Chapter 1 & 2: Importance of Health Assessment and the Interview

Question 1

What is the purpose of a Health Assessment ?

Answer 1

it’s a systematic method of collecting and analyzing data for the purpose of planning patient-centered care

Question 2

What are the ANA’s Standards of Practice aka The Nursing Process ?

Answer 2

1. Assessment
2. Analysis/Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
   a) coordination of care
   b) Health Teaching and Health Promotion
6. Evaluation

Question 3

Nursing Process:
Assessment

Answer 3

collecting data and information relative to the patient’s health or the situation
- can be through percussing, palpating, oscillation, etc
- info we gather from our patients

Question 4

Nursing Process:
Analyze/Diagnosis

Answer 4

analyze the assessment data to determine actual or potential diagnoses, problems, or issues
- more analyze since Nurses don’t diagnosis (physicians do)

Question 5

Nursing Process:
Outcome Identification

Answer 5

identifying expected outcomes for a plan we make for our patient or the situation
- What is the goal now ?

Question 6

Nursing Process:
Planning

Answer 6

developing a plan that prescribes strategies to attain expected, measurable outcomes
- How will we obtain our goal and what will we do ?

Question 7

Nursing Process:
Implementation

Answer 7

coordination of the care and putting it into action
- carrying out the plan and putting it into action

Question 8

Nursing Process:
Evaluation

Answer 8

evaluate progress toward attainment of goals and outcome
- reaccess and see if the goals/outcomes were met

Question 9

What are the components of a Health Assessment ?

Answer 9

1. Conducting a Health History
2. Physical Examination
3. Documenting the Findings/Data

Question 10

Health History

Answer 10

subjective data collected during an interview
- biographic data
- family history
- current medications
- preview illnesses and surgeries
- personal and psychosocial history
- review of systems

Question 11

Primary Source Data

Answer 11

subjective data directly from the patient

Question 12

Secondary Source Data

Answer 12

subjective data from another individual

Question 13

Objective Data

Answer 13

data we collect and/or observe as a Nurse
- signs like rashes, enlarged lymph nodes, swelling of an extremity
- felt
- heard
- measured
- observed

Question 14

Subjective Data

Answer 14

symptoms perceived and/or reported by the patient
- pain, itching, nausea,

Question 15

Physical Examination

Answer 15

gathering of objective data - can be through palpation, inspective, percussion
- Ex) pulse rate, blood pressure, temperature, etc.

Question 16

What is the purpose of the EHR (electronic health record) ?

Answer 16

to integrate documentation of care across participating health systems for any single patient

Question 17

What are the levels of Health Promotion ?

Answer 17

1. Primary Prevention
2. Secondary Prevention
3. Tertiary Prevention

Question 18

Primary Prevention

Answer 18

steps that everyone takes to prevent the development of a disease through the promotion of a healthy lifestyle
- immunization
- healthy diet
- exercise
- drinking water
- wear sunscreen and avoid the sun

Question 19

Secondary Prevention

Answer 19

Screening efforts that at-risk people take to promote the early detection of disease
- mammograms
- pap smears
- prostate exams
- blood pressure screenings
- concussion screenings

Question 20

Tertiary Prevention

Answer 20

Steps that people take to minimize the severity of a disease that they already are diagnosed with
- insulin management
- hypertension management
- diet for diabetes management
- cardiac rehabilitation

Question 21

What is the difference between Health Promotion and Health Protection ?

Answer 21

• Health Promotion is behavior motivated by the desire to increase you’re well-being and actualize human health potential
• Health Protection is behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within it’s constraints

Question 22

What is a Comprehensive Assessment ?

Answer 22

detailed history and physical exam at the onset of care in a primary care setting
- includes a full examination of the body systems
- like admission to a hospital or long-term care facility
- encompasses things like health problems the patient has, health promotion, disease prevention, etc

Question 23

What is a Problem Based/Focused Assessment ?

Answer 23

limited to a specific problem or complaint
- like for a sprained ankle
- commonly used in walk-in clinics or the ER

Question 24

What is an Episodic/Follow-Up Assessment ?

Answer 24

when a patient is following up with a healthcare provider for a previously identified problem
- like a pneumonia follow-up or regular visits for diabetes

Question 25

Shift Assessment

Answer 25

head-to-toe assessment at routine times during a shift or based on changes
- purpose is to identify changes to the patient’s condition

Question 26

Screening Assessment/Examination

Answer 26

short, focused on a specific potential problem
- can be performed in a healthcare provider’s office or a health fair
- blood pressure screenings
- glucose screenings
- cholesterol screenings

Question 27

What is the purpose of a Health History?

Answer 27

obtain important info from the patient so a plan to promote health, prevent disease, resolve acute health problems can be developed

Question 28

Chief Complaint/Presenting Problem

Answer 28

the main reason you go to seek care
- you record this in quotes

Question 29

Review of Systems

Answer 29

subjective data collected directly from the patient regarding his/her perception of the body systems

Question 30

What are the Components of the Past Health History ?

Answer 30

1. childhood illnesses
2. surgeries
3. hospitalizations
4. accidents or injuries
5. immunizations
6. last examinations
7. obstetric history

Question 31

What are the components of the Present Health Status ?

Answer 31

1. current health conditions
2. medications
3. allergies

Question 32

Why is the Family History important ?

Answer 32

it can affect the patient’s current or future health
- a genogram is an easy way to diagram any illnesses or dieases

Question 33

What are the Phases of the Interview ?

Answer 33

1. Intro- introduce yourself, describe the purpose of the interview, describe interview process
2. Discussion- facilitate and maintain patient-centered discussion
3. Summary- summarize the data with the client, allow patient to clarify the data, plan for the next steps and end interview

Question 34

Active Listening

Answer 34

listening with a purpose
- concentrate on what the patient is saying and don’t try to anticipate what they may say
- noticing verbal and nonverbal cues and focus on the patient’s response

Question 35

Facilitation

Answer 35

using phrases to encourage patient to continue
- “go-on” and “ok”
- nodding, shifting forward in seat

Question 36

Clarification

Answer 36

obtaining more information about conflicting, vague, or ambiguous statements
- “what do you mean by that”

Question 37

Restatement

Answer 37

a way to gain clarification by restating a phrase
- encourages elaboration and confirms interpretation

Question 38

Reflection

Answer 38

responding to the content and emotional components of a message by stating the patient’s feelings
- Ex.) “that must have been frustrating to go through”
- empathizing

Question 39

Confrontation

Answer 39

used when inconsistencies are noted between reports and observation
- careful with your tone of voice because it’s easy for this to go negative

Question 40

Interpretation

Answer 40

opportunity to share conclusions drawn from given data
- allows patients to confirm, deny, or revise information

Question 41

Summary

Answer 41

condenses and orders data obtained during the interview to help clarify a sequence of events

Question 42

Context of Care

Answer 42

the circumstances or situations related to the health care delivery
- environment, setting
- physical, psychological, or socioeconomic circumstances surrounding patients