Health Assessment Exam 1

Front 1

Evidence

Back 1

Supporting data that supports a diagnosis

Front 2

Subjective Data

Back 2

What the person says about the themselves

Front 3

Objective Data

Back 3

What the health professional observes by inspecting. percussing, palpating and auscultating during the physical examination.

Front 4

Database

Back 4

All the subjective and objective data compiled

Front 5

Diagnostic Reasoning

Back 5

the process of analyzing health data and drawing conclusions to identify diagnoses.

Front 6

Nursing Process

Back 6

1. Assessment

2. Diagnosis

3. Outcome Identification

4. Planning

5. Implementation

6. Evaluation

Front 7

Critical Thinking Skills

Back 7

1. Identifying assumptions

2. Identifying an organized and comprehensive approach

3. Validation

4. Distinguishing normal from abnormal

5. Making Inferences

6. Clustering Related Cues

7. Distinguishing Relevant from Irrelevant

8. Recognizing Inconsistencies

9. Identifying Patterns

10. Identifying Missing Information

11. Promoting Health

12. Diagnosing Actual and potential (risk) problems

13. Setting Priorties

14. Identifying Patient-Cetnered Expected Outcomes

15. Determining Specific Interventions

16. Evaluating and Correcting Thinking

17. Determining a Comprehensive Plan

Front 8

Identifying Assumptions

Back 8

Recognizing taking information for granted and the seeing as fact even when there is no evidence to support it.

Front 9

Identifying an Organized and Comprehensive Approach

Back 9

Depends on the priorities for the particular patient and personal and institutional preferences.

Front 10

Validation

Back 10

Checking accuracy and reliability of data

Front 11

Distinguishing Normal from Abnormal

Back 11

Identifying signs and symptoms and how it correlates to the normal of person.

Front 12

Making Inferences

Back 12

Hypotheses by interpreting data

Front 13

Clustering Related Cues

Back 13

Helps see relationships among the data

Front 14

Distinguishing relevant from irrelevant

Back 14

A complete history and physical examination furnish a vast amount of data.

Front 15

Recognizing Inconsistencies

Back 15

When seeing conflicting information, must investigate and further clarify situation.

Front 16

Identifying Patterns

Back 16

Helps fill the whole picture and discover missing pieces of information.

Front 17

Identifying Missing Information

Back 17

Gaps in data or need for more data to make a diagnosis.

Front 18

Promoting Health

Back 18

Identify risk factors to provide client with information to promote healthy living

Front 19

Diagnosing Actual and Potential (risk) problems

Back 19

Assessing data and determining diagnoses from information

Front 20

Nursing Diagnosis

Back 20

Clinical judgements about a person's response to an actual and potential health state.

Front 21

Steps of Nursing Diagnosis

Back 21

1. Actual Diagnoses

2. Risk Diagnoses

3. Wellness Diagnoses

Front 22

Setting Priorties

Back 22

Order to work on when there is more than one diagnosis.

Front 23

First-Level Priority Problems

Back 23

Diagnosis that are emergent, life-threatenng and immediate

Front 24

Second-Level Priority Problems

Back 24

Diagnosis that are next in urgency

Front 25

Setting Priorities

Back 25

A-Airway Problems

B- Breathing Problems

C- Cardiac/Circulation Problems

V- Vital Signs Concerns (e.g. High Fever)

Front 26

Third-Level Priority Problem

Back 26

Diagnosis that are important to patients health but are addressed after more urgent heath problems

Front 27

Collaborative Problems

Back 27

Problems that are approached in treatment involving multiple disciplines.

Front 28

Identifying Patient-Centered Expected Outcomes

Back 28

What specific, measurable results you would like to see with a specific date and time

Front 29

Determining Specific Interventions

Back 29

Interventions that are used to achieve specific outcomes

Front 30

Evaluating and Correcting Thinking

Back 30

Looking at expected outcomes, and apply them for evaluation.

