Health Assessment Ch. 1- General Background Info Flashcards
Health Assessment
observing the clients and situations, collecting and grouping data to make sound nursing judgements.
4 steps to the Health Assessment
a. collect subjective data
b. collect objective data
c. validating and grouping the data
d. documenting the data
Factors that affect how a nurse performs a health assessment
a. developmental considerations
b. physical health
c. emotional status
d. culture
e. religion
f. socioeconomic status
g. ADLs
h. client’s perception
i. environment
ADL
activities of daily living
5 steps of the nursing process
a. assessment
b. diagnosis
c. planning
d. implementation
e. evaluation
5 types of assessment
a. comprehensive
b. focused
c. follow-up
d. system-specific
e. ongoing
Preparations for an Assessment/Interview/Health History
a. read the patient’s chart BEFORE entering the room
b. pick a time when the patient is free of distractions and most comfortable
c. arrange the right environment
d. gather ALL supplies and equipments
e. position yourself at eye level with the patient
f. interview distance is typically 2-3 feet
g. don’t be rushed
h. education yourself on anything that you are unfamiliar with BEFORE entering the room
Subject Data
what the patient tells the nurse
Objective Data
what the nurse observes about the patient
Two sources of Data
Primary Data: client
Secondary Data: support people, records, other healthcare personnel
