HEALTH ASSESSMENT NOTES

• What is ADPIE in the nursing process?

  1.Assessment:Gather data about the patient's health status.

  
  

  2.Diagnosis:Identify the patient's health problems based on assessment.

  
  

  3.Planning:Develop a plan of care outlining goals and interventions.

  
  

  4.Implementation:Carry out the planned interventions.

  
  

  5.Evaluation:Assess the effectiveness of the interventions and modify the plan as needed.
• What is involved in the nursing assessment process?

  Involves discovery, decision making, critical thinking skills, and data collection.
• What are the main concerns in gathering data for nursing assessment?

  1.Context Dependence:Varied depending on the setting (hospital, doctor's office, home health, etc.).

  
  

  2.Health History:Explores existing conditions and their impact on current care.

  
  

  3.Specific Care Needs/ALDs:Assesses independence, mobility, dietary habits, and presence of wounds.
• What are the types of nursing assessments, including interviews?

  1.Emergency/Primary Assessment:Swift evaluation in urgent situations.

  
  

  2.Focused Assessment:Specific evaluation targeting particular issues.

  
  

  3.Head-to-Toe Assessment:Comprehensive evaluation covering the entire body.

  
  

  4.Interview:Gathering information through conversation.
• What is the difference between subjective and objective data in nursing assessment?

  1.Subjective:Involves feelings, perceptions, and self-reported information.

  
  

  2.Objective:Comprises observations, measurements, and verifiable facts.
• What are the levels of data sources in nursing assessment?

  1.Primary Sources:The client and the nurse directly involved in care.

  
  

  2.Secondary Sources:Family, medical record and the chart, allied health professionals (PT/OT), and physicians.

  
  

  3.Tertiary Sources:Literature and overall nursing experience.
• What is the Primary assessment in nursing?

  1.ABCDE Assessment:The first assessment conducted upon meeting the client.

  
  

  2.Repetition:It is repeated whenever there is suspicion or recognition that the client's status is becoming unstable.
• What does the Point of Care Risk Assessment in nursing include?

  1.Infection Control Practices:Ensures adherence to infection control protocols.

  
  

  2.Falls Prevention:Strategies to prevent falls in the healthcare setting.

  
  

  3.Safety:Emphasizes overall safety considerations in patient care.
• What is inspection in physical assessment?

  1.Visual Check:Observation using sight.

  
  

  2.Position and Exposure:Properly position and expose body parts for a thorough view.

  
  

  3.Inspect for:Size, shape, color, symmetry, position, drainage, and abnormalities.

  
  

  4.Comparison:Compare one side with the other for symmetry and differences.
• What is auscultation in physical assessment?

  1.Use of Stethoscope:Listening to internal sounds using a stethoscope.

  
  

  2.Familiarity with Normal Sounds:Identify normal sounds before recognizing abnormal sounds or variations.

  
  

  3.Characteristics of Sounds:Includes frequency, loudness, quality, and duration.

  
  

  4.Requires:Concentration and practice to develop proficiency.
• What is palpation in physical assessment?

  1.Touch:Utilizing hands to assess.

  
  

  2.Assesses for:Tenderness, distension, and masses.

  
  

  3.Different Parts of Hands:Used to distinguish texture, temperature, and movement.

  
  

  4.Light Palpation:Generally sufficient for assessment.

  
  

  5.Tender Areas:Palpated last in the examination process.
• What is percussion in physical assessment?

  Primarily Used by:Nurse practitioners and physicians in clinical practice.

  
  

  1.Tapping with Fingertips:Creating vibrations by tapping the client's body.

  
  

  2.Sound Indication:Reveals the location, size, and density of structures.
• What are the considerations for older persons?

  1.Considerations:Communication may take longer, rest periods may be needed, and signs/symptoms may differ.

  
  

  2.Atypical Presentations:Be aware of unusual signs of illness in older individuals.

  
  

  3.Utilize Knowledge:Differentiate between normal aging changes and misconceptions.
• What does diagnosing involve in nursing assessment?

  Analyze data collected in the assessment Identify health problems, risks & strengths Formulate diagnostic statements and identify client needs.
• What is a nursing diagnosis in ADPIE?

  A clinical judgement about client responses to an actual or potential health problem.

  
  

  Nursing focus:Treat or prevent.

  
  

  Example: Ineffective airway clearance.
• What is a medical diagnosis?

  The identification of a disease or condition based on a specific evaluation of signs and symptoms.

  
  

  Nursing focus:Implement orders and monitor the client.

  
  

  Example: Pneumonia.
• What is a collaborative problem in nursing?

  An actual or potential complication that nurses monitor to detect a change in client status.

  
  

  Nursing focus:Prevent and monitor for complications.

  
  

  Example: Potential complication of pneumonia - Sepsis (systemic infection).
• What is a nursing plan in ADPIE?

  Where goals and outcomes are formulated that directly impact client care
• What things does a nursing plan also involve?

  1. Consider short & long-term goals

  
  

  2. set priorities

  
  

  3. establish client-centered goals/outcomes

  
  

  4. select nursing interventions

  
  

  5. write a plan of care (PoC)
• What is the focus of the Plan of Care in nursing?

  Determine how to help the client meet their goals and tailor the plan based on the client's specific needs and diagnosis.
• What is a nursing implementation in ADPIE?

  Carrying out or delegating nursing interventions
• what is a nursing evaluation in ADPIE?

  Process of comparing pt responses to preselected outcomes to determine whether goals have been met
• What does establishing priorities involve in nursing?

  Determining the order of importance for nursing actions and interventions.
• What is the order of priorities in Maslow's Hierarchy of Needs from lowest to highest?

  1. Physiological Needs

  2. Safety and Security

  3. Love and Belonging

  4. Self-Esteem

  5. Self-Actualization
• What signs indicate awareness of potential abuse?

  1. Neglect

  
  

  2. Physical injury

  
  

  3. Is there fear?

  
  

  4. History
• How can nurses be aware of potential substance abuse?

  1. Missed appts

  
  

  2. Excuses

  
  

  3. GI bleeds or ulcers

  
  

  4. CAGE (screening tool to assess potential alcohol misuse or dependence.)
• What aspects of the nursing process are documented in nursing care?

  Documentation Includes:

  
  

  ADPIE:

  1. Assessment Findings

  
  

  2. Diagnosis, often included in

  
  

  3. Plan of Care

  
  

  4. Implementation of Interventions

  
  

  5. Evaluation of Interventions
• What does charting, also known as documentation, aim to achieve in nursing?

  Key Objectives:

  
  

  1. Facilitate Communication

  
  

  2. Ensure Safe & Appropriate Care

  
  

  3. Adhere to Professional & Legal Standards
• What priniciples should be followed when documenting?

  1. Anything heard, seen, felt, or smelled should be reported accurately

  
  

  2. Subjective client information should be placed in quotation marks

  
  

  3. Accurate terminology and abbreviations must be used