🕯️ HEALTH ASSESSMENT 🕯️
Cards (130)
- this type is for you to get comprehensive information from your client as your database
- this type- evaluate medical management and nursing care in a SPECIFIC time
- this type- sudden occurrence of stress
- ALWAYS consider ___________ pag matanda ang client
- -FIRST step, CRUCIAL, continuous process
- -base on response of client to his/her problem/illness, you are making CLINICAL judgement. Use PES format (problem, etiology, signs/symptoms.
- -identify the outcomes to be met, goal must be SMART
- we need to establish rapport or NPR (Nurse patient relationship)
- introduce yourself, explain purpose of interview, greet patient
- -gather clients info, review their medical record
- actual interview, asking medications/history of illness
- allow gather more information, probe more deeper
- pain in less 6months
- pain more than 6months
- document
- legal document, permanent, privileged communication
- What is the meaning of A
- what is the meaning of S and P
- presence of dehydration
- erosion, ulceration, SCAR, fissure
- hemorrage is checked by CRT
- -Blood lack of oxygen
- when you inflate bp cuff, hanggang saang millimeters
- which of the two assess wound healing, skin breakdown?
- (tools to assess bed sore) Push tool & Braden scale... which of the two predict if client is at risk of bed sore?
- an essential nursing function which provides foundation for quality nursing care and interventions.
- •Is a SYSTEMATIC, organized method of planning, and providing quality and individualized nursing care. •IN SHORT – THE _______ ______ IS A SYSTEMATIC PROBLEM-SOLVING APPROACH
- According to ______: • Cyclic and Dynamic • Client Centered • U niversally Applicable • Focus on problem solving • Interpersonal Collaborative • Used of Critical Thinking
- systematic collection of data, most important, identify patients strength and limitation
- Also called a TRIAGE, purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages.
- A statement or conclusion regarding the nature of phenomena • Analyzing subjective and objective data to make a professional judgement • Provides basis for the selection of nursing Intervention Nursing Diagnosis
- Deliberative, systematic phase of nursing process that involves decision making and problem solving • Involves setting goals and outcomes • Individualized plan of care for patient once diagnosis have been prioritize
- Also called “Intervention” • Putting the nursing care plan into action • Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal health. • Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patience outcomes. • The “doing” phase
- Assessing client’s response to nursing progress toward health care and effectiveness of nursing care plan • Final step of the nursing process • Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process.
- Also known as “Cardinal signs” • refers to measurement of the client’s body temperature (T), pulse (P) and respiratory (R) rates, and blood pressure (BP) • The first step in the physical examination; common, non-invasive physical assessment procedure done to clients.
- normal respiratory rate

- Balance between the heat produced by the body and heat lost from the body
- Is a small region located at the base of the brain that plays a vitals role such as releasing of hormones • Temperature regulatory center found in the brain
- temperature is above normal or the patient has fever, may be seen in viral or bacterial infections, malignancies, trauma, blood and immune disorders.Â
- lower than 36.5) may be seen in prolonged exposure to cold, hypoglycemia, hypothyroidism or starvation