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21 Cards in this Set
- Front
- Back
ASSESSMENT OVERVIEW
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-The first step of the nursing process
-Involves data collection -Holistic assessment (head to toe) -Data collection leads to Nursing diagnosis |
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DATA COLLECTION
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Leads to nursing diagnosis
-interpret data -identify related factors -document diagnosis |
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SUBEJECTIVE DATA
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What the person relates during history taking
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OBEJECTIVE DATA
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What the health professional observe
-inspecting -palpating -auscultation -percussing Lab results |
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TYPES OF DATA BASE
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-Complete
-Episodic -Follow up -Emergency |
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COMPLETE DATA BASE
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Head to toe
-Complete health history and full physical examination -Describes the current and past health state and forms baseline -yields the first diagnosis |
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EPISODIC OR PROBLEM CENTERED DATA BASE
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-For a limited or short-term problem
-Collect a mini data base, smaller in scope - more focused than complete data base -concerns only one problem, one cue complex, one body system |
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FOLLOW UP DATA BASE
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The status of any identified problem should be evaluated at regular and appropriate intervals
-what changes occured? did it get better or worse? -Used in all settings to follow up short term or chronic health problems |
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EMERGENCY DATA BASE
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-Rapid collection of data
-Complied with life-saving measures -Diagnosis must be swift and sure |
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LIFE CYCLE INFLUENCES
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-Transcultural
-Developmental -Subjective/Objective data collection -Risk factors -Functional Assessment (ADL) -Environmental -Self-Care behavior |
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HEALTH INTERVIEW
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Structured interaction between health care provider and client
-Collects subjective data |
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COMPONENTS OF COMPLETE HEALTH HISTORY
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-Bio data and source of history
-Past, present and family history -Review of Systems (ROS) -Environmental Health -Functional (ADL) what is impeding it? -Self perception of health -Reason for seeking care (CC) |
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SYMPTOM CHARACTERISTIC
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-Location
-Quality -Quantity and Severity -Timing -Setting -Aggravating/Relieving factors -Associated factors -Client's perception |
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GENERAL SURVEY
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Done when first entering room
-Physical Appearance -Body Structure -Mobility -Behavior |
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MENTAL STATUS
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Appearance (clean, shaved, groomed, posture, body movements)
-Behavior (LOC, Facial expression, speech) -Cognition (orientation, attention span, new learning, recent memory) Tool used to test cognition is the mini mental status AAOx3 (awake, alert, oriented to person, place, time) |
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ASSESSMENT TECHNIQUES
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1. Inspection
2. Palpation 3. Percussion 4. Auscultation |
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INSPECTION
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Concentrated watch
-close careful scrutiny first of the individual as a whole then of each body system -always come first |
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PALPATION
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-Follows and often confirms points noted on inspection
-with the sense of touch you assess: texture, temperature, moisture, organ location, swelling, vibration, pulsation |
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PERCUSSION
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Done with plexor and plexometer
-avoid bone -assess for sound and vibration |
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INSPECTION
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Concentrated watch
-close careful scrutiny first of the individual as a whole then of each body system - |
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AUSCULTATION
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Listening to sounds a body produces such as: heart, blood vessels, lungs and abdomen
uses a stethoscope |