Chapters 1, 2, 3 Health Assessment Chapter 1 Basic Nursing

Front 1

3 Types of prevention

Back 1

Primary, Secondary, Tertiary

Front 2

Primary Prevention

Back 2

True prevention. It precedes disease and dysfunction and applies to patients considered physically and emotionally healthy.

Front 3

Secondary Prevention

Back 3

Directs activities at diagnosis and prompts interventions [pap smears, mammogram, colonoscopy]

Front 4

Tertiary Prevention

Back 4

involves preventing further disability or reduced functioning [example: wellness plan for diabetic- to minimize risks for further problems]

Front 5

What is a risk factor?

Back 5

A risk factor is any situation, habit, environmental condition, physiological condition, or other variable that increases the vulnerability of an individual or group to an illness or accident.

Front 6

Modifiable risk factors

Back 6

stress, smoking/drugs, pregnancy, weight, environment, financial status, access to healthcare, job lifestyle

Front 7

Non-modifiable risk factors

Back 7

genetics, age, gender

Front 8

Internal/External Variables

Back 8

affect illness behavior such as the likelihood of seeking health care and the participation in therapy, which ultimately affect health outcomes.

Front 9

Internal Variables

Back 9

influence the way patients behave when they are ill. If patients believe their symptoms disrupt their normal routine they are more likely to seek health care assistance. Acute illness is more likely for a patient to seek treatment, than a chronic illness where they may not adhere to the therapy plans.

Front 10

External Variables

Back 10

A patient with visible symptoms is more likely to seek assistance than a patient who does not have visible symptoms.

Front 11

Types of Assessments

Back 11

Comprehensive, Focused, Follow-up

Front 12

Comprehensive Assessment

Back 12

involves a detailed history and physical examination performed at the onset of care in a primary care setting or on admission to a hospital or long-term care facility The comprehensive assessment encompasses health problems experienced by the patient; health promotion, disease prevention, and assessment for problems associated with known risk factors; or assessment for age and gender-specific health problems.

Front 13

Focused Assessment [Problem Based]

Back 13

The problem-based or problem-focused assessment involves a history and examination that are limited to a specific problem or complaint. This type of assessment is more commonly used in a walk-in clinic or emergency department. Although the focus of data collection is on a specific problem, the potential impact of the patient's underlying health status also must be considered.

Front 14

Follow-up Assessment [Episodic]

Back 14

usually done when a patient is following up with a health care provider for a previously identified problem.

Front 15

What helps enhance data collection? [8]

Back 15

Active Listening, Facilitation, Clarification, Restatement, Reflection, Confrontation, Interpretation, and Summary.

Front 16

Active Listening

Back 16

listening with a purpose to spoken words as well as noticing nonverbal behaviors.

Front 17

Facilitation

Back 17

uses phrases to encourage patients to continue talking (“go on”, “uh huh”, “then?” head nodding, shifting forward in your seat)

Front 18

Clarification

Back 18

used to obtain more information about conflicting, vague, or ambiguous statements

Front 19

Restatement

Back 19

repeating what patients say to confirm the interpretation of what was said.

Front 20

Reflection

Back 20

asks patient a question to clarify a phrase or sentence.

Front 21

Confrontation

Back 21

when consistencies are noted between what the patient reports and observations or other data about the patient.

Front 22

Interpretation

Back 22

to share with patients the conclusions drawn from data they have given.

Front 23

Summary

Back 23

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

Front 24

What diminishes data collection? [5]

Back 24

Using Medical Terminology, Expressing Value Judgments, Interrupting the Patient, Being Authoritarian or Paternalistic, and Using "Why" Questions.

Front 25

Using Medical Terminology

Back 25

interferes with the communication process if the patient does not know the meaning of the medical terms.

Front 26

Expressing Value Judgments

Back 26

might cause the patient to feel guilty or defensive when he or she must answer the contrary

Front 27

Interrupting the Patient

Back 27

allow patients to finish their sentences, don't finish it for them. The ending you add may be different from which the patient might used.

