Health Assessment for Nursing

First level Priority Problem
-those that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing

Second level Priority Problem
Are those that are next in urgency-those requiring your prompt intervention to forestall further deterioration. Ex:Mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab results, risk of infection, risk of safety or security.

Third Level Priority Problem
-Those that are important to the patients health but can be addressed after more urgent health problems are addressed. Interventions to treat these problems are more long term, and the response to treatment is expected to take more time.

Collaborative problems
-those in which the approach to treatment involves multiple disciplines, collaborative problems are certain physiologic conditions in which nurses have the primary responsibility to diagnose the inset and monitor the changes in status.

4 types of Databases/ histories
-Complete(total Heath) Database
-Focused or problem centered Database
-Follow-up database
-Emergency database

Complete (total Health) database
-Complete history and full physical examination
-Describes the current and past health state and forms a baseline against which all future changes can be measured.

Focused or Problem-Centered Database
-for a limited or short term problem
-Collect a “mini” database, more targeted than the complete database.

Follow-up Database
-used in all settings to follow up both short-term and chronic health problems.

Emergency Database
-an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures.

Comparison of the Novice to Expert Nurse
-The *novice* has no experiance with a specified patient population and uses rules ti guide performance. It takes time perhaps 2-3 years to achieve competency.
-The *proficient* nurse understands a patient situation as a whole rather than a list of tasks. At this level you can see long term goals for the patient.
-The *expert* nurse vaults over the steps and arrive at the clinical judgement in one leap. Has an intuitive grasp of a clinical situation.

Nursing process
Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

Diagnostic Reasoning
-Attend to initial cues, ex. medical records, subjective and objective data, diagnostic tests.
-Formulate hypothesis
-Gather data to relevant

Critical thinking
-Identify assumptions
-Use an organized and comprehensive approach
-Differentiate between expected vs. unexpected
-Set priorties

Therapeutic Communication
-encourage them to keep talking and don’t tell them what to do.
-Begin with open ended questions
-Dont give false reassurance
-Dont use authority.

Subjective Data
-tools of interaction
-what the patient tell you

Objective Data
-tools of observation and measurement
-Things you can *see* and *measure*

Cultural considerations in assessment
-asking the right questions
-knowing if there are any cultural considerations you need to be informed about
-getting a translator.

Sources of information
-Primary source – the patient
-Secondary source- immediate family members, possibly friends
-If your not sure if they are reliable you can ask twice or ask a question you know the answer too.

Interviewing traps
1. Providing false Assurance or Reassurance
2. Giving Unwanted advice
3.Using Authority
4.Using Avoidance Language
6.Using Professional Jargon
7.Using Leading or Biased Questions
8.Talking to much
10. Using “why” questions

Reason for seeking care
-brief spontaneous statement in the persons own words that describe the reason for the visit.
-They will say a subjective symptom and you will pay attention to the sign or objective abnormality.

Categories in the health history
– Reason for seeking care
-Present health or History of present illness
-Past health
-Family history
-Review of systems
-Functional Assessment (including activities of daily living)
-Perception of health

Symptom analysis
1. Location-be specific
2.Character or Quality-specific descriptive terms
3. Quantity or Severity -pain scale 1-10
4.Timing-(onset, duration, frequency)
5.Setting-What where you doing or where where you when it started
6.Aggravating or Relieving Factors- what makes it worse? what makes it better?
7.Associated Factors-primary symptom associated with any others?
8.Patients Perception-How does it affect daily actives?

General Survey
-Physical Appearance
-Level of consciousness
-skin color
-facial features
-Overall appearance
-Body Structure
-Body build, contour
-obvious physical deformities
-Range of motion
-Facial expression
-Mood and affect
– Speech
-Speech pattern
-Personal hygiene
-Body Mass index
-Waist circumfrence
-Vital signs
-Blood pressure

Weight (in pounds)
————————– X 703
Height (in inches)2
Weight(in kilograms)
Height(in meters) 2

Validation of Data confirming/verifying subjective and objective data collected are reliable and accurate Steps of Validation 1) deciding whether the data require validation 2) determining ways to validate the data 3) identifying areas where data are missing WE WILL WRITE …

Nursing Process 1. Assess 2. Diagnose 3. Plan outcomes 4. Plan interventions 5. Implement interventions 6. Evaluate Interventions What is Assessment? The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of a person, community, …

Nursing process Assessment Database Cue Inference Nursing process:Fundamental blueprint for how to care for a patient Assessment: Collection, verification, and analysis of data Database: The patient’s perceived needs, health problems, and responses Cue: Information that was obtained through the use …

Nursing Assessment Collection of subjective and objective data Nursing diagnostic phase Analysis of subjective and objective data to make a professional nursing judgment WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write …

Nursing process Approach to identify, diagnose, and treat human responses to health and illness Assessment Collection, verification, and analysis of data (1st step in nursing process) WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR …

Nursing The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities, and populations. Phases of the …

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