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Flashcards in Assessment Deck (10)
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1
Q

i. Diagnosis & treatment of human response

ii. Actual & potential responses

A

Nursing Diagnosis

2
Q

Interview Considerations

A

i. Obtain good health history
ii. Open approach
iii. Verbal/non-verbal communication
iv. SOLER
v. Active historian-do they remember their health history
vi. Determine is pt priority same as our priority

3
Q

Important Health Information

A

Medications
Allergies
Surgery or other treatments

4
Q

PE: Objective Data

A

General Survey

5
Q

General Survey Statement has what included?

A
Body Features
mental state
speech
body movements
obvious physical signs
nutritional status
behavior
Vitals signs & BMI (may be included)
6
Q

i. Emergency or life-threatening situation

ii. Rapid history/examination of pt while supporting vital functions

A

Emergency assessment

7
Q

i. Includes a detailed health history & PE of all body systems
ii. Done on admission to hospital or onset of care in PC setting

A

Comprehensive assessment

8
Q

i. Abbreviated health history/examination

ii. Assess particular problem

A

Focused assessment

9
Q

i. How patient best learns & how we assess what they need to know at that time
ii. What do they need to know about the topic?

A

Learning assessment

10
Q

Learning assessment includes: (5 things)

A
Readiness to learn
Prior experiences
Motivation to learn
orientation to learning
self concept