Front 31

Determining a Comprehensive Plan

Back 31

Also evaluating and updating the plan and recording the revised plan of care and keep it up-to-date.

Front 32

Complete (Total Health) Database

Back 32

Database that includes the clients complete health history and full physical examination.

Front 33

Focused or Problem-Centered Database

Back 33

Limited or Short-Term problem focused data

Front 34

Follow-Up Database

Back 34

Status of any identified problems that are evaluated on regular and appropriate basis.

Front 35

Emergency Database

Back 35

Rapid Collection of the data usually complied quickly while doing life-saving measures.

Front 36

Holistic Health

Back 36

Consideration of whole person, vies mind, body and sprit as interdependent and functioning as a whole within the environment.

Front 37

Health Promotion and Disease Prevention

Back 37

Guidelines to prevention emphasize the link between health and personal behavior

Front 38

Examination Steps

Back 38

1. Screening History

2. Physical Examination

3. Counseling

4. Depression

5. Healthy Diet

6. Chemoprophylaxis

7. Type 2 Diabetes Mellitus

Front 39

Open-Ended Questions

Back 39

Questions that ask for narrative information in general terms

Front 40

Closed or Directive Questions

Back 40

Asking for specific information and are typically short answer such as Yes and No.

Front 41

Ten Traps of Interviewing

Back 41

1. Providing False Assurance or Reassurance

2. Giving Unwanted Advice

3. Using Authority

4. Using Avoidance Language

5. Engaging in Distancing

6. Using Professional Jargon

7. Using Leading or Biased Questions

8. Talking Too Much

9. Interrupting

10. Using "Why" Questions

Front 42

NonVerbal Skills

Back 42

Physical Appearance

Posture

Gestures

Facial Expression

Eye Contact

Voice

Touch

Front 43

Graphic Speech

Back 43

Usually a combination of a noun and a verb and includes only words that have concrete meanings.

"All gone" "Me Up" "Baby crying"

Front 44

Telegraphic

Back 44

Sentence with 3 to 4 words that contain just the essential words.

Front 45

Decenter

Back 45

Not having everything about one's self and consider all sides of the situation to form a conclusion

Front 46

Symptom

Back 46

Subjective sensation that a person feels from the disorder

Front 47

Sign

Back 47

Objective abnormality that the nurse detects, sees in examination or in laboratory reports.

Front 48

Present Health or History of Present Illness

Back 48

1. Location

2. Character or Quality

3. Quantity or Severity

4. Timing

5. Setting

6. Aggravating or Relieving Factors

7. Associated Factors

8. Patient's Perception

Front 49

Acronym of Present Health

Back 49

P: Provocative or Palliative

Q: Quality or Quantity

R: Region or Radiation

S: Severity Scale

T: Timing

U: Understand Patient's Perception

Front 50

HEEADSSS Method

Back 50

H: Home Environment

E: Education and Employment

E: Eating, Peer-Related

A: Activities

D: Drugs

S: Sexuality

S: Suicide/Depression

S: Safety from injury and violence

Front 51

Inspection

Back 51

Concentrates on Watching

Front 52

Palpation

Back 52

Confirm points and applies the sense of touch to assess factors: texture, temperature, moisture, organ location and size, also swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses and presence of tenderness or pain

Front 53

Percussion

Back 53

Tapping the person's skin with short, sharp strokes to assess underlying structures.

Front 54

Production of Sound

Back 54

1. Amplitude: Intensity

2. Pitch: Frequency

3. Quality: Timbre

4. Duration: Length

Front 55

Auscultation

Back 55

Listening to sounds produced by the body

Front 56

Diaghram

Back 56

is flat edge of stethoscope and is best for high-pitched sounds; breaths bowel and normal heart sounds

Front 57

Bell

Back 57

is end piece of stethoscope and is best for soft, low-pitched sounds such as extra heart sounds or murmurs.

Front 58

Nosocomial Infection

Back 58

Infection that is acquired during hospitalization