HEALTH ASS NR 302Final Exam Concepts

Chapter 1: Evidence-Based Assessment  Critical Thinking and the Diagnostic Process o The Nursing Process Assessment: Collection of data, health history, physical exam Diagnosis: Interpret data and findings, derive d ...

Chapter 1: Evidence-Based Assessment  Critical Thinking and the Diagnostic Process o The Nursing Process Assessment: Collection of data, health history, physical exam Diagnosis: Interpret data and findings, derive diagnosis Outcome identification: Identify expected outcomes Planning: Establish priorities, individualize plan to the patient Implementation: Taking action, evidence-based interventions Evaluation: Gauge process towards outcomes o Levels of Nursing Experience Novice: No experience Proficient: 2-3 years of experience, understands a patient situation as a whole rather than a list of tasks Expert: Intuitive grasp of a clinical situation and zeros in on solutions o First-level, second-level, third-level, and collaborative priority problems First-level: emergent, life threatening and immediate, A,B,Cs & Vitals Second level: Requires prompt intervention, Mental health change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of infection, or risk to safety or security Third level: Important but can be attended to after more urgent health problems, treatment takes more time. Collaborative priority problems: Requires the collaborative effort between interdisciplinary team to treat complex medical problems.  COLLECTING FOUR TYPES OF DATA Complete Database: Complete health history, full physical examination, collected at primary care facilities Focused: Mini database, smaller in scope, and targeted to one problem, cue, or body system, it is used in all settings Follow up: Status of identified problems are evaluated in appropriate intervals Emergency: Urgent, rapid collection of crucial information, compiling lifesaving measures. Can get from family of friend if patient is unconscious Chapter 3: The Interview  Standardized Communication (SBAR): Situation, Background, Assessment, and Recommendation Chapter 4: The Complete Health History  THE HEALTH HISTORY- THE ADULT: Biographic data- name, age, gender. Source of data-who provides the information, reason for seeking care-signs and symptoms, Present or history of present illness- general statement of health, Past health, Family history- past health events