Nursing Health Assessment Concepts

Vocabulary flashcards generated from nursing health assessment review notes.

ANA's Four Main Goals for Nursing

1. Promote health 2. Prevent illness 3. Treat human responses to health or illness 4. Advocate for individuals, families, communities, and populations

Two Guiding ANA Documents (Ch. 1)

Code of Ethics for Nurses with Interpretive Statements (2015a) and Nursing Scope and Standards of Practice (2015b)

APRN

Advanced Practice Registered Nurse; requires a BSN, then an MSN or DNP

Four APRN Roles

Nurse Practitioner (NP), Certified Nurse Midwife (CNM), Certified Registered Nurse Anesthetist (CRNA), and Clinical Nurse Specialist (CNS)

Health Assessment (AACN definition)

Gathering information about the health status of the patient, analyzing and synthesizing that data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes.

Two Parts of a Health Assessment

Health history and physical assessment

Starting Point of the Nursing Process

A complete, accurate health assessment

Wellness

An integrated method of functioning oriented toward maximizing potential

Healthy People

The national model for health promotion and risk reduction, with goals of illness prevention, planning, intervening, updating, and evaluating

Primary Prevention

Strategies aimed at preventing problems before they occur

Secondary Prevention

Early diagnosis and prompt treatment

Tertiary Prevention

Preventing complications of existing disease and promoting the highest level of health possible

Six Steps of the Nursing Process

1. Assess 2. Diagnose 3. Identify Outcomes 4. Plan Care 5. Implement 6. Evaluate Outcomes (ADPIE)

Assess (Nursing Process)

Complete, accurate health data compilation

Diagnose (Nursing Process)

Clustering data to make a judgment or statement about the patient's difficulty or condition

Implement (Nursing Process)

Any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes

Critical Thinking in Nursing

Purposeful, outcome-directed thinking driven by patient/family/community needs, based on the nursing process, evidence-based thinking, and the scientific method

Diagnostic Reasoning

Gathering and clustering data to draw inferences and propose diagnoses or hypotheses, based on the nurse's critical thinking

Seven Steps of Diagnostic Reasoning

1. Identify strengths and abnormal data 2. Cluster data 3. Draw inferences 4. Propose nursing diagnoses 5. Check for defining characteristics 6. Confirm or remove nursing diagnosis 7. Document conclusions

Collaborative Problems

Problems that require the expertise of other healthcare providers for interventions; involve interprofessional collaboration, progress notes, and SBAR

Formula for Clinical Judgment

Nursing process + Critical thinking + Diagnostic reasoning = Clinical judgment ability

Next Generation NCLEX (NGN)

Tests the ability to form hypotheses, prioritize them, generate solutions, and take action

Three Common Types of Nursing Assessments

1. Emergency 2. Comprehensive 3. Focused

Emergency Assessment

Life-threatening or unstable situation; based on A, B, C, D, E

Comprehensive Assessment

Complete health history and physical assessment; done annually for outpatients or upon hospital/long-term care admission

Focused Assessment

Smaller in scope but increased depth on a specific issue; occurs in all settings, e.g. after specific treatments are given

Top Priority in Patient Care

A life-threatening situation

Determinants of Assessment Frequency

Patient needs, purpose of data collection, and healthcare setting

Cultural Competence

The complex combination of knowledge, attitudes, and skills healthcare providers use to deliver care that considers the total context of the patient's situation across cultural boundaries

Subjective Cues

Information for which the patient is the primary source (gathered through therapeutic dialogue)

Objective Cues

Measurable information, such as vital signs, auscultation findings, and visual appearance

Essential Purpose of Documentation

Records both subjective and objective findings, forms the baseline, meets HIPAA/legal confidentiality requirements, and supports communication with other providers

Common Documentation/Communication Formats

SOAP and SBAR

Three Major Health Assessment Frameworks

1. Functional assessment 2. Head-to-toe assessment 3. Body systems approach

Framework Promoting Critical Thinking

Body systems approach

Evidence-Based Practice Reliance

Research findings and high-grade scientific support (minimizes reliance on intuition and personal experience)

Four Steps of Solving Problems with Evidence-Based Practice

1. Clearly identify the issue 2. Search literature for relevant research 3. Evaluate research evidence using established criteria 4. Choose interventions, justifying with the most valid evidence