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Health Care
It refers to efforts that are made to maintain or restore physical, mental, or emotional well-being especially by trained and licensed Professional.
Healthcare Process
It is a plan of actions or measures, and are carried out by a trained and licensed professional to restore the well-being of the patient.
Healthcare Process
The actions that guide the health care provider in his/her approach to individuals, families and communities in an attempt to promote good health conditions and cope up with health problems.
Healthcare Process
It is a method that is goal-oriented, systematic, and client-centered.
Principles of Health Care
Goal-oriented, Client-centered, scientific and Problem-oriented
Clien/Patient-Centered
Responsive
Clien/Patient-Centered
Patient advocate
Interpersonal
Interaction between the client and healthcare professional.
Dynamic and Cyclical
Phases or stages of health care process.
Assessment
What data is collected?
Assessment
A phase of the healthcare process to establish a database about the client's response to health concerns and illness and the ability to manage health needs.
Assessment
A phase of the healthcare process that involves collecting, organizing, validating and documenting client's data.
Data Collection
A part of assessment wherein it is the process of gathering information regarding of client's health status.
Data Collection
A part of assessment where it it undergoes health interviews, physical examination, and observation.
Data Validation
A phase of the healthcare process wherein it undergoes the act of double checking or verifying data to confirm that they are accurate and factual.
Planning
What is the Problem?
Planning
A phase of the healthcare process wherein it is the setting of measurable and achievable short- and long- range goals for his or her patient.
Planning
A phase of the healthcare process wherein it develops an individualized care plan that specifies client's goals/desired outcomes, and related healthcare interventions.
Implementation
A phase of the healthcare process that assists the client to meet the desired goals/outcomes: promote wellness, prevent illness and disease; restore health; and facilitate coping with altered functioning.
Implementation
A phase of the healthcare process where it involves carrying out or delegating and documenting the planned healthcare interventions.
Implementation
A phase of the healthcare process where it involves recording the patient's response to healthcare actions.
Evaluation
Did the plan work?
Evaluation
A phase of the healthcare process where it checks if the desired outcome has been met.
Evaluation
A phase of the healthcare process determines whether to continue, modify, or terminate the plan of care.
Health History
It is typically done on admission to a hospital or a care agency, or with initial contact with community.
Health History
It gives information (subjective data).
Health History
It takes place before the physical assessment.
Health History
It is the collection of data/information about the client's level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness and other health conditions.
Sources
A guideline in taking health history wherein it includes the information about the client, family or significant others, health team members, and the client's health record.
Subjective Data
A guideline in taking health history wherein the information by the patient focuses on perceptions and feelings.
Subjective Data
A guideline in taking health history that contains signs and symptoms.
Subjective Data
A guideline in taking health history that contains the demographic information, patient and family information, about past and current medical conditions, and patient information about surgical procedures and social history.
Physical Assessment
It involves collecting objective data using the techniques inspection, palpation, percussion and auscultation as appropriate.
Inspection
A method of physical examination that includes the visual examination of the appearance of the client and the condition of each body part.
Inspection
A method of physical examination that is the most difficult technique.
Inspection
A method of physical examination that needs good lighting and exposure.
Inspection
A method of physical examination that each body area is inspected for size, shape, color, position, symmetry and presence of abnormalities.
Palpation
A method of physical examination wherein the examiner uses their sense of touch to elicit specific information. It is done to assess for any masses or lumps anywhere in the body.
Functional Assessment
It assists the health care provider in collecting, organizing and categorizing data.
Functional Assessment
Contained the Gordon's Functional Health Pattern.
Gordon's Functional Health Pattern
Made by Marjory Gordon.
Health Perception-Health Management Pattern
A part of functional assessment that includes a person's description of his/her current health.
Health Perception-Health Management Pattern
A part of functional assessment that includes the activities that the person does to improve or maintain his health.
Health Perception-Health Management Pattern
A part of functional assessment that includes the person's knowledge about links between lifestyle choices and health.
Health Perception-Health Management Pattern
A part of functional assessment that includes the extent of person's problem on financing health care.
Health Perception-Health Management Pattern
A part of functional assessment that includes the person's knowledge of the names of current medications he is taking and their purpose/s.
Health Perception-Health Management Pattern
A part of functional assessment that includes the activities that the person does to prevent problems related to allergies.
Health Perception-Health Management Pattern
A part of functional assessment that includes the person's knowledge about medical problems in the family.
Health Perception-Health Management Pattern
A part of functional assessment that includes any important illnesses or injuries in this person's life.
Nutrition-Metabolic pattern
A part of functional assessment that includes the person's nourishment.
Nutrition-Metabolic pattern
A part of functional assessment that includes the person's food choices in comparison with recommended food intake.
Nutrition-Metabolic pattern
A part of functional assessment that includes any disease that affects nutritional-metabolic function.
Elimination pattern
A part of functional assessment that includes a person's excretory pattern.
Elimination pattern
A part of functional assessment that includes any disease of the digestive system, urinary system or skin.
