SAS 1

• The subject orientation for Health Assessment (Lecture) includes calendar of activities for major examinations, classroom rules and regulations, computation of grades specific for this subject, the essence and significance in grade computation of these modules, and if this is the first subject of the class, the instructor must initiate an election for block officers.
• The main lesson for Health Assessment (Lecture) is the study and reading of Chapter 1 of the book about this lesson: Definition of Health.
• Health is a relative state in which a person is able to live to their potential and includes the “7 facets”: Physical health, Emotional health, Social well-being, Cultural influences, Spiritual influences, Environmental influences, and Developmental level.
• The nursing health assessment entails both a comprehensive health history and a complete physical examination, which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate a plan to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family.
• Past medical records may also be used to collect additional information.
• Learning about the patient’s physical and psychological issues, social and cultural associations, environment, developmental level, and spiritual beliefs contribute to the history.
• The assessment phase of the nursing process continues throughout the entire patient encounter.
• The ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal of the nursing process.
• When the patient is communicative with her friends about his marital problems, environmental influences, cultural influences, and social well-being are being applied.
• Problem-oriented assessment allows the nurse to obtain a full picture of the patient’s health status and current problems.
• The phase of the nursing process where the nurse establishes both the short-term and the long-term goals for the patient is known as Assessment.
• Spiritual influences, physical health, cultural influences, and emotional health are facets of health that can be demonstrated if the patient feels very much optimistic about the results of her pregnancy.
• Follow-up history focuses on gathering information about the patient’s problem and evaluating the outcomes of the plan of care.
• When the patient is identifying a solution to financial problems in order to be rid of his financial stresses, developmental level, physical health, social well-being, and environmental influences are being demonstrated.
• The nursing diagnosis is based on real or potential health problems and determines the medical diagnosis of the patient.
• The evaluation phase of the nursing process determines whether the goals made for the patient have been attained.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.
• Implementation of the interventions can be completed by the patient, the family, or members of the health care team.
• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually requires a comprehensive health assessment.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors, and need for education as a basis for developing a nursing plan of care.
• The information obtained throughout the health assessment should be documented in a clear, concise manner.
• An unusual or abnormal finding may support the history data or trigger additional questions.
• Assessment is the first step of the nursing process and is the subjective and objective data gathered during the initial health history and physical examination and collected on each patient encounter.
• The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal.
• Evaluation is a continuing process to determine if the goals have been attained.
• A follow-up history is a form of a focused assessment.
• An emergency history is the data collection which focused on the patient’s emergent problem with a systematic prioritization of need beginning with the ABCs of airway, breathing, and circulation.
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and develop an action plan; implement the plan; and evaluate the outcome.
• Planning is devising the best course of action to address the patient’s diagnoses.
• The nursing care plan is revised based on the patient’s condition and whether the goals are realistic or appropriate for the patient.
• A focused or problem-oriented assessment is where the nurse focuses on gathering information about the patient’s problem.
• Diagnosis has a nursing focus and is based on real or potential health problems or human responses to health problems.