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19 Cards in this Set
- Front
- Back
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components of health assessment
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health history (subjective) = interview
physical exam = objective |
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clinical manifestations
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signs and symptoms
symptoms = subjective signs = objective |
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purpose of an assessment
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make a judgment or diagnosis
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diagnostic reasoning
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attending - to initial cues
formulating - hypothesis gathering - date to test hypothesis evaluating - based on date collected |
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nursing process
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assessment
diagnosis outcome identification planning implementation evaluation |
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outcome should be...
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time frame
measurable individualized realistic |
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nursing diagnosis
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holistic - concern regarding impact of the health problem on the whole person + individual response to problem
different than medical |
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types of health assessments
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comprehensive (complete) - annual exam
problem based - earache, sore throat episodic/follow-up - post-op, diabetic exam emergency - chest pain, MVA |
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3 types of health promotion
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primary - protection, vaccine
secondary (screening) - leads to early diagnosis; pap smear tertiary - treatment after disease starts, meds for cholesterol |
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health definition
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state of balance between physical, mental, social well-bring
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cultural competence
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ability to interact effectively with people of different cultures
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heritage
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genetics and other characteristics transmitted to offspring
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heritage consistency
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degree to which lifestyle reflects traditional heritage
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culture
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shared artifacts, attitudes, beliefs, customs, entertainment, ideas, language, laws, learning, moral conduct
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characteristics of culture
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learned
shared adapted dynamic - changes! |
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ethnicity
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shared traits such as religion, culture, language, appearance
social group within a society |
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socialization
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adapting individual to the social customs of society
being raised within a group and acquiring the characteristics of that group |
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purpose of an interview
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to get subjective sata
decide on hunch |
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interview techniques
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facilitation - go non
reflection - repeat back clarification - make more clear empathy - name emotion confrontation - confused? interpretation - cause and effect |
