Health Assessment Exam 1 (ch. 1-4)

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Health Assessment Exam 1 (ch. 1-4) health assessment ans: term in nursing used to include health history and physical exam health history ans: - info from patient and medical records - gathered... data about patient through guided questions/pkt to fill out - provide dates whenever possible - pt telling their story (subjective) - beginning of the nursing POC physical exam ans: - completed by nurse/provider - be systematic **do the same every time** - trend findings - DOCUMENT assessment ans: term used by PROVIDERS to include the medical diagnosis plan ans: term used by PROVIDERS to include how they will tx the dx primary, secondary, and tertiary ans: 3 levels of prevention primary ans: prior to onset of problems secondary ans: screening tertiary ans: rehab assessment, diagnosis, planning, implementation, and evaluation ans: steps of the nursing process (patient is the focus!!) assessment ans: - subjective data (symptoms) - objective data = measurable (signs) - clump data to SUPPORT DX diagnosis ans: - what is the problem or potential problem? - subjective and objective data MUST support nursing dx planning ans: - what is the goal of care? - what interventions are needed to get to the goal? - how long should this take? implementation ans: - now do what you planned (update changes) evaluation ans: - was the goal achieved? onset, location, duration, characteristics of symptoms, associated characteristics, relieving factors, treatment, severity/scale ans: OLD CARTS - for questioning onset, provoking factors, quality, region/radiation, severity, time/treatment, understanding/impact ans: OPQRSTU - for questioning feelings, ideas, function, expectations ans: FIFE - explore pt's perspective mutual agreement, pt empowerment, and achievable POC ans: Why FIFE/explore pt's perspective? feelings ans: FIFE - fears or concerns about problem ideas ans: FIFE - about nature and cause of problem function ans: FIFE - effect on pt's life expectations ans: FIFE - of disease, health care team, or health care based on prior experiences therapeutic communication ans: the act of developing pt rapport nonverbal, active listening, accepting, exploring, reflecting, restating, and guiding ans: characteristics of therapeutic communication active listening ans: listening more than talking accepting ans: never using "why?" exploring ans: "tell me more..."; "go on.." reflecting ans: validation within therapeutic communication restating ans: making sure you heard the pt correctly and emphasize important points guiding ans: using open vs. closed ended questions the silent patient ans: - active listening - nonverbal cues - do not try to fill silence with words the confusing patient ans: - multiple symptoms, positive review of symptoms, provider should focus on context of symptoms, emphasize patient's perspective, and guide the interview into a psychosocial assessment - assess mental status - **know the law** - check responses against chart or seek permission to speak with family members [Show More]

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