Health Assessment

Health Assessment

Systematic and individualized method of providing nursing care

Nursing Process

Organized framework using ADPIE to deliver patient care

ADPIE

Assessment, Diagnosis, Planning, Implementation, Evaluation

Assessment

Systematic collection of patient data

Emergency Assessment

Rapid assessment during life-threatening situations

Initial Assessment

Comprehensive data collection upon admission

Time-Lapsed Assessment

Reassessment after intervention

Focused Assessment

Problem-centered assessment of specific concern

Subjective Data

Information verbalized by the patient

Objective Data

Observable and measurable data

Primary Source

The client

Secondary Source

Family, records, or healthcare team

Cue

Observable or gathered piece of data

Inference

Nurse's conclusion based on cues

Validation

Verification of data to remove ambiguity

Nursing Diagnosis

Clinical judgment about human response to health conditions

PES Format

Problem, Etiology, Signs and Symptoms

SMART Goals

Specific, Measurable, Achievable, Relevant, Time-bound

Independent Intervention

Action based on nurse's judgment

Dependent Intervention

Action requiring physician order

Evaluation

Determining if goals were met

Evaluation Outcomes

Improved, stabilized, worsened

Discharge Planning

Preparation for continuity of care beginning at admission

Care Plan

Structured guide promoting continuity and delegation

Cognitive Skills

Critical thinking abilities

Therapeutic Communication

Purposeful interaction to build trust

Pre-interaction Phase

Preparation phase without patient involvement

Introductory Phase

Establishes rapport and identifies purpose

Working Phase

Data gathering and goal implementation

Termination Phase

Closing interaction and evaluating progress

Rapport

Trusting relationship between nurse and patient

Open-Ended Question

Question encouraging elaboration

Closed-Ended Question

Question answerable by yes or no

Probing Question

Question seeking more detail

Social Distance

1.5 to 4 feet during interview

Communication Barrier

Factor such as interruptions that blocks effective exchange

Cultural Competence

Respecting beliefs to improve trust and care

Inspection

Visual examination

Palpation

Using hands to assess texture, size, tenderness

Percussion

Tapping to produce sound

Auscultation

Listening with stethoscope

IPPA

Inspection, Palpation, Percussion, Auscultation

Abdominal Sequence

Inspection, Auscultation, Percussion, Palpation

Supine Position

Lying flat on back

Dorsal Recumbent

Supine with knees flexed

Fowler's Position

Head elevated 45-60 degrees

Orthopneic Position

Sitting upright leaning forward to ease breathing

Lithotomy Position

Supine with hips and knees flexed for pelvic exam

Trendelenburg Position

Head lower than feet

Sims Position

Left semi-prone position

Activities of Daily Living

Basic self-care tasks like bathing

Instrumental Activities of Daily Living

Complex tasks like managing finances

Katz Index

Tool measuring independence in ADLs

Lawton Scale

Tool measuring independence in IADLs

Fulmer SPICES

Framework screening older adults for common syndromes

Mental Status Assessment

Evaluation of mood, cognition, and behavior

Illusion

Misinterpretation of a real stimulus

Hallucination

False perception without external stimulus

Erikson

Theorist of psychosocial development

Psychosocial Crisis

Developmental conflict described by Erikson

Piaget

Theorist of cognitive development

Kohlberg

Theorist of moral development

Postconventional Level

Highest level of moral reasoning

Abuse

Act of commission causing harm

Neglect

Act of omission resulting in harm

Domestic Violence

Violence between intimate partners

Ethnicity

Socially acquired group identity

Spiritual Assessment

Ongoing conversation evaluating spiritual needs

Body Mass Index

Weight screening index calculated as kg per meter squared

Normal BMI

18.5 to 24.9

Waist-to-Hip Ratio

Measurement assessing fat distribution

Normal Female Waist-Hip Ratio

0.80 or less

Arm Circumference Standard Male

Approximately 29.3 cm

Vital Signs

Temperature, pulse, respiration, blood pressure

Baseline

Initial reference measurement

Objective Sign

Observable indicator of disease

Subjective Symptom

Patient-reported experience

Holistic Assessment

Evaluation including physical, emotional, spiritual, social aspects

Critical Thinking

Analytical reasoning in clinical decisions

Validation in Interview

Clarifying unclear patient statements

Goal Achievement

Determined during evaluation phase

Continuity of Care

Ongoing coordinated healthcare management

Nutritional Screening

Assessment using BMI and body ratios

Developmental Assessment

Evaluation based on life stage theories

Violence Assessment

Screening for abuse and safety concerns

Spiritual Care

Addressing patient's meaning, beliefs, and coping

Final Phase of Nursing Process

Evaluation

First Step of Nursing Process

Assessment

Three-Part Nursing Diagnosis

PES

Four Techniques of Physical Exam

Inspection, Palpation, Percussion, Auscultation

Assessment Tool for ADLs

Katz Index

Instrument for IADLs

Lawton Scale

Framework for Older Adult Syndromes

Fulmer SPICES

Cognitive Development Theorist

Piaget

Moral Development Theorist

Kohlberg

Psychosocial Development Theorist

Erikson

Weight Screening Formula

BMI

Fat Distribution Ratio

Waist-to-Hip Ratio

Semi-Sitting Position

Fowler's Position