Health assessment study guide Exam 1
Subjective vs objective data
Subjective/symptom - What patient says about themselves
Objective/sign – observed when inspecting, percussing, palpating and auscultating patient duri
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Health assessment study guide Exam 1
Subjective vs objective data
Subjective/symptom - What patient says about themselves
Objective/sign – observed when inspecting, percussing, palpating and auscultating patient during physical exam
Diagnostic reasoning
Attend to initially available cues
Formulate diagnostic hypotheses
Gather data relative to tentative hypotheses
Evaluate each hypothesis with new data collect to arrive at final diagnosis
Nursing process
ADOPIE
Assessment, diagnosis, outcome identification, planning, implementation and evaluation
Critical thinking skills
Identifying assumptions, organized approach, validation, normal and abnormal, inferences or drawing valid conclusions, clustering related cues, relevance, inconsistencies, identify patters, missing information, health promotion, risk diagnosis, set priorities, collaborative problems, outcomes, interventions, evaluation and corrective thinking, comprehensive plan of care.
4 types of data collecting
Episodic or problem centered data base
Follow up data base
Emergency data base
Complete and total health data base
Health and illness
Health is a balance of a person is a complex interlaced phenomenon, within physical, mental and spiritual nature
Illness is a loss of that person’s balance
Difference between culture, norms, social learning, religion, ethnicity and spirituality.
Cross culture model of health care is a holistic model.
Hot and cold theory of illness vs yin/yang theory.
Naturalistic – forces of nature must be kept in balance. Yin and yang, hot and cold.
Transcultural expression of pain.
Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation and other factors unique to the person.
Purpose of health history
Biographical data
Source of history
Reason for seeking care
Present health or history of present illness
Past health
Family health
Review of systems
Function assessment including activities of daily living (ADL)
PQRSTU
Provocative or palliative
Quality or quantity
Region or radiation
Severity scale 1-10
Timing or onset
Understand patient’s perception of problem
Purpose of the CAGE test
Cut, annoyed, guilty and eye opener
4 questions in regards to alcohol addiction
Purpose of functional assessment
Self-esteem, self-concept
Activity and exercise
Sleep and rest
Nutrition and elimination
Interpersonal relationships
Coping and stress management
Personal habits
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