Introduction to Health Assessment and Nursing Process

Health Assessment

Collection and evaluation of client information.

Comprehensive Assessment

Full head-to-toe examination of the client.

Focused Assessment

Examination of a specific body system or part.

Subjective Assessment

Information based on patient's personal experiences.

Objective Assessment

Data obtained through physical examination techniques.

Subjective Data

Patient-reported symptoms and health history.

Objective Data

Quantifiable information like vital signs.

Plan of Care

Collaborative strategy addressing client needs.

Evidence-Based Practice

Using research to guide clinical interventions.

Health Record

Legal document communicating assessment findings.

Nursing Process

Structured approach for client care delivery.

Assessment Phase

Information gathering through interviews and exams.

Analysis Phase

Data evaluation to develop care plans.

Nursing Diagnosis

Identification of prevalent client health issues.

Planning Phase

Prioritizing care based on client outcomes.

Implementation Phase

Carrying out nursing interventions and monitoring progress.

Evaluation Phase

Assessing effectiveness of care and adjusting plans.

Contextual Awareness

Understanding client's background and care reasons.

Analyzing Assumptions

Evaluating clinical situations to modify approaches.

Exploring Alternatives

Considering holistic treatment options for clients.

Using Credible Sources

Incorporating standards and guidelines for practice.

Reflecting and Deciding

Self-reflection to choose best interventions.

Non-Maleficence

Ethical principle: do no harm.

Beneficence

Promoting client well-being and health.

Autonomy

Client's right to make their own decisions.

Justice

Fair treatment regardless of client background.

Confidentiality

Respecting client privacy and HIPAA regulations.

Therapeutic Communication

Professional interaction to build client rapport.

ISBARR

Structured communication for healthcare team interactions.

Inspection

Visual examination for body symmetry and conditions.

Palpation

Feeling body areas for abnormalities and conditions.

Auscultation

Listening to internal body sounds with a stethoscope.

Percussion

Advanced technique to assess body structures.

Documentation

Legal record of healthcare provider actions.