Chapter 1: Intro to health assessment
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36 Terms
What is health assessment?
A systematic method of collecting and analyzing data used to create a patient-centered plan of care.
What are the 3 primary components of health assessment?
History → subjective data
Physical examination → objective data
Documentation of data
A patient says, “My stomach has been hurting since yesterday.” Is this a sign or symptom?
Symptom. A symptom is what the patient feels or communicates and is subjective.
Application: If the nurse documents what the patient reports experiencing, that is subjective information.
The nurse observes that a patient's skin is pale. Is this a sign or symptom?
Sign. A sign is a clinical finding that is objective and collected during the physical examination.
What are clinical manifestations?
Signs and/or symptoms collected using inspection, palpation, percussion, and auscultation.
A patient tells the nurse, “I feel dizzy.” The nurse then observes the patient having difficulty maintaining balance. Which combination did the nurse collect?
The patient's dizziness is a symptom, while the observed difficulty maintaining balance is a sign.
What 3 things determine which health assessment the nurse should perform?
Context of care
Patient needs
Health assessment skills/expertise of the nurse
What does “context of care” mean?
The circumstance or situation related to health care delivery, including:
Setting/environment
Physical factors
Psychological factors
Socioeconomic factors
Expertise of the nurse
What patient factors should influence the nurse's choice of assessment?
Age
General level of health
Presenting problems
Knowledge level
Support system
A nurse working in an adult intensive care unit is assessing a patient with hemodynamic instability. Why is this nurse particularly suited to perform this assessment?
The nurse has expertise gained through specialization in that area of practice.
Give the example from the PowerPoint of specialized nursing expertise.
An adult ICU nurse has expertise assessing a patient with hemodynamic instability, while a family nurse practitioner in a women's clinic has expertise performing routine pelvic examinations.
What are the 5 types of health assessment?
Comprehensive
Problem-based/focused
Episodic
Shift
Screening
A nurse needs to perform a complete assessment of a patient's overall health. Which type would be appropriate?
Comprehensive health assessment.
A patient comes in specifically because of a respiratory problem. The nurse focuses questions and assessment on systems related to that problem. What type of assessment is this?
Problem-based/focused assessment.
What must the nurse do before initiating a plan of care?
Analyze and interpret the data.
What information does health assessment provide about the patient?
Physical status
Health problems/comorbidities
Strengths
Weaknesses
Abilities
Support system
Health beliefs
Access to resources
Activities used to maintain health
A nurse collects assessment findings but immediately starts interventions without analyzing what the findings mean. What part of the process is missing?
Clinical reasoning and judgment. The nurse must analyze and interpret the data before initiating the plan of care.
Why does the nurse organize and cluster assessment data?
Organization and clustering allow problems to become more clearly apparent.
How can assessment data be organized?
It can be organized by:
Body system — cardiovascular, musculoskeletal, etc.
Conceptual format — oxygenation, perfusion, mobility
A nurse groups several abnormal findings under “oxygenation” rather than under individual body systems. What type of organization is being used?
Conceptual format.
What are the steps involved in analysis, interpretation, and clinical judgment?
Identify abnormal findings.
Correctly interpret findings to select an appropriate plan of care.
Apply clinical judgment to interpret/make conclusions regarding patient needs, concerns, or health problems.
After understanding the situation, the nurse determines appropriate interventions.
The nurse notices an abnormal assessment finding, determines what it means, and then decides what intervention is appropriate. What process is occurring?
Analysis, interpretation, and clinical judgment.
What is health promotion?
Behavior motivated by the desire to increase well-being and actualize health potential.
What is health protection?
Behavior motivated by the desire to avoid illness, detect illness early, and maintain functioning when ill.
A patient changes their lifestyle because they want to improve their overall well-being. Is this health promotion or health protection?
Health promotion
A person participates in screening to detect disease early. Is this health promotion or health protection?
Health protection.
What is primary prevention?
Preventing disease from developing through promotion of a healthy lifestyle.
What is secondary prevention?
Screening efforts that promote early detection of disease.
What is tertiary prevention?
Minimizing disability from acute or chronic illness/injury and allowing the person to have the most productive life within limitations.
A nurse teaches healthy lifestyle behaviors to prevent disease before it develops. Which level?
Primary.
A patient receives a screening test intended to identify disease early. Which level?
Secondary.
A patient already has a chronic illness. Nursing interventions focus on minimizing disability and helping the patient function as productively as possible. Which level?
Tertiary.
⭐ QUICK WAY TO REMEMBER
Primary = Prevent
Secondary = Screen
Tertiary = Limit disability
What is Healthy People 2030?
A framework for health promotion efforts addressing significant preventable threats to health with goals to reduce those threats.
Who manages Healthy People 2030?
The U.S. Department of Health and Human Services.
What are the 4 overarching goals of Healthy People 2030?
Attain high-quality, longer lives free from preventable diseases.
Achieve health equity, eliminate disparities, and improve health for all groups.
Create social and physical environments that promote health for all.
Promote quality of life, healthy development, and healthy behaviors across all life stages.
A community program is designed to eliminate health disparities and improve health among all groups. Which Healthy People 2030 goal does this represent?
Achieve health equity, eliminate disparities, and improve the health of all groups.