HEALTH ASSESMENT LEC part 1

Cards (43)

  • Nursing is an art of applying scientific principles in a humanitarian way to care of people
  • Health assessment is an essential nursing function which provides foundation for quality nursing care and intervention.
  • Nursing process serves as the organizational framework for the practice of nursing.
  • Diagnosis – It is the determination of the nature and extent of a disease.
  • Prognosis – It is the forecast of the course and duration of a disease.
  • Etiology – It is the science of the cause of a disease.
  • Signs – The presence of a disease that can been seen or elicited
  • Symptoms – Any evidence as to the nature and location of a diseases noted by the client.
  • Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter.
  • Assessment Process Is a systematic method by which nursing plans and provides care for patients.
  • Assessment Process involves a problem-solving approach that enables the nurse to identify patient problems and potential at-risk needs (problems) and to plan, deliver, and evaluate nursing care in an orderly, scientific manner.
  • Nursing Process ANA defines the nursing process as the “essential core of practice for the registered nurse to deliver holistic, patient-focused care“
  • Nursing Process 5 components assessment, diagnosis, planning, implementation, and evaluation.
  • Nursing Process series of steps that the nurse takes in planning and giving nursing care. It provides a logical framework on which the nursing care is based
  • Assessment a deliberate, systematic and logical collection of subjective and objective data that are helpful to identify and define problems of the client, before the nurse proceeds to plan the care.
  • Subjective data are the client’s feelings and statements about his or her health problems.
  • Objective data are observable, perceptible and measurable data during physical examination using techniques-measurable information such as vital signs, auscultation, visual appearance, lab values
  • Primary source is the client himself
  • Secondary source are the health sources include family members or significant others, health record, laboratory tests and diagnostic procedures, health team members and literature review.
  • Diagnosis is the clinical act of identifying the problems. involves a nurse making an educated judgment about a potential or actual health problem with a patient.
  • Diagnostic label is the name of the nursing diagnosis. It describes the essence of the problem using as few words as possible
  • Qualifiers are words used to give additional meaning to a nursing diagnosis.
  • Definition describes the characteristics of the human response under consideration.
  • Defining characteristics are major and minor clinical cues that validate the presence of an actual nursing diagnosis
  • Risk factors are identifiable intrinsic and extrinsic characteristics of the client.
  • Related factors: they describe the conditions, circumstances or etiologies that contribute to the problem.
  • Problem-focused diagnosis - also known as actual diagnosis. is a client problem that is present at the time of the nursing assessment. are based on the presence of associated signs and symptoms.
  • Problem-focused nursing diagnoses have three components: nursing diagnosis, related factors, and defining characteristics
  • Risk Nursing Diagnosis These are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. no etiological factors
  • Health Promotion Diagnosis also known as wellness diagnosis. is a clinical judgment about motivation and desire to increase well-being. is concerned in the individual, family, or community transition from a specific level of wellness to a higher level of wellness.
  • Syndrome Diagnosis is a clinical judgment concerning with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event
  • Planning the nurse sets measurable and achievable short- and long-term goals for the patient.
  • All patient goals should follow the "SMART" framework: Specific, Measurable, Attainable, Relevant, and Time-Bound
  • Implementation This is the action phase of the nursing process. It is the actual initiation of the plan and documenting of nursing actions. involves both direct and indirect patient care
  • Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision
  • Dependent ( Physician initiated )-nursing actions requiring MD orders
  • Collaborative- nursing actions performed jointly with other health care team members
  • Evaluation last phase of the nursing process which include the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses. determine the success/effectiveness of the whole nursing process and the decision either to continue, modify or repeat the process is depend on evaluation.
  • Nursing Care Plan provides direction on the type of nursing care the patient may need. to facilitate standardised, evidence-based and holistic care
  • Initial Comprehensive Assessment is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health status