wellness and health assesment

primary prevention

an intervention implemented before there is evidence of a disease or injury

secondary prevention

An intervention implemented after a disease has begun but before it’s symptomatic

tertiary intervention

an intervention implemented after a disease or injury is established

characteristics of health assessment

collects, validates, and clusters data to assess the whole patient

critical thinking

apply to make sound judgements especially before acting or causing to act

clinical reasoning

analyzing health data and drawing conclusions to identify a diagnosis

nursing process

dynamic, interactive, five phases, complex in today’s health care world

clinical judgement

interpreting or understanding a patient’s needs, concerns, or health problems

person-centered

individuals nested in families, nested in communities

care

incorporates the cultural norms and values of the client

encourage self empowerment

in patient decisions and self care

stereotyping

Ascribing certain beliefs and behaviors about a given racial and ethnic group to an individual

without assessing for individual differences

prejudice

Emotional manifestation of deeply held stereotypes about a group

Usually refers to negative feelings

racism

Form of prejudice that occurs through the exercise of power by individuals and institutions against people who are judged to be inferior

Subjects are denied certain opportunities.

ethnocentric

The belief that one’s own cultural group determines the standards by which another group’s behavior is judged

cultural blindness

Inability to recognize differences in between one’s own cultural beliefs, values, and practices and those of another culture

Title VI of Civil Rights Act of 1964

Services cannot be denied to people of limited English proficiency

FICA

Faith/Belief, Importance/Influence, Community, Address/action

therapeutic communication

• Shared understanding of patient’s report

  • Be clear and concise

  • Keep questions simple

• Listen attentively

• Maintain eye contact

• Do not interrupt patient

• Avoid documenting excessive notes

• Be cognizant of your posture and nonverbal body language

open ended questions

what, why, how, explore the focused topic more broadly

close ended questions

who, which, when, where, have, has, help to clarify or focus on specific details

cultural competence

the ability to understand, appreciate, and interact effectively with people from cultures or belief systems different from one's own

SBAR

situation, background, assessment, recommendation

situation

Provide a brief description of pertinent patient variables, 

demographics, clinical diagnosis, and location 

background

Provide pertinent history as it directly relates to patient’s current health status

assessment

State pertinent assessment findings obtained with interpretation of data 

recommendation

State what you need or want for the patient in terms of medical treatment  and/or assistance

primary source

patient

secondary source

family members, significant others, or medical records

HIPPA

health insurance portability and accountability act

ABCs

Airway, Breathing, Circulation

subjective data

What the patient says about themselves during history taking

objective data

Observed when inspecting, percussing, palpating, and auscultating patient during physical examination

health history

• Collect subjective data to combine with objective data from physical exam and lab studies to form the database developmental considerations

chief compliant

often written in quotes in patients own words (symptoms) as the reason why patient is seeking medical attention i.e. “My chest hurts”

OLD CARTS

onset, location, duration, characteristics, alleviating and aggravating factors, radiating or relieving factors, timing, severity

ADLs

Self-care activities of daily living as they relate to general health status, measure functional status

Neglect

failure to provide for children’s basic needs

physical abuse

nonaccidental injury that leads to harm of a child

sexual abuse

fondling, sexual acts, exploitation, and trafficking

emotional abuse

pattern of behavior that harms a child’s sense of self-worth or development

Older Adult Abuse and Neglect

Involves both intentional and failure to act by a caregiver or trusted person

CAGE

questionnaire screens for alcohol and drug use. 

BATHE

A screening test for anxiety, depression, and situational stress disorders. Background, affect, trouble, handling, empathy

functional assessment

consists of adl’s, functional status

domestic violence

HITS, score greater than 10 is considered positive

substance abuse

CAGE AID and TICS

low to moderate drinking

less than 2 drinks a day for men, less than 1 drink a day for women

CAGE screening

2 or higher is significant

complete assessment

gathers total health data

focused assesment

targets specific problems

emergent assessment

a critical assessment for life threatening situations