NUR 202 (Sas 1-4)

• A relative state in which a person is able to live in their potential and sum of 7 facets

  health
• A sum of all facets and is not solely defined as the absence of disease or eating right, but rather by the contribution of all dimensions.

  health
• The 7 facets of health

  physical health, emotional health, socio well-being, cultural influence, spiritual influence, environmental influence, developmental level
• A comprehensive health history and complete physical examination, used to evaluate the health and status of a person.

  nursing health assessment
• A systematic data collection that provides information to facilitate a plan to deliver best care plan for the patient.

  nursing health assessment
• this is the first part of health assessment

  health history
• the second component of health assessment

  physical examination
• an assessment used by the nurse to identify changes in the patents body systems

  head-to-toe examination
• The purpose of health assessment

  To determine the patients health status, risk factors, and need for education as a basis for developing a nursing plan care.
• nursing process


  the ability of a nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care as the overall goal.
• how should information from health assessment be documented?

  clear & concise
• It is used to identify the patients problems, set a goal, and develop an action plan of care, implement the plan, & evaluate the outcomes

  Nursing process
• the nursing process steps are

  assessment, diagnosis, planning, implementation, evaluation
• This is the subjective & objective data gathered during the initial health history and physical examination and collected on each patient encountered

  Assessment
• The nurse uses clinical reasoning to formulate diagnosis based on the assessment data and patient's problem list.

  diagnosis
• Devising the best course of action to address patients diagnosis

  planning
• It should relate to the diagnosis and planned goals; intervention can be complete by the patient, family members, and healthcare team.

  Implementation
• A continuing process to determine if the goal have been attained; then the nursing care is revised based on the patients condition and whether the goals are realistic, or appropriate for the patient

  Evaluation
• The admission of a new patient to a clinic, hospital, long-term care facility, visiting nurse agency requires a type of assessment

  Comprehensive health assessment
• an assessment where the nurse focuses on gathering information about the patients problems

  Focused/problem-centered assessment
• A form of focused assessment

  Follow up history
• The data collection focuses on the patients emergent problem with a systemic prioritization of need beginning with the abc's 


  emergency history
• what is the abc's in health assessment

  airway, breathing, circulation,
• A conversation with a purpose within 3 folds using health history format

  health history interview
• 3 folds in health history interview

  establish a trusting and supportive relationship, gather information, offer information
• A structures framework for organizing patient information written, electronic, and verbal form to communicate effectively with other health care providers

  health history format
• a patients information is organized into 3 categories

  past, present, family history
• what are the phases of interview

  pre-interview, introduction, working, termination
• Phases of interview that set the stage for a smooth interview

  pre-interview
• it put the patient at ease and established trust

  introduction
• part of interview which obtain the patient information

  working
• It summarizes the important points and discuss plan of care

  termination
• A type of data that are information from the clients point of view which include feelings, perceptions, and concerns obtained through interview 


  Subjective data
• An observable and measurable data obtained through observation, physical examination, and laboratory and diagnostic testing.


  Objective data
• This section of the history is a complete, clear, and chronological account of the problems prompting the patient to seek care. It should reveal the patients responses to the symptoms and the effect the illness has had daily living,

  History of present illness (HPI)
• what are the 7 attributes of symptoms

  onset, location, duration, characteristic of symptoms, associated manifestations, relieving/exacerbating factors, treatment
• key elements of the past history

  allergy, medication, childhood disease, adult illness, health maintenance
• A key element in past history that include specific reaction to medications, food & etc.

  Allergy
• This include the name, dose/route and frequency of use of medication and including home remedies & vitamins.

  Medication
• This include disease like measles, rubella, whooping cough, chickenpox, scarlet fever, polio, rheumatic fever, & asthma.

  Childhood illness