HEALTH ASSESSMENT MIDTERM

Assessing

Determining health problems and care needs of a patient.

Precision

Measures how close results are to one another.

Accuracy

Measures how close results are to the true or known value.

Purpose of the Assessment

To collect data pertinent to the patient’s health status and identify deviations from normal.

Purpose of Health Assessment

To obtain baseline data about the client’s functional abilities and evaluate physiological outcomes of health care.

Cognitive Skills

Assessment involves critical thinking, critical decision-making, and problem-solving skills.

Psychomotor Skills

Assessment involves physical movements and coordination essential for tasks like administering medication and physical assessments.

Affective/Interpersonal Skills

Assessment involves building trust, mutual respect, and ethical responsibility.

Four Types of Assessment

Initial assessment, focused assessment, time-lapsed assessment, and emergency assessment.

Methods of Assessment

Observation, interview, health history, and examination techniques like inspection, palpation, percussion, and auscultation.

Signs

Observable effects of a health problem based on what is seen by someone else.

Symptoms

Subjective evidence of disease based on what patients say.

Acute vs

Acute pain lasts up to 6 months, while chronic illness lasts for more than 3 months.

Physical Assessment Techniques

Include inspection, palpation, percussion, and auscultation.

The Nursing Process

Involves assessment, diagnosis, planning, intervention, and evaluation for individualized nursing care.

Diagnosis

Involves identifying and prioritizing actual or potential health problems or responses.

Planning

Involves setting goals and outcome criteria for patient care.

Intervention

Includes direct and indirect care, independent, dependent, and collaborative interventions.

Evaluation

Involves assessing if outcome criteria have been met and revising the plan as needed.

Documentation

Essential for safe, quality nursing practice, including clear, accurate, and accessible records in electronic health records.

Nursing Documentation Principle

The principles guiding nursing documentation, including characteristics, education, policies, protection systems, documentation entries, and standardized terminologies.

SBAR

A structured communication technique for sharing essential information about a patient's situation, background, assessment, and recommendation.

FDAR (Focus, Data, Action, Response)

A method of charting that focuses on patient-oriented notes, including the date and time of entry, separate topics, and signing each entry.

General Survey

The initial assessment of a patient's physical appearance, body structure, mobility, and behavior to evaluate their overall health status and objective parameters.

Getting Ready

Steps to prepare for patient interaction, including handwashing, observing precautions, ensuring privacy, and addressing safety concerns before and after the encounter.