REVIEWER IN HEALTH ASSESMENT

CHAPTER 1 AND 2

ASSESSMENT

-Collecting subjective and objective data.

DIAGNOSIS

-Analyzing subjective and objective data to make a professional nursing judgment(collaborative problem
or referral)

PLANNING

-Determining outcome criteria and developing a plan

IMPLEMENTATION

-Carrying out the plan

EVALUATION

-Assesing whether outcome criteria have been met and revising the plan as necessary

FOUR BASIC TYPES OF ASSESSMENT:

-Initial comprehensive assessment

-ongoing or partial assessment

-focused or problem-oriented assessment

-emergency assessment

INITIAL COMPREHENSIVE ASSESSMENT

-Collection of subjective data about the client's perception of his or her past health history, family
history and lifestyle and health practices.

ONGOING OR PARTIAL ASSESSMENT

-This consist of a minioverview of the client's body system and holistic health patterns as a follow up
on health status.
FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

-Consists of a through assessment of a particular client problem and does not address areas not
related to the problem.

-It is performed when a comprehensive database exists for a client who comes to the health care agency with
specific health concern.

EMERGENCY ASSESSMENT

-It is a very rapid assessment performed in life-threatening situations in such choking, cardiac arrest, drowning
an immediate assessment is needed to provide prompt treatment

PREPARING FOR THE ASSESSMENT

-before actually meeting the client and beginning the nursing health assessent, there are several things the
nurse should do to prepare.

-Review the client's medical record if available knowing the client's basic biographical
data( age,sex,religion,educational level, and occupation)

COLLECTING SUBJECTIVE DATA

-Are sensations or symtoms( pain,hunger) feelings ( happiness, sadness)

preceptions,desires,preferences,beliefs,ideas,values and personal informations that can verified only the client.

COLLECTING OBJECTIVE DATA

-This type of data obtained by general observation and by using the four physical examination
techniques(inspection, palpation, percussion, and auscultation.

VALIDATING ASSESSMENT DATA

-Is a crucial part of assessment that often occurs along with collection of subjective and objective data.

DOCUMENTING DATA

-Is an important step of asessment because ot forms the database for the entire nursing process and provides
data for all other members of the health care team.

ANALYSIS OF DATA/NURSING DIAGNOSIS

-Is the second phase of the nursing process.

-Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment.

-is defined by the north american nursing diagnosis association as " a clinical judgment concerning a human
response to health conditions/life processes

PROCESS OF DATA ANALYSIS

-This process requires diagnostic reasoning skills, often called critical thinking

VITAL SIGNS

-Inicators of health status depicting effectiveness of circulatory,respiratory,neural, and endocrine body

functions,

HEAT PRODUCED-- HEAT LOST = BODY TEMPERATURE

CORE TEMPERATURE

Regulation

-neural and vascular control heat production

*metabolism *shivering

*voluntary movement *non shivering thermogenesis

HEAT LOSS ( REDCOCO)

-Radiation

-Conduction

-Convection

-Evaporation

-Diaphoresis

RADIATION

-Is the transfer of heat from the surface of once object to the surface.

CONDUCTION

-Is the transfer of heat from one object to another with direct cotact. (tepid sponge bath)

CONVECTION

-Is the transfer of heat away by air movement.

EVAPORATION

-Is the transfer of heat energy. (newborn)

DIAPHORESIS

-Is visible perspiration primarily occurring on the forehead and upper thorax.

BEHAVIOR
-DEGREE OF TEMPERATURE CONTROL

*EXTREMES *THOUGHT PROCESS AND EMOTIONS

*COMFORTABILITY *MOBILITY

AGE -----NEWBORN SUSTAINED

<Adequate clothing -Constant body temperature continuosly above 38* that has

<Use of cap lifted fluctuation.(laging may lagnat)

OLDER ADULT INTERMITTED

<Poor control mechanism -Fever sprikes interspeed with usual temparature.

<Poor vasomotor control REMITTENT

<Reduced subcutaneous -Fever sprike and falls without a return to normal.

<Reduced sweat gland activity RELAPSING

<Reduced metabolism -PERIODS OF FEBRILE EPIS/CODES.

EXERCISE NURSING

*METABOLISM -Is an art of applying scientific pronciples in a humanitarian

*HEAT PRODUCTION way to care of people.

HORMONE LEVEL COMPONENTS OF NURSING PROCESS:

*PROGESTERONE 1.ASSESSMENT 3.PLANNING 5.EVALUATION

*MENSTRUATION 2.DIAGNOSIS 4.IMPLEMENTATION

RESPIRATION

-Mechanism the body uses to echange gases between the atmosphere and the blood and the cells.

VENTILATION

-The movement of gases in and out of the lungs.

DIFFUSION

-The movement of oxygen and carbon dioxide between the axeoli and the red blood cells.

PERFUSION

-The distribution of red blood cells to and from the pulmonary capillaries.

HOW CAN WE ASSESS VENTILATION

-By determining respiratory rate,depth,rythm,and end tidal carbon dioxide

HOW CAN WE ASSESS DIFFUSION

-By determining O2 saturation

HYPOXEMIA

-Decrease of oxygenation in the blood.

HYPERCARBIA

-Increase CO2 concentration in the blood.

ORTHOPNEA

-Inability to breathe when lying down.

OXYGEN SATURATION

-Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment 98-100.

BLOOD PRESSURE

-The force on the walls of an artery by the pulsing.

-The pressure exerted by the blood to the wall.

SYSTOLIC

-The peak pressure, produced by the contracting ventricles

DIASTOLIC

-The pressure in your arteries when the venticles are relaxed.

HYPERTENSION

-Is associated with thivkening and loss of elasticity in the arterial walls.

-peripheral vascular resistance increases within thick and inelastic vessels.

ORTHOSTATIC HYPERTENSION

-Low blood pressure and lightheadedness upon standing up.

BLADDER

-Arm not suported

repeating assessment too quickly errone

PULSE
-An indicator of circulatory status the pulse isa palpable bounding of blood flow noted at various points on the
body.

-Is a wave of blood created by contraction of the left ventricle of the heart.

NORMAL <120 <80

PREHYPERTENSION 120 -139 80-89

STAGE 1 HYPERTENSION 140-159 90-99

STAGE 2 HYPERTENSION _>160 _>100

PREINTRODUCTORY

-The nurse reviews the medical record before meeting with the clint.

-knowing some of the client's already documented biographical information may assist the nurse with
conducting interview.

INTRODUCTORY PHASE

-After introducing herselft to the client, the nurse explains the purpose of the interview, disscusses the types of
questions that will asked.

WORKING PHASE

-Durig this phase the nurse elicits the client's comments about major biographical data,reasons for seeking
care,history of present health concern,past health history.

SUMMARY AND CLOSING PHASE

-During the summary and closing the nurse summarizes information obtained during the work phase and
validates problems and goals with the client.

NONVERBAL COMMUNICATION

-Is as important as verbal communication,your apperance,demeanor,posture,facial expressions,and attitude

strongly influence how the client perceives the questions you ask.

APPEARANCE

-Fist take care to ensure that your appearance is professional. the client is expecting to see a health professional
therefore you should look the part.

DEMEANOR

-Your demeanor should also be professional, when you enter a room to interview a client display poise focus on
the client and upcoming interview and assessment.

FACIAL EXPRESSION
-Are often an overlooked aspect of comunication. because facial expressions often show what you are truly
thinking monitor them closely.

ATTITUDE

-One of the most important nonverbal skill to develop as a health car professional is a nonjudgment