HEALTH ASSESSMENT PRELIM

• The Fourth Industrial Revolution involves disruptive technologies like the Internet of Things (IoT), artificial intelligence (AI), robotics, virtual reality (VR), augmented reality (AR), 3D printing, genetic engineering, and quantum computing

  
• Industry 4.0 is the current environment where technologies like IoT, AI, robotics, VR, AR, 3D printing, genetic engineering, and quantum computing blur the lines between physical, digital, and biological spheres

  
• An image of a man holding a key and a shield with a keyhole, with a background of a database and servers, could represent data security

  
• Penalties for violations in data protection laws include imprisonment, fines ranging from 100,000 to 5,000,000 pesos, and imprisonment terms from 6 months to 7 years
• The nursing process involves Assessment, Diagnosis, Planning, Implementation, and Evaluation

  
• Types of Health Assessment:

  • Initial Comprehensive Assessment
  • Problem-Focused Assessment
  • On-going Assessment
  • Emergency Assessment
• Initial Comprehensive Assessment includes:

  • Client health history, health status, and health-related needs
  • Client's status and needs related to various aspects like HIV disclosure, mental health, domestic violence, and more
• Focused assessment is the stage where the problem is exposed and treated, vital signs are continuously monitored, and initial treatment for pain and long-term treatment for the root cause of the disease is administered and monitored
• Steps of Ongoing Assessment:

  1. Reassess and record vital signs

  2. Repeat focused assessment regarding patient complaints and injuries

  3. Check on interventions/treatment in progress
• ABCCS assessment (airway, breathing, circulation, consciousness, safety) is the first assessment done when meeting a patient, repeated when the patient's status is unstable
• Emergency assessments focus on rapidly identifying root causes of concern for the patient, assessing the airway, breathing, and circulation (ABCs), and ensuring scene safety
• Steps of Health Assessment:

  1. Collection of Subjective Data

  2. Collection of Objective Data

  3. Validation of Data

  4. Documentation of Data
• Subjective data can be elicited and verified only by the client

  
• Subjective data is obtained through interviewing or questioning
• Effective communication and interviewing skills are vital for accurate and thorough collection of subjective data
• Obtaining valid nursing history requires professional, interpersonal and interviewing skills
• Nursing interview focuses on establishing rapport and gathering information on the client’s status
• Nonverbal communication is as important as verbal communication and strongly influences how the client perceives the questions asked
• Verbal communication is essential to a client interview and includes techniques like open-ended questions, close-ended questions, and providing information
• Gerontologic, cultural, and emotional variations in communication should be considered
• The nursing assessment process provides the foundation for identifying nursing problems and focus for the physical examination
• The nursing assessment includes eight sections such as biographical data, reasons for seeking health care, and lifestyle and health practices profile
• Questions related to the client’s personal history aim to determine genetically based problems or predispositions
• The physical examination involves assessing various body systems like skin, eyes, ears, heart, abdomen, and musculoskeletal system
• Client’s human responses include nutritional habits, activity patterns, self-concept, relationships, stress levels, and environment
• Objective data is the physical data observed from the patient using senses and comes from measurements or direct observations
• Equipment needed for a physical examination includes a sphygmomanometer, penlight, otoscope, and stethoscope
• The physical assessment involves inspection, palpation, percussion, and auscultation techniques
• Proper positioning of the patient is crucial during the assessment procedure to fully visualize or evaluate the body part being assessed
• Inspection, palpation, percussion, and auscultation are the four basic techniques that must be mastered for a thorough assessment
• Palpation involves using touch to feel for texture, temperature, moisture, mobility, consistency, and size of body structures
• Palpation techniques include light palpation, moderate palpation, deep palpation, and bimanual palpation
• Percussion involves tapping body parts to produce sound waves and assess underlying structures
• Auscultation requires using a stethoscope to listen for heart sounds, blood movement, bowel sounds, and air movement
• The physician primarily works with physical examination instruments, but the medical assistant must be familiar with their uses to assist during physical examinations

  
• The medical assistant is responsible for disinfecting and sanitizing instruments and preparing them for the physician before the next physical examination
• Audioscope: Used to screen patients for hearing loss by making a series of tones that the patient responds to
• Examination Light: The medical assistant ensures all lights in the examination room are functioning properly and directed appropriately for the physician to examine the patient's body
• Laryngeal Mirror: Used to examine the larynx and other areas of the throat by reflecting the inside of the mouth and throat
• Nasal Speculum: Inserted into the nostril to assist the physician with the visual inspection of the lining of the nose, nasal membranes, and septum