HA lec.

• Collection of subjective data about the client’s perception of the health of all body parts or systems, past health history , family history, lifestyles and health practices

  Initial comprehensive Assessment
• The nursing assessment process begins at the moment the nurse meets the client
• mini-overview of the client’s body systems and holistic health patterns as a follow up on health status

  On-going or Partial Assessment
• Consist of a thorough assessment of a particular client problem and does not cover areas not related to the problem

  Focus or Problem Oriented Assessment
• Rapid assessment performed in life-threatening situations

  • Ex. Choking, cardiac arrest, drowning which needs prompt treatment

  Emergency Assessment;
• IS USED TO FORMULATE A NURSING PLAN OF CARE FOR THE PATIENT.

  Information
• A NURSE TAKES NOTE OF ACTUAL OR POTENTIAL PROBLEMS HER PATIENT MAY HAVE DURING A HEALTH ASSESSMENT.

  NURSING DIAGNOSES AND CARE PLANNING
• THE NURSE CONTINUOUSLY DOES A HEALTH ASSESSMENT ON HER PATIENT TO SEE IF HER CARE PLAN IS HAVING THE DESIRED EFFECT

  MANAGING PROBLEMS
• DETERMINE IF A PATIENT HAS RESPONDED TO NURSING CARE SUFFICIENTLY ENOUGH TO BE RECOMMENDED FOR DISCHARGE.

  EVALUATION
• THIS PROVIDES THE NURSE WITH AN OPPORTUNITY TO IMPART THIS INFORMATION BEFORE HE IS DISCHARGED.

  DISCHARGE TEACHING
• WHEN A NURSE PERFORMS A HEALTH ASSESSMENT, SHE MAY FIND A PROBLEM THAT REQUIRES THE EXPERTISE OF OTHER MEMBERS OF THE HEALTH CARE TEAM.

  ADVOCATE
• Sources of Data:

  1. Primary data = patient/ client

  b. Secondary data = family members
• It serves to ensure that the assessment process is not ended before all relevant data have been collected, and it helps to prevent documentation of inaccurate data

  Validating assessment data
• it forms the data base for the entire nursing process and provide data for all other member of the health team

  Documenting data
• Analyzing subjective/objective data to make a professional nursing judgment

  Diagnosis
• Determining outcome criteria and developing a plan

  Planning
• Life threatening, ABC’s, Maslow’s Needs, pain, unstable conditions, actual problems, and client’s first before contraptions.

  Prioritization
• Activities during Planning:

  Prioritization

  Outcome Criteria
• what is SMART

  SPECIFIC

  MEASURABLE

  ATTAINABLE

  REALISTIC

  TIME-FRAMED
• Care plan is put into action

  Implementation
• Assessing outcome criteria have been met and revising the plan as necessary

  Evaluation
• Establishing rapport and a relationship with a client to elicit accurate and meaningful information

  trusting
• 2 Types of Communication: Verbal and Non-verbal
• the appearance, demeanor, posture, facial expression and attitude strongly influence how client perceives the questions you ask.

  Non-Verbal Communication
• the client is expecting a health professional, therefore you should look as one

  Appearance
• It is after an overlooked aspect of communication.

  Facial Expression
• one of the most important non-verbal skills to develop as a health care professional

  Attitude
• allow you and the client to reflect and organize thoughts which facilitate a more accurate reporting and data collection

  Silence
• most important skills to learn and develop fully

  to collect complete and valid data from your client

  listening
• The goal of the interview process is to elicit as much data about the client health status as possible

  Verbal Communication
• elicits the client’s feelings begins with how or what and perception. Ex. How have you been feeling lately?

  Open-ended questions
• to focus on specific information.

  Close-ended questions
• provide client with a choice of words to choose.

  Laundry list
• listen closely to the client during his or her description and use phrases such as “um-um”, “yes”, or I agree” to encourage the patient to continue

  Well-place phrases
• this technique helps to clarify information the client has stated. It enables you and the client to reflect on what has been said.

  Rephrasing
• another important thing to consider throughout the entire interview is to provide the client with information as questions and concerns arises

  Providing information
• may elicit more data or verify existing data.

  Inferring
• an excellent way to begin assessment process because it lays the ground work for identifying nursing problems and provides a focus for the physical examination

  Health History
• include information that identify the patient such as name, address, phone number, gender, and who provided the information

  Biographic Data
• The information gained from these assist the nurse to identify risk factors that stem from previous health problems. Risk may be to the client or to his significant others

  Past History