HA M1-2

• Health is the relative state in which a person is able to to his or her potential and includes the '' 7 facets''.
• Physical Health - how the body works and adapts.
• Emotional Health - positive outlook and emotions channeled in a healthy manner.
• Social well-being - supportive relationships with family and friends.
• Cultural Influences - favorable connections to promote health.
• Spiritual Health - Living peacefully, morally, and ethically.
• Environmental Influences - Favorable condition to promote health
• Developmental level - How one thinks, solves problems, and make decisions
• The nursing health assessment entails both a comprehensive health history and a complete physical examination, which are used to evaluate the health and status of a person.
• The nursing process is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal.
• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually requires a comprehensive health assessment.
• A focused or problem-oriented assessment is where the nurse focuses on gathering information about the patient's problem.
• A follow-up history is a form of a focused assessment.
• An emergency history is the data collection which focused on the patient's emergent problem with a systematic prioritization of need beginning with the ABC's of airway, breathing, and circulation
• What is the 5 vital signs?

  - Pulse Rate, Blood pressure, Respiratory rate, Temperature, and Pain
• Blood pressure measures the force exerted against the walls of blood vessels as the heart pumps out blood.
• Pulse rate is measured by counting the number of beats per minute (bpm) using your fingers over an artery at the wrist or neck.
• Respiratory Rate is the number of breaths taken per minute.
• Health History Interview - A conversation with a purpose within three folds using health history format.

  1. Establish a trusting and supportive relationship

  2. Gather information

  3. Offer information
• Health History Format - is a structured framework for organizing patient information in written, electronic, and verbal form to communicate effectively with other healthcare providers.
• Pre-Interview : set the stage for a smooth interview.
• Introduction: Put the patient at ease and establish trust
• Working: obtain patient information
• The Patients Perspective : Feelings, Ideas, Functions, Expectations
• Termination: Summarize important points
• Phases of interview: Pre Interview, Introduction, Work, Termination
• History of present Illness: The section of the history is a complete, clear, and chronologic account of the problems.prompting the patient to seek care. This also should reveal the patient's responses to the symptoms and the effect the illness has had on daily living.
• Seven Attributes of the symptom: Onset, Location, Duration, Characteristic, Associated Manifestation, Relieving Factors, Treatment
• PQRST: Provocation, Quality, Region, Severity, Timing
• Past History: Allergies, Medications, Childhood Illness, Adult Illnesses (Medical, Surgical, Accidents, Psychiatric)
• Health Maintenance: Immunization, Screening tests, Safety Measures
• Family History: A record of the family's health history, including the presence of disease and the presence of certain genetic variants.
• Health Patterns: Provide guide for gathering personal/social history from the patient and daily living routines that may influence health and Ilnesses.
• Physical Examination: The process by which a healthcare provider assesses a person's physical condition through observation, measurement, and palpation to identify signs or symptoms of illness or injury.
• Health: is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
• Initial comprehensive -in-depth assessment of the patient's health status, physical examination, risk factors, psychological and social aspects of the patient's health that usually takes place on admission or transfer to a hospital or healthcare agency.
• Ongoing-Time-Time lapsed - or partial assessment
• Focussed Assessment - problem-oriented assessment: an assessment of a specific condition, problem, identified, risks or assessment of care
• Emergency Assessment - mini assessment: A snapshot view of the patient based on a quick visual and physical assessment.
• Clinical Reasoning Process: Used to analyze the patient data and develop hypotheses as to the patient's problem or problems.