NCM101-Health-Assessment-PRELIM-ENDTERM

Flashcards for health assessment review.

Health

The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

Physical Health

Relates to the efficient functioning of the body and its systems, including the physical capacity to perform tasks and physical fitness.

Mental Health

A state of well-being in which an individual recognizes their own abilities, can cope with normal stresses, work productively, and contribute to the community.

Social Health

Involves being able to interact with others and participate in the community in both an independent and cooperative manner.

Orem's Model of Health

Therapeutic self-care.

Leininger's Model of Health

A culturally defined, valued, and practiced state of well-being reflective of the ability to perform role activities.

Nightingale's Model of Health

The state of well-being and the use of every power the person possesses to the full extent.

Ecologic Model of Health

Examines the interaction of agent, host, and environment; health is present when these three variables are in harmony.

Clinical Model of Health

Defines health as the absence of disease or injury.

Eudaimonistic Model of Health

Views health as the actualization of a person's potential; illness prevents self-actualization.

Health Promotion Model

Defines health as the actualization of inherent and acquired human potential through goal-directed behavior and competent self-care.

Health Assessment

Plan of care that identifies specific needs of a patient and how those needs can be addressed.

Health Assessment

A systematic method of collecting data about a patient to determine their current and ongoing health status and predict health risks.

Techniques of Physical Assessment (IPPA)

Inspection, Palpation, Percussion, Auscultation

Why Conduct Health Assessment?

To gather subjective and objective data to determine a patient's overall level of functioning.

Purpose of Health Assessment

Collecting physiological, psychological, sociocultural, developmental, and spiritual data about the patient.

Assessment

The first and most critical phase of the nursing process.

The Nursing Process

A systematic problem-solving process that guides all nursing actions.

Five Phases of the Nursing Process (ADPIE)

Assessment, Diagnosis, Planning, Implementation, and Evaluation

Assessment Phase

Collection of subjective and objective data.

Diagnosis Phase

Analyze the gathered data to make a professional nursing judgment.

Planning Phase

Determine the outcome criteria and develop a plan.

Implementation/Intervention Phase

Carry out the plan.

Evaluation Phase

Measure and assess if the outcome criteria have been met; revise if goals are not met.

Emergency Assessment

A rapid assessment performed in life-threatening situations.

Subjective Data

The verbal statements provided by the patient.

Objective Data

Data directly observed by the examiner.

Validation of Data

Ensures that the assessment process is not ended before all relevant data have been collected.

The Interview

Gathers subjective data during health history taking and focused interviews.

The Health History

Obtain information about the patient's health in their own words and based on their own perceptions.

Physical Assessment

Hands-on examination of the patient.

Constant Data

Information that does not change over time such as race, sex, blood type, etc.

Accurate Documentation

Documentation is limited to facts or factual accounts of observations rather than opinion

Interpretation of Findings

Making determinations about all of the data collected in health assessment process.

Integumentary System

The skin, hair, nails, and sweat glands

Functions of the Skin

protection (mechanical, chemical, microbe, UV), temperature regulation, sensation (pressure), vitamin D synthesis, excretion.

Epidermis

Superficial or outermost portion of the skin consisting of stratified squamous epithelial tissue; provides a waterproof barrier and creates our skin tone.

Keratinocytes

Produces keratin.

Stratum Basale

Lies closes to the dermis,stem cells constantly dividing -germinating layerthrough mitosis. As cells moves outwards, they are dying.

Stratum Corneum

20 to 30 layers thick cornified,or horny, cells(cornu = horn) three-quarters of the epidermal thickness

Melanin

ranges from yellow to brown to black; produced by melanocytes found chiefly in the stratum Basale.

Merkel Cells

Seen at the epidermal-dermal junction

Dermis

"core" of the integumentary system,thick layer of living connective tissue found below the epidermis, containing blood and lymphatic vessels, nerve endings, smooth muscles, and other structures, such as hair follicles and sweat glands.

Papillary

Superficial dermal region

Reticular

Connective tissue, blood vessels, sweat and oil gland

Hypodermis

Provides insulation, storage of caloric reserves,and cushioning against external forces.

Lanugo

Very thin, soft, unpigmented hair that covers newborn babies

Vellus Hair

Short, fined, pigmented, and replaces lanugo on the rest of the body except for the scalp, eyelids,eyebrows.

Terminal Hair

long, coarse, and pigmented, replaces the lanugo in the scalp, eyelids, eyebrows, also replaces the vellus hair in the pubic and axillaryregions in puberty

Sebaceous Glands

secrete sebum. Sebum production decreases with age.

Nail

Epidermal appendage that arises from a nail matrix in the epidermal layer.

Configuration

Check for the following:shape and the outline of the lesion.

Morphology

Check for the following:Morphology -study of the form of the lesion, key determinant in identifying a skin problem.

Freckles

small patch of light brown color on the skin, often becoming more pronounced through exposure to the sun.

Pallor

Condition in which a person's skin and mucous membranes turn lighter than they usually are

Stretch Marks

Scar that develops when our skin stretches or shrinks quickly. Especially had history of pregnancy

Papule

Small, solid, raised bump on the skin that has a border with edges that are easy to see.

Ulcer

Open, painful sore

Cyanosis

A bluish discoloration of the skin resulting from poor circulation caused by low oxygen levels in the RBC.

Erythema

Superficial reddening of the skin

Hyperpigmentation

Patches of skin are darker than the surrounding skin

Coarse (Dry) Hair

Hypothyroidism can cause your hair to become dry, coarse, or brittle

Normal

Muscle strength grading.

Evenly distributed weight

Weight is evenly distributed, client is able to standweight is evenly distributed, no limping.

Temporomandibular Joint

The temporomandibular joint (TMJ) is a smalljoint located in front of the ear (tragus) where the skull and lower jaw meet. It permits the lower jaw to move and function.

Nontender spinous process

Anterior and Posterior

Lasegue's test

straight leg test is a fundamental maneuver during the physical examination of a patient with lowerback pain; is performed to check forherniated nucleus pulposus (the inner core of vertebral disc.