Health Assessment BATTERY EXAM Passed

• The Nursing Process is a systematic, rational method of planning and providing individualized nursing care.
• The purpose of the Nursing Process is to identify a client's health status and actual or potential health care problems or needs, establish plans to meet the identified needs, and deliver specific nursing interventions to meet those needs.
• The client in the Nursing Process may be an individual, family, community, group, or a combination of these.
• The Nursing Process is cyclical, with its components following a logical sequence, but more than one component may be involved at one time.
• At the end of the first cycle of the Nursing Process, care may be terminated if goals are achieved, or the cycle may continue with re-assessment, or the plan of care may be modified.
• The Nursing Process is a systematic problem-solving approach used to identify, prevent, and treat actual or potential health problems and promote wellness.
• The Nursing Process is a systematic way to plan, implement, and evaluate care for individuals, families, groups and communities.
• The term Nursing Process was originated by Lydia Hall in 1955, and Dorothy Johnson in 1959, Ida Jean Orlando in 1961 and Ernestine Wiedenbach in 1963.
• These theorists were among the first to use the Nursing Process and refer to a series of phases describing the practice of nursing.
• Since then, various nurses have described the process of nursing and organized the phases in different ways.
• The most current SCOPE AND STANDARDS OF NURSING PRACTICE includes SIX (6) PHASES OF NURSING PRACTICE: Assessment, Diagnosis, Outcome identification, Planning, Implementation, Evaluation.
• Asking about any breathing problem such as APNEA (breathing stops and starts during sleep) or HYPOXIA (low levels of oxygen in body tissues) is a part of health assessment.
• Roles and relationships pattern in health assessment is focused on the person's roles in the world and relationships with others.
• Presence of cough, whether it's productive or non-productive, is also assessed during health assessment.
• On-going or partial assessment is another type of assessment that takes place after the initial assessment to evaluate any changes in the client's functional health.
• Any changes in heartbeat during exercise, type of exercise the patient did, or any problem during exercise are assessed during health assessment.
• Self-perception and self-concept pattern in health assessment is focused on the person's attitudes towards self, including identity, body image, and sense of self-worth.
• Cognition and perception pattern in health assessment is focused on the ability to comprehend and use information on the sensory functions.
• Values and belief pattern in health assessment is focused on the person's values and beliefs, including spiritual beliefs, goals that guide his/her decisions.
• Coping and stress tolerance pattern in health assessment is focused on the person's perception of stress and the coping strategies.
• Data pertaining to neurologic functions are collected to aid this process.
• Sexuality and reproductive pattern in health assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions.
• Dysfunctional sleeping pattern, fatigue, and responses to sleep deprivation may be identified during health assessment.
• Sensory experiences like pain and altered sensory may be identified and further evaluated during health assessment.
• Assessment in sleep and rest pattern in health assessment is focused on the person's sleep, rest, and relaxation practices.
• The national licensure examination for registered nurses (NCLEX) uses the FIVE PHASES: Assessment, Diagnosis, Planning, Implementation, Evaluation.
• FOWLER’S position is a semi-sitting position, in which the head and trunk are raised to between 15 and 45°, with a 30° elevation being the most frequently used bed angle.
• HIGH FOWLER’S position is a position in which the head and trunk are raised 60° to 90°, most often meaning the client is sitting upright at a right angle to the bed.
• FULL FOWLER'S position is a position in which the head of the bed is raised 90°.
• LITHOTOMY position is a back-lying position with the patient's legs flexed in the chip (90 degrees) and abducted (30 degrees) in the hip, the knees are bent 70 to 90 degrees, and the lower legs are supported on padded leg shells.
• DORSAL RECUMBENT position is a back-lying position with the knees flexed and hips externally rotated, a small pillow under the head, and the soles of the feet on the surface.
• All instruments needed for the health assessment must be ready for use, clean, in good working condition, and readily accessible.
• SITTING position is a seated position, back unsupported and legs hanging freely.
• DRAPING should be arranged so that areas to be assessed is exposed and other body areas are covered.
• LATERAL position is a side-lying position with the patient's head and trunk raised to 45° to 60° relative to the bed, and the lower is positioned behind the client, the upper arm is flexed at the shoulder & the elbow.
• SIMS position is a side-lying position with the lower arm behind the body, the upper leg flexed at the hip and knee, the upper arm flexed at the shoulder and elbow.
• Examples of subjective data include itching, pain, feelings of worry, and the client's sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation.
• Examining is the major method used in the physical health assessment.
• Observing occurs when the nurse is in contact with the client or support persons.
• Directive interviews are highly structured and the nurse will elicit specific information.