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Health Assess - Mod 1 Key Concepts

Health Assess - Mod 1 Key Concepts

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Published by: Allison Doubek Gibson on Nov 20, 2010
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Health AssessmentModule 1 ± Introduction to Health AssessmentKey Terms and Concepts
Health Assessment
Biomedical model
Western view is that health is the absence of disease. Biomedical focus is ondiagnosis and treatment of pathogens and curing of the disease.
Critical thinking
The means by which we learn to assess and modify before acting. Required for sound diagnostic reasoning and clinical judgment. Enables us to:
y
 
Analyze complex data about patients
y
 
Make decisions about the patients problems and alternate possibilities
y
 
Evaluate each problem to decide which applies
y
 
D
ecide on the most appropriate interventions for the situation
D
ata
objective What we observe from the PEsubjective What the patient says they feel
D
atabase
Complete ± Complete health history and full physical exam; current and pasthealth state; forms a baseline; yields the first diagnosis.Episodic ± for a limited or short term problem; ³mini´ database, smaller in scopeand more focused; mainly only one problem, one cue complex, or one bodysystem.Follow up ± problems evaluated at regular intervals; assess changes, is it getting better or worse, coping strategies.Emergency ± rapid collection of the data compiled concurrently with lifesavingmeasures.
D
iagnosis
 Nursing diagnosis ± clinical judgmentsabout a person¶s response to an actualor potential health state. Evaluates the person as a whole.Medical diagnosis ± identification of adisease from its symptoms. Evaluatesthe cause and etiology. Focuses on thefunction or malfunction of an organ.
Health Promotion
A set of positive acts we can take, such as teaching and helping the consumer choose a healthier lifestyle. Based on risk factors.
Heritageassessment
Gather data that is accurate and meaningful; intervene with culturally sensitiveand appropriate care.
Holistic health
Consideration of the whole person: mind, body, spirit ± interdependent andfunction as a whole.
Nursing process
Assessment ± 
y
 
Collect data: review the clinical record, interview, health history, PE,functional assessment, consultation, review of the literature
D
iagnosis ± 
y
 
interpret data: I
D
clusters of cues, make inferences;
y
 
validate inferences;
y
 
compare clusters of cues with definition and defining characteristics;
y
 
I
D
related factors;
y
 
document the diagnosisOutcome identification-
y
 
I
D
expected outcomes;
y
 
individualize to the person;
 
y
 
realistic and measurable;
y
 
include a time framePlanning ± 
y
 
establish priorities;
y
 
develop outcomes;
y
 
set time frames for outcome;
y
 
I
D
interventions;
y
 
document plan of careImplementation-
y
 
review the planned interventions;
y
 
schedule and coordinate the person¶s total health care;
y
 
collaborate with other team members;
y
 
supervise implementation of the care plan by delegating appropriateresponsibilities;
y
 
counsel the person and significant others;
y
 
involve the person in the health care plan;
y
 
refer individuals who require cont. care;
y
 
document the care providedEvaluation ± 
y
 
refer to established outcomes
y
 
evaluate the individual¶s condition and compare actual outcomes withexpected outcomes
y
 
summarize the results of the evaluation
y
 
Identify reasons for the person¶s failure, if indicated, to achieve expectedoutcomes stated in the plan of care.
y
 
Take corrective action to modify the plan of care as necessary
y
 
D
ocument the evaluation of the person¶s achievement of outcomes andmodifications, if any, in the plan of care.
Prevention
Link between health and personal behavior. Counseling designed to changeunhealthy behaviors. I.e. Counseling on smoking, alcohol, drug use, lack of exercise, poor nutrition, injuries, ST
D
s.
Priority problems
Used when there is more than one diagnosis.
y
 
1
st
level: emergent, life threatening. ABCs.
y
 
2
nd
level: require prompt intervention to stop further deterioration. Ex:mental status, acute pain, urinary elimination problems, risks of infection.
y
 
3
rd
level: important to health but can be addressed after the urgent problems.
V
alidation
Checking the accuracy and reliability of data.
Wellness
A move toward optimal functioning. Optimal health = high level wellness. It is adynamic process, moving in the direction of progress. Health care professionalstry to maximize the person¶s potential to grow towards high level wellness.
Health History
The InterviewActive listening
Complete attention so you understand. Listen to
what 
the person saysand
the way
they say it.
Closed/direct question
Ask for specific information. Limiting. Want a short, one or two word
 
answer. Cold facts. Limits rapport and leaves interaction neutral.
Communication
Exchanging information so that each person clearly understands theother.
Confrontation
Includes your own thoughts and feelings. Focus the person¶s attentionon a specific action, feeling, or statement. Give your honest feedback.Use with discrepancies or inconsistencies in the story.
Empathy
Viewing the world from the other person¶s inner frame of referencewhile remaining yourself. Recognize and accept another person¶sfeelings without criticism. This response recognizes a feeling and putsit into words, helping the patient feel accepted and deal with thefeeling openly. Allows the person to express without embarrassment.
Etiquette
Conventional code of good manners that governs behavior and variescross culturally.
External factors
Physical setting. Ensure privacy, refuse interruptions, physicalenvironment (room temp, lighting, noise level, personal space), dress(patient in street clothes, nurse appears professional), note taking, tapeand video recording.
Facilitation
Responses that encourage the patient to say more or continue with thestory (aka general leads). Shows the person you are interested and willlisten further. ³Yes, go on.´ ³Uh-huh.´
Internal factors
What the examiner (you) bring to the interview: Liking others,empathy, and the ability to listen.
Interpretation
Based on your inference or conclusion. Links events, makesassociations, or implies cause. There is risk of making the wronginferences.
Nonverbal communication
Body language ± posture, gestures, facial expressions, eye contact, foottapping, touch.
Open-ended questions
Asks for narrative information. General. Used to begin the interview,introduce a new topic, or new section of questions. Unbiased, the person can answer however he/she wants. Elicits feelings, opinions,and ideas. Builds rapport.
Reflection
Response that echoes the patients words or reflects feelings. Repeat part of what the patient just said. Helps the person elaborate on the problem.
Silence
Use with open-ended questions. Silent attentiveness gives the patienttime to think and organize what he¶s going to say.
Subjective
What the person tells you they are feeling, what they say aboutthemselves.
V
erbal communication
The words you speak, vocalizations, tone of voice.
The Complete Health HistoryActivities of daily living(A
DL)
 
Part of a functional assessment to measure a person¶s self-care abilityin general physical health. Bathing, dressing, toileting, eating, walking,
D
isease burden
The impact of health problems in an area.
Functional assessment
Measures a person¶s self-care ability in the areas of general physicalhealth or absence of illness; A
D
Ls, IA
D
Ls, nutrition, socialrelationships and resources, self-concept and coping, and homeenvironment.
Instrumental activities of daily living (IA
DL)
 
 Needed for independent living: Housekeeping, shopping, cooking,laundry, using the telephone, managing finances.
Sign
An
objective
abnormality that you as the examiner could detect on a

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