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36 Cards in this Set
- Front
- Back
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HEALTH ASSESSMENT |
-SYSTEMATIC, ONGOING APPROACH TO DATA GATHERING, FACT FINDING AND DECISION MAKING ABOUT THE DATA THAT IS GATHERED. -FIRST, CRUCIAL STEP IN THE NURSING PROCESS |
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SOURCES OF INFORMATION/DATA |
-PRIMARY SOURCE -SECONDARY SOURCE -SUBJETIVE DATA -OBJECTIVE DATA |
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PRIMARY SOURCE |
-CLIENT -SOME POPULATIONS MAY NOT BE ABLE TO PARTICIPATE -SOME MAY BE HESITANT TO PARTICIPATE |
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SECONDARY SOURCES |
-OTHER PEOPLE -OTHER SOURCES |
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SUBJECTIVE DATA |
-FROM THE PERSON/CLIENT -WHAT THEY SAY |
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OBJECTIVE DATA |
-OUTCOMES OF ASSESSMENT -NUMERICAL DATA OBTAINED -ASSESSMENT DATA OBTAINED
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COMPONENTS OF HEALTH ASSESSMENT |
-INTERVIEW -COMPLETE HEALTH HISTORY -FOCUSED INTERVIEW -PHYSICAL ASSESSMENT -DOCUMENTATION |
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THE HEALTH HISTORY |
-IN DEPTH RECORD OF PAST AND PRESENT HEALTH STATUS -AN IN DEPTH COMMUNICATION PROCESS |
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THE INTERVIEW INTERVIEW |
-INTRODUCTORY COMMENTS -COMPREHENSIVE HISTORY -ANSWER CONCERNS |
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FOCUSED INTERVIEW |
-ONSET -LOCATION -DURATION -CHARACTERISTICS -AGGRAVATING FACTORS -RELIEVING FACTORS -TREATMENT -IMPACT ON ADL'S -COPING STRATAGIES -EMOTONAL RESPONSE |
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COMPONENTS OF THE HEALTH HISTORY |
-BIOGRAPHIC DATA -PRESENT HEALTH OR ILLNESS -PAST HISTORY -FAMILY HISTORY -PSYCHOLOGICAL HISTORY -REVIEW OF SYSTEMS |
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BIOGRAPHIC DATA |
-NAME AND ADDRESS -DATE OF BIRTH AND AGE -BIRTHPLACE -GENDER -MARITAL STATUS -RACE -RELIGION -OCCUPATION -HEALTH INSURANCE -INFORMATION SOURCE |
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PRESENT HEALTH OR ILLNESS |
-REASON FOR SEEKING CARE:TRY TO DOCUMENT USING THE PERSONS OWN WORDS -HEALTH BELIEFS AND PRACTICES: -CULTURE AND HERITAGE -AVAILABLE OF INFORMATION -HEALTH PATTERNS, BELIEFS, LIFESTYLE -MEDICATIONS: PRESCRIPTION, OVER THE COUNTER, FOLK REMEDIES, ALTERNATIVE THERAPY |
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PAST HISTORY |
-CHILDHOOD HISTORY -IMMUNIZATIONS -ALLERGIES -BLOOD TRANSFUSIONS -MAJOR ILLNESSES -INJURIES -HOSPITALIZATIONS -SURGERIES -PREGNANCIES, DELIVERIES -MENTAL,EMOTIONAL, PSYCHOLOGICAL PROBLEMS -SMOKING, ETOH, SUBSTANCE ABUSE |
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FAMILY HISTORY |
-CHRONIC ILLNESS -NERVOUS -EMOTIONAL -MENTAL ILLNESS -CARDIOVASCULAR -CANCER -PROBLEMS WITH ANESTHESIA |
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PSYCHOLOGICAL HISTORY |
-EDUCATIONAL LEVEL -FINANCIAL BACKGROUND -ROLES/RELATIONSHIPS -SPIRITUALITY -SELF CONCEPT -CULTURE/ETHNICITY |
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REVIEW OF SYMPTOMS |
-SKIN,HAIR, NAILS -HEAD,NECK,ASSOCIATED LYMPH -EYES -EARS, NOSE, MOUTH, THROAT -LUNGS/THORAX -BREASTS/ AXILLAE -CARDIOVASCULAR -PERIPHERAL VASCULAR -ABDOMEN -GENITOURINARY -REPRODUCTIVE -MUSCULOSKELETAL -NEUROLOGIC |
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STEPS OF PHYSICAL ASSESSMENT |
