NURS 301 HEALTH ASSESSMENT EXAM 1 FOCUS TOPICS TO REVIEW

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Explain the purpose of a nursing health assessment.  Collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical... judgement Compare and contrast medical assessment from nursing health assessment.  Medical assessment o Focuses on the client’s physiologic status  Nursing health assessment o Collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgement Describe the phases of the nursing process involved in health assessment by the nurse. 1. Assessment – collecting subj. & obj. data 2. Diagnosis – analyzing subj. & obj. data to make a professional nursing judgement (nursing diagnosis, collaborative problems, or referral) 3. Planning – determining outcome criteria & developing a plan 4. Implementation – carrying out the plan 5. Evaluation – assessing whether outcome criteria have been met and revising the plan as necessary Compare and contrast subjective from objective data  Subjective Data o Sensation or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, & personal info that the client tells & verifies for you  Objective Data o Obtained by general observations and by uses the 4 physical examination techniques “IPPA” o Objective data observes:  Physical characteristics  Body functions  Appearance  Behavior  Measurements  Results of lab testing Compare and contrast the four basic types of nursing assessment: (a) initial comprehensive, (b) ongoing or partial, (c) focused/problem-oriented, (d) emergency. 1. Initial comprehensive o Collection of subjective data about the client’s perception of his or her health of all body parts or systems, PHx., FamHx., and lifestyles and health practices as well as obj. data gathered during a step-by-step physical examination o When client 1st enters a health care system o Establishes a baseline 2. Ongoing or partial o Occurs after the comprehensive database is established o Minoroverview of client’s body system and holistic health patterns as a follow up on health status o Any problems that were detected are reassessed to determine any changes form the baseline data o Reassessment of client’s body systems & holistic health patterns is performed to detect any new problems 3. Focused/problem-oriented o Does not replace comprehensive health assessment o Performed when a comprehensive database exists for a client who comes ot the healthcare agency w/ a specific health concern o Thorough assessment of a particular client problem and does not address areas not related to the problem 4. Emergency o Rapid assessment performed in life-threating situations Describe the three phases of a client interview process. Give examples of what occurs in each phase.  Preintroductory Phase o Reviews medical record before meeting w/ the client Introductory Phase o Introduce yourself to the client o Explain the purpose of the interview, types of questions that will be asked, reason for taking notes, and assure client that confidential info will remain confidential o Make sure client is comfortable and has privacy o Conduct interview at eye level – demonstrates respect o Essential to develop trust & rapport – to promote full disclosure of info  Ex. o The nurse introduces herself to Mrs. Gutierrez and explains that she will be asking questions in order to better assist her with control of her diabetes. The nurse then sits down with Mrs. Gutierrez at eye level, explaining and ensuring confidentiality of information that will be shared. At that point the nurse asks her if she has any questions, to verify that the client is following and understanding the interview process. The nurse observes and listens to Mrs. Gutierrez to determine her level of comprehending and speaking English.  Working Phase o Nurse obtains client’s comments about major biographical data, reasons for seeking cate, hx. of present health concern, PMHx., FamHx., review of body system (ROS) current health problems, lifestyle & health practices, & developmental level o Listens , observes cues, uses critical thinking skills to interpret & validate info received from the client o Nurse & client collab. To identify client’s problems and goals  Ex. o Once the nurse verifies that Mrs. Gutierrez speaks and comprehends English, the nurse then enters the working phase with Mrs. Gutierrez, asking questions about her biographical data, reasons for seeking care, history of present health concern, past health history, family history, ROS for current health problems, lifestyle and health practices, and developmental level. The nurse asks Mrs. Gutierrez what her beliefs are regarding what may be causing her conditions and if she believes she may be experiencing “susto” related to her husband’s accident 1 month ago  Summary & Closing Phase o Nurse summarizes ingo obtained during the working phase &validates problems and goals w/ the client o Identifies and discusses possible plans to resolve the problem w/ the client o Ask if anything else concerns the client & if there are any further questions  Ex. o The nurse reviews the data she has gathered from Mrs. Gutierrez and reflects on it. She shares with Mrs. Gutierrez that she thinks her insomnia may be related to stress and anxiety associated with her husband’s accident and work setbacks. She outlines a plan for Mrs. Gutierrez to return to see her primary physician for her anxiety, to modify her diet and caffeine intake, and to engage in a daily exercise walking routine. After discussing ways to fully relax before going to sleep, Mrs. Gutierrez agrees to try a bedtime routine of warm milk and enjoyable reading materials. The nurse concludes that the client has insomnia and anorexia related to anxiety associated with her husband’s accident. Her collaborative prob [Show More]

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