Health assesment exam 1

nursing process

1. assessment
2. diagnosis
3. planning
4 implementation
5. evaluation
ADPIE

first-level priority

Emergent, life threatening, and immediate

second-level priority

next in urgency, requiring attention to avoid furthur decline

subjective data

What patient says about himself or herself during history taking

objective data

observed when inspecting, percussing, palpating, and auscultating pateint during physical examination

database

formed from subjective and objective data, pateints record, and lab studies
-cluster data that is related

abductive reasoning

used with incomplete data to produce an initial diagnosis

deductive reasoning

used as you complete your assesment and apply knowledge you have about physiology and pathophysiology

inductive reasoning

used as you consider signs and symptoms of disease as a guide for decision making

clinical judgement model

structure for nursing education to improve clinical judgement skills
1. recognize cues
2. analyze cues
3. prioritize hypotheses
4. generate solutions
5. take action
6. evaluate outcomes

third-level priority

Important to patient's health but can be addressed after more urgent problems are addressed

collaborative problems

approach to treatment involves multiple disciplines

evidence based assesment

-current and best clinical practice based on reasearch standards focused on systematic reviews of randomized clinical trials
-utilizing EBP with provider experience leads to better patient outcomes

complete total health database

-includes health history and physical exmaination
-describes current and past health states
-provides baseline to measure all future changes
-helps from the first diagnosis

focused or problem centered database

This is for a limited or short-term problem. Here, you collect a "mini" database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system.

follow-up database

-The status of any identified problems should be evaluated at regular and appropriate intervals
-Is it getting better or worse?
-used in all settings

emergency database

rapid collection of the database, often compiled concurrently with lifesaving measures

nurse-initiated intervention

actions performed by a nurse without a physician's order

Provider-initiated/dependent interventions

these are interventions nurses initiate as a results of a provider's rx (written, standing or verbal)

collaborative interventions

interdependent nursing actions performed jointly by nurses and other members of the health care team

holistic health

-mind, body, and spirit are interdependent
-individuals and the environment are open systems
-each person is responsible for their health state
-health promotion and disease prevention from the core fo nursing

immigration and healthcare

-some patients you come in contact with as a nurse may have been born in a foreign country.
-It is important to consider lanuage barriers

social determinants of health

The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels
-EBP indicates that poverty has greatest influence on health status

healthcare disparities

the population-specific differences in the presence of disease, health outcomes, and qualities of healthcare in different social groups

vulnerable populations

ethnic and racial minorities, people with disabilities, and the LGBT community

National Standards for Culturally and Linguistically Appropriate Services in Health Care

published by the office of minority health to improve quality of care and eliminate health disparities

four basic concepts of culture

1. learned
2. shared
3. adapted
4. dynamic

race

self-identification with a group who share similar and distinct physical characteristics.

ethnicity

social traits, nationality, regional culture, ancestry, and language

Acculturation

2 or more cultures encounter eachother and exchange ideas, values, and behaviors

assimilation

assuming characteristics of the dominant culture

acculturative stress

Losses and changes associated with integration of new beliefs

religion and spirituality

Organized system of beliefs versus individual's unique experience

Biomedical/scientific theory

all events in life have a cause and effect

naturalistic or holistic theory

Belief in the forces of nature that there is balance in the universe (ex: yin/yang theory)

magicoreligious perspective

illness is caused by supernatural powers and can be treated by voodoo or witchcraft
-forces of good and evil

cultural competence

-understand one's own heritage based values, beliefs, attitudes, and practices
-identify meaning of health to patient
-understand how health care systems works
-accquire knowledge about social backgrounds
-become familiar with languages, interpretive services, and community resources avaliable

becoming a culturally sensitive practitioner

1. cultural awareness: recognize your own culture before you can work with to understand a different culture
2. cultural knowledge and skills: learn about other cultures
3. cultural humility: see value in other beliefs

completing cultural assesment

- do not apply stereotypes but listen and learn
-recommended list of domains of interest: heritage, health practices, communication, etc.

spiritual assessment

FICA
-faith
-importance (how is faith or belief important in their life)
-community
-address/action: how should health care team address issues related to patient