-INSPECTION -PALPATION -PERCUSSION -AUSCULTATION -MAY NOT PERTAIN T ALL BODY SYSTEMS BUT PROVIDES A SYSTEMATIC APPROACH TO EACH ONE IN TERMS OF THE PSYCHOMOTOR ASPECT OF HEALTH ASSESSMENT AS WELL AS A WAY TO INTERPRET AND DOCUMENT FINDINGS |
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INSPECTION |
-GENERAL SURVEY -APPEARANCE -BODY STRUCTURE -MOBILITY -BEHAVIOR -MEASUREMENTS -FUNCTIONAL ASSESSMENT -BODY SYSTEMS -NOTES -USES ALL OF THE SENSES |
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THE GENERAL SURVEY: APPEARANCE |
-AGE -GENDER -LEVEL OF CONSCIOUSNESSS -SKIN COLOR -FACIAL FEATURES |
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THE GENERAL SURVEY: BODY STRUCTURE |
-STATURE -NUTRITION -POSTURE -POSITION -BODY BUILD -CONTROL |
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THE GENERAL SURVEY: MOBILITY |
-GAIT -RANGE OF MOTION |
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THE GENRAL SURVEY: BEHAVIOR |
-EXPRESSION -MOOD/AFFECT -SPEECH -DRESS -HYGIENE |
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THE GENERAL SURVEY: MEASUREMENTS |
-HEIGHT -WEIGHT -BODY MASS INDEX - WT/HT -WAIST: HIP RATIOR -VITALS SIGNS |
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THE GENERAL SURVEY: FUNCTIONAL ASSESSMENT |
-ABILITY TO PERFORM TASKS -ABILITY TO PERFORM ADL'S |
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BODY SYSTEMS |
-GENERAL COLOR -COMPARISON TO NORMS FOR RACE AND ETHNICITY -VASCULARITY AND CIRCULATION ISSUES ARE REVEALED -PULSATIONS -SWELLING -SIZE/SHAPE/CONTOUR -COMPARISON TO EXPECTED RANGES FOR AGE AND DEVELOPEMNTAL LEVEL
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PALPATION |
-TEXTURE -TEMP -MOISTRE -ORGAN LOCATION AND SIZE -SWELLING -VIBRATION -CREPITUS -MASSES |
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LOCATIONS |
-FINGERTIPS: DISCRIMINATION -GRASPING/PALMAT ASPECT: PSITION, LOCATION -DORSA: TEMPERATURE -ULNAR ASPECT/ BASE OF THE FINGERS:VIBRATION |
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TECHNIQUES |
-LIGHT -MODERATE -DEEP -BIMANUAL |
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PERCUSSION |
-LOCATION -SIZE -DENSITY -PAIN -DEEP TENDON REFLEXES |
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TEQUNIQUES FOR PERCUSION |
-DIRECT -BLUNT -INDIRECT |
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ILLICIT |
-AMPLITUDE -PITCH -QUALITY -DURATION |
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PERCUSSION SOUNDS |
-RESONANCE: NORMAL LUNG -HYPERRESONANCE: OVER INFLATED LUNG -TYMPANY: AIR FILLED ORGAN -DULL: DENSITY -FLAT: MUSCLE, BONE, LARGE TUMOR |
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AUSCULTATION |
-LISTENING WITH A STEPHOSCOPE -DIAPHRAGM : USED FOR HIGH PITCHED SOUNDS -BREATH SOUNDS -NORMAL HEART SOUNDS -BOWEL SONDS -BELL: USED FOR LOW PITCHED SOUNDS -EXTRA HEART SOUNDS -VASCULAR SOUNDS -MURMURS |
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DOCUMENTATION |
-ELECTRONIC MEDICAL RECORD -NUMERIC ENTRY -NARRATIVE -CHECK BOX -FLOW SHEETS -NARRATIVE -SBAR: SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION |
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GENERAL DOCUMENTATION GUIDELINES |
-KEEP ALL INFORMATION CONFIDENTIAL -USE CORRECT SPELLING AND USE APPROPRIATE MEDICAL TERMINOLOGY -USE ONLY ACCEPTABLE AND APPROVED ABBREVIATIONS -USE PROFFESSIONAL LANGUAGE AND MEDICAL ARGON -USE PHRASES INSTEAD OF FULL SENTENCES TO RECORD DATA -WRITE OBJECTIVELY, AVOID JUDGEMENTAL COMMENTS -RECORD PATIENT UNDERSTANDING, INTERPRETATION AND PERCEPTIONS IN AS MUCH OF THEIR OWN WORDS AS POSSIBLE -AVOID USING THE WORD NORMAL, BE SPECIFIC IN FINDINGS |