Front 28

Being Authoritarian or Paternalistic

Back 28

nurses who use the approach “I know what's best for you, and you should do what I say” risk alienating the patient.

Front 29

Using "Why" questions

Back 29

can be perceived as threatening and may put patients on the defensive. The implication is that they must defend their choices.

Front 30

Phases of the Interview

Back 30

Introduction, Discussion, Summary

Front 31

Introduction Phase

Back 31

Introduces self to patient.
Describes purpose of interview.
Describes interview process.

Front 32

Discussion Phase

Back 32

Facilitates and maintains patient-centered discussion.
Uses various communication techniques to collect data.

Front 33

Summary Phase

Back 33

Summarizes data with patient.
Allows patient to clarify data.
Validates to patient that he or she understands problems.

Front 34

Techniques used during Health Assessment

Back 34

Inspection, Palpation, Percussion, and Auscultation

Front 35

Inspection

Back 35

refers to visual examination of the body, including body movement and posture.

Front 36

Palpation

Back 36

using hands to feel texture, size, shape, consistency, pulsations, and location of certain parts of the patient's body and also to identify areas the patient reports as being tender or painful. Uses palmar surface of fingers, not fingertips.

Front 37

Percussion

Back 37

performed to evaluate the size, borders, and consistency of internal organs; detect tenderness and determine the extent of fluid in a body cavity.

Front 38

Two types of Percussion

Back 38

Direct and Indirect

Front 39

Direct Percussion

Back 39

striking a finger or hand directly against the patient's body.

Front 40

Indirect Percussion

Back 40

performed by placing the distal aspect of the middle finder of the nondominant hand against the skin over the organ being percussed and striking the distal interphalangeal joint with the tip of the middle finger of the dominant hand.

Front 41

Auscultation

Back 41

listening to sounds within the body.

Front 42

Clinical Judgment

Back 42

“an interpretation or conclusion about a patient's needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response. Although clinical judgment requires accurate collection of assessment data, it is the nurse's interpretation of the data that impacts the decisions made. Clinical judgment is influenced more by the nurse's experiences, knowledge attitudes, and perspectives than the data alone.

Front 43

Four components of Clinical Judgment

Back 43

The process of clinical judgment includes four components: noticing, interpreting, responding and reflecting.

Front 44

Components of the Health History

Back 44

Biographic data
Reason for seeking care
History of present illness
Past health status
Past health history
Family history
Personal and psychosocial history
Review of systems

Front 45

Health Belief Model description

Back 45

Addresses the relationship between a person's beliefs and behaviors. It provides a way of understanding and predicting how patients will behave in relation to their health and how successful they will be in following health care therapies and regimens.

Front 46

Health Belief Model Diagram

Back 46

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Front 47

Health Promotion Model description

Back 47

defines health as a positive, dynamic state, not merely the absence of disease.
Focuses on three areas
1. Individual characteristics and experiences
2. Behavior-specific cognitions and affect
Behavioral outcomes

Front 48

Health Promotion Model diagram

Back 48

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Front 49

Primary Prevention examples
(Health Promotion & Specific Protection)

Back 49

Health education, Immunizations, Genetic screening, personal hygiene, environmental sanitation, protection from accidents, carcinogens, occupational hazards, avoidance of allergies

Front 50

Secondary Prevention examples
(Diagnosis and Prompt Treatment & Disability Limitations)

Back 50

cure and prevention of disease process to prevent spread of communicable disease, prevent complications, and shorten period of disability,

Front 51

Tertiary Prevention examples
(Restoration and Rehabilitation)

Back 51

Provision of hospital and community facilities for training and education to maximize use of remaining capacities.

Front 52

Maslow's Hierarchy of Needs

Back 52

humans needs using a pyramid divided into five levels. As people meet the needs of one level, they move to the next level. Unsatisfied needs motivate human behavior.

Front 53

Maslow's Hierarchy of Needs diagram

Back 53

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