a patient’s attitude, behavior, and health care
choices.
● Culture influences the foods patients eat, their hygiene and exercise habits, as
well as their beliefs about the cause of illness.
● It is important for the nurse to practice culturally competent nursing care and
respect patients’ cultural preferences.
● The nurse must be willing to negotiate and incorporate the patient’s cultural
health practices into the treatment plan.
● When caring for patients from different cultural backgrounds, the nurse should
understand the patient’s preferences related to nutrition, personal space, and eye
contact.
● A patient’s cultural beliefs may limit the patient’s food choices or set specific
requirements for preparation.
● Whereas some cultures prefer a large personal space be maintained, others
prefer a more intimate space.
Acc ration: when individuals '
adopt to the culture
of the majority
, ● Direct eye contact can be considered disrespectful or aggressive, depending on
the patient’s culture. Other cultures may prefer direct eye contact as a sign of
respect.
● When interacting with patients who speak unfamiliar languages, the nurse should
enlist the assistance of a medical interpreter.
CHAPTER 3: The Interview
The purpose of the interview is to gain an understanding of patients beliefs, concerns
and perception of their health state.
It is important to establish trust to foster acceptance and allow data sharing.
The interview Contract terms.
★ Locatiion: The time and place with the follow up for physical exams
★ Explanation: introduction and delineation of role.
★ Purpose: the mutual goal is optimal health.
★ Time Frame: Lenth of time for process
★ Participation: Expected paraticipation and or presense of others.
★ Confidentiality: reasonable and or limited as it applies to legal/ethical standards.
★ Cost: disclosure of any financial costs
.
There are 2 types of sending communication: verbal and nonverbal.
Verbal communication is the words that you vocalized, and tone used in that
conversation.
Nonverbal communication is the body language that helps to provide cues which may
be correlated with truer feelings.
There are internal factors that are specific to the health care team member, which can
help maximize communication skills.
The internal factors are: liking others - using a “genuine” approach. Empathy- develop
an understanding and sensitivity for others feelings. Ability to listen: using an active
process and self-awareness- be aware of implcit bias.
Some of the external factors are: ensure privacy - aim for geographic privacy but
ensure psychological privacy. Avoid interruptions-minimize and or refse. Physical
CHAPTER 1: EVIDENCE-BASED ASSESSMENT
Assessment is a point of entry and it's an ongoing process.
It starts with Subjective data ( this is the data collected from the Patient) and Objective
data ( this is the data the nurse sees, hears, and smells) plus any medical history.
The Data collected is what the nurse uses to make clinical judgments and make a
nursing diagnosis.
The 5 steps of the Nursing Process (ADPIE)
Assessment, Diagnosis, Planning, Implementation, and Evaluate
Critical thinking and the nursing process go hand in hand.
Novice: Starting out in an area of learning. Uses rules to guide performance
Competent: Building on 2 to 3 years of clinical experience. See actions in the context of
patient goals or plans
Proficient: Adding to time and experience. Understands the patient situation as a whole
rather than individual parts—apply long term goals
Expert: Attained mastery of an area of learning. Performs clinical
judgment using intuitive analysis
There are 3 priority problem levels.
First level priority: This is Emergent, life-threatening, and immediate.
Second level priority: Next in urgency, requiring attention so as to avoid further
deterioration.
Third level priority: important to patient health, but can be addressed after more
urgent problems are addressed.
Collaborative problems: approach to treatment involves multiple disciplines.
There are 4 types of Data
1. Complete total health database:
, 2. Episodic or problem-centered database
3. Follow-up database
4. Emergency database
CHAPTER 2: CULTURE AWARENESS
The importance of cultural awareness: it increases understanding of cultural diversity by
being self-aware and knowledgeable about one’s own culture
Culture plays a major role in patients’ attitudes, behaviors, and beliefs related to health
care practices. The nurse should practice cultural competence in caring for every
patient, recognizing that cultural differences exist and should be respected. Culture has
an impact on nearly every aspect of a patient’s life, from food to beliefs about death.
The nurse must assess the patients’ cultural food preferences, preferences regarding
eye contact and personal space, and the need for a medical interpreter. Using culturally
competent nursing care facilitates a thorough, accurate assessment and helps ensure
clear communication, development of a culturally appropriate plan of care, and overall
patient satisfaction
Key Points
● Culture has a major impact on a patient’s attitude, behavior, and health care
choices.
● Culture influences the foods patients eat, their hygiene and exercise habits, as
well as their beliefs about the cause of illness.
● It is important for the nurse to practice culturally competent nursing care and
respect patients’ cultural preferences.
● The nurse must be willing to negotiate and incorporate the patient’s cultural
health practices into the treatment plan.
● When caring for patients from different cultural backgrounds, the nurse should
understand the patient’s preferences related to nutrition, personal space, and eye
contact.
● A patient’s cultural beliefs may limit the patient’s food choices or set specific
requirements for preparation.
● Whereas some cultures prefer a large personal space be maintained, others
prefer a more intimate space.
Acc ration: when individuals '
adopt to the culture
of the majority
, ● Direct eye contact can be considered disrespectful or aggressive, depending on
the patient’s culture. Other cultures may prefer direct eye contact as a sign of
respect.
● When interacting with patients who speak unfamiliar languages, the nurse should
enlist the assistance of a medical interpreter.
CHAPTER 3: The Interview
The purpose of the interview is to gain an understanding of patients beliefs, concerns
and perception of their health state.
It is important to establish trust to foster acceptance and allow data sharing.
The interview Contract terms.
★ Locatiion: The time and place with the follow up for physical exams
★ Explanation: introduction and delineation of role.
★ Purpose: the mutual goal is optimal health.
★ Time Frame: Lenth of time for process
★ Participation: Expected paraticipation and or presense of others.
★ Confidentiality: reasonable and or limited as it applies to legal/ethical standards.
★ Cost: disclosure of any financial costs
.
There are 2 types of sending communication: verbal and nonverbal.
Verbal communication is the words that you vocalized, and tone used in that
conversation.
Nonverbal communication is the body language that helps to provide cues which may
be correlated with truer feelings.
There are internal factors that are specific to the health care team member, which can
help maximize communication skills.
The internal factors are: liking others - using a “genuine” approach. Empathy- develop
an understanding and sensitivity for others feelings. Ability to listen: using an active
process and self-awareness- be aware of implcit bias.
Some of the external factors are: ensure privacy - aim for geographic privacy but
ensure psychological privacy. Avoid interruptions-minimize and or refse. Physical