Activity-Exercise pattern
A part of functional assessment that includes a person's description of his weekly pattern of activities, leisure, exercise and recreation.
Activity-Exercise pattern
A part of functional assessment that includes any disease that affects his cardio-respiratory and/or musculoskeletal systems.
Sleep-rest pattern
A part of functional assessment that means the person's sleep-wake cycle.
Sleep-rest pattern
A part of functional assessment that includes a person's physical appearance (rested and relaxed).
Cognitive-Perceptual pattern
A part of functional assessment that includes any sensory deficit and if corrected.
Cognitive-Perceptual pattern
A part of functional assessment that includes a person's ability to express himself clearly and logically.
Cognitive-Perceptual pattern
A part of functional assessment that includes a person's education.
Cognitive-Perceptual pattern
A part of functional assessment that includes any disease that affects mental or sensory function.
Cognitive-Perceptual pattern
A part of functional assessment that includes a person's pain description and causes.
Self-Perception-Self-concept pattern
A part of functional assessment that includes anything unusual about the person's appearance.
Self-Perception-Self-concept pattern
A part of functional assessment that mentions if the person is comfortable with his/her appearance.
Role Relationship pattern
A part of functional assessment that includes the person's description of his various roles in life.
Role Relationship pattern
A part of functional assessment the includes positive role models of his/her roles.
Role Relationship pattern
A part of functional assessment the includes important relationship at present.
Role Relationship pattern
A part of functional assessment that includes any big changes in role or relationship.
Sexuality-Reproductive pattern
A part of functional assessment that includes a person's satisfaction with his situation related to sexuality.
Sexuality-Reproductive pattern
A part of functional assessment that includes any disease/dysfunction of the reproductive system.
Coping-Stress Tolerance pattern
A part of functional assessment that includes a person's means/actions of coping with problems.
Coping-Stress Tolerance pattern
A part of functional assessment that mentions if coping actions can help of make things worse.
Coping-Stress Tolerance pattern
A part of functional assessment that includes any treatment for emotional distress.
Value-Belief pattern
A part of functional assessment that includes the principles that the person learn as a child which are still important to him/her.
Value-Belief pattern
A part of functional assessment that includes a person's identification with any cultural, ethnic, religious, regional or other groups.
Value-Belief pattern
A part of functional assessment that includes the support systems that the person has.
Physical Examination
It is a complete health assessment generally conducted from head to toe.
Physical Examination
It presents objective data.
Physical Examination
In here, the examiner must have both technical skills and knowledge base to be effective.
Physical Examination
In here, it involves the sense of sight, smell, touch and hearing.
Sitting position
A kind of positioning the client for evaluating the skin, head and neck; eyes, ears, nose, mouth and throat; back; posterior thorax and lungs; anterior thorax and lungs; breast; axillae; heart; peripheral vasculature; musculoskeletal; neurological.
Supine position/Horizontal recumbent
A kind of positioning the client for evaluating the head, neck, chest, breasts, axillae, abdomen, heart, lungs and all extremities.
Dorsal recumbent position
A kind of positioning the client for evaluating the head, neck, chest, axillae, lungs, heart, extremities, breasts and peripheral pulses; female genitalia.
Sim's position
A kind of positioning the client for rectal and vaginal area assessment.
Standing position
A kind of positioning the client for assessment of posture, balance and gait; and male genitalia.
Prone position
A kind of positioning the client for hip joint and back assessment.
Knee-chest position
A kind of positioning the client for examining rectum and prostate.
Lithotomy position
A kind of positioning the client for examining female genitalia, reproductive tracts, and the rectum.
Fowler's position
A kind of positioning the client for evaluating the skin, head and neck; eyes, ears, nose, mouth and throat; thorax and lungs; heart and peripheral vascular, musculoskeletal; neurological.
Side lying position/Lateral
A kind of positioning the client for evaluating skin, thorax and lungs.
Inspection
A technique in physical assessment for concentrated watching. It involves using the senses of vision, smell and hearing. And it is also an ongoing process.
Palpation
A technique in physical assessment wherein it shows the act of touching a patient in a therapeutic manner to elicit specific information.
Light
It is a type of palpation wherein it reveals information on skin texture and moisture; overt, large or superficial masses; fluid, muscle guarding and superficial tenderness; for pulses and temperature. It is superficial, delicate and gentle palpation with 1 cm depth.
Moderate
It is a type of palpation wherein it depressed the skin surface to 1 to 2 cm and use a circular motion to feel for easily palpable organs and masses.
Deep
It is a type of palpation wherein it the depression between 2.5 to 5 cm allowing feeling very deep organs or structures that are covered by thick muscles. It is most often used for abdominal, male and female reproductive assessments.
Bimanual
It is a type of palpation wherein it uses two hands placing one on each side of the body part being palpated.
Percussion
It is a technique of striking one object against another to cause vibrations that produce sound. These sounds or vibrations enable the examiner to assess underlying structures.
Auscultation
It is the act of active listening to body organs and it includes listening to both voluntary and involuntary sounds.
Interview
The most common tool used in collecting patient health information.
Note
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