1b Concepts in Health Assessment

subjective & objective data collection via gen surv + HH + physical examination

professional nursing, health care participants, health & illness, health care contexts -> health assessment

refers to homeostasis, concepts of A&P

where are we working? who are we working with?

Assessment
Analysis
Planning Goals & Outcomes
Implementation/Intervention
Evaluation

collect data (e.g. health history, general survey, etc.) in order to continue nursing process for providing care

use subjective & objective data to make a judgement or statement about the patient's condition
-nursing diagnosis (clinical judgement concerning human response to health conditions/life processes, or vulnerability for that response)

SMART goals (specific, measurable, achievable, realistic, time-oriented)
-patient centered goals

determining nursing interventions, resources, writing the plan of care
-individualized plan of care

actions you perform based on clinical judgement & nursing knowledge to enhance patient outcomes
-incl: therapeutic communication, assessment, education, monitoring, supervision, coordination, referral, support, application of technical skills

make judgements about the patient's progress, analyze effectiveness of nursing care, review potential areas for collaboration and referral to other HCP, monitoring quality of nursing care & its effect

Noticing
Interpreting
Responding
Reflecting

-functional: questioning during health history (health perception & management, activity & exercise, nutrition, sleep, etc)
heat-to-toe: efficient conduction of physical exam
body systems: organize findings to document & communicate

performed in a life-threatening or unstable situation, like patient in ED who has experienced traumatic injury
-use ABCDE (airway, breathing, circulation, disability, exposure)
-performing assessment and intervention at the same time

complete health history and physical examination
-outaptient basis (e.g. annual examination), following admission into hospital)
-head to toe assessment (includes all body systems & regions)

based on patient's issues
-usually involves a narrower scope of body systems & regions
-e.g. assessing someone based on their symptoms (like coughing, headache -> assess head and neck)

varies with patient's need, purpose of assessment, and context
-e.g. long term care: once a year
-acute: once a shift
-icu: up to one every 15 mins