Upload
stephanie-aragon-bacani
View
215
Download
0
Embed Size (px)
Citation preview
8/15/2019 1. conceptual overview.pptx
1/28
8/15/2019 1. conceptual overview.pptx
2/28
HEALTH
• State of complete physical,mental and social well-
being. (WHO,!"#$
8/15/2019 1. conceptual overview.pptx
3/28
HEALTH ASSESSMENT /
NURSING ASSESSMENT
8/15/2019 1. conceptual overview.pptx
4/28
ASSESS%E&T
• Systematic and contin'o'scollection, alidation, and
comm'nication of patientdata, whe)e data )e*ects howhealth f'nctioning is
enhanced by healthp)omotion o) comp)omised byillness
8/15/2019 1. conceptual overview.pptx
5/28
ASSESS%E&T
• Systematic and contin'o'scollection, alidation, and
comm'nication of patientdata, whe)e data )e*ects howhealth f'nctioning is
enhanced by healthp)omotion o) comp)omised byillness
8/15/2019 1. conceptual overview.pptx
6/28
ASSESS%E&T
• Systematic collection of dataabo't a client fo) the p')pose of
dete)mining the+. clients c'))ent and ongoinghealth stat's
. )edicting )is/ to health0. 1dentifying health-p)omoting
actiities.
8/15/2019 1. conceptual overview.pptx
7/28
ASSESS%E&T
• Attaining s'b2ectie andob2ectie data f)om p)ima)y
and seconda)y so')ces, toidentify and g)o'p signi3cantdata, and to comm'nicate
this info)mation to othe)membe)s of the health team
8/15/2019 1. conceptual overview.pptx
8/28
ASSESS%E&T
Primary Sources Or Direct Source. The client
.
Secondary sources. 4amily membe)s,
. ca)egie)s,
0. othe) membe)s of the health team
". %edical )eco)ds
8/15/2019 1. conceptual overview.pptx
9/28
ASSESS%E&T
• The data incl'des+
. physical ,
. social,0. c'lt')al,
". eni)onmental and
5. emotional facto)s•. That impact the oe)all well-beingof the client
8/15/2019 1. conceptual overview.pptx
10/28
ASSESS%E&T
• Efective communicationtechniques and the use ocritical thinking skills a)eessential in helping the n')se togathe) detailed , complete,)eleant, ob2ectie, s'b2ectie and
meas')able data needed tofo)m'late a plan of ca)e to meetthe need of the client.
8/15/2019 1. conceptual overview.pptx
11/28
ASSESS%E&T
• 6ende)s info)mationnecessa)y fo) clinical-
decision ma/ing
8/15/2019 1. conceptual overview.pptx
12/28
ASSESS%E&T
• Health assessment incl'des7
. The inte)iew
. hysical assessment0. 8oc'mentation
". And inte)p)etation of3ndings
8/15/2019 1. conceptual overview.pptx
13/28
ASSESS%E&T
• Health assessment incl'des7
. The inte)iew
•.S'b2ectie data is gathe)edwhich incl'des
A. health histo)y and9. foc'sed inte)iew
8/15/2019 1. conceptual overview.pptx
14/28
ASSESS%E&T
• Health assessment incl'des7
. hysical assessment
• Hands on e:amination of theclient
• ;omponents+
a. S')ey
b. e:amination of system
8/15/2019 1. conceptual overview.pptx
15/28
ASSESS%E&T
• Health assessment incl'des70. 8oc'mentation
8oc'mentation of data f)omthe health assessment c)eatesa client )eco)d o) becomes an
additional to e:isting )eco)ds
8/15/2019 1. conceptual overview.pptx
16/28
ASSESS%E&T
• Health assessment incl'des70. 8oc'mentation
8oc'mentation of data f)omthe health assessment c)eatesa client )eco)d o) becomes an
additional to e:isting )eco)ds
8/15/2019 1. conceptual overview.pptx
17/28
ASSESS%E&T
• Health assessment incl'des70. 8oc'mentation
8/15/2019 1. conceptual overview.pptx
18/28
ASSESS%E&T
All planning fo) ca)e isdi)ected by the
inte)p)etation of 3ndingsf)om the ob2ectie ands'b2ectie data gathe)ed.
8/15/2019 1. conceptual overview.pptx
19/28
ASSESS%E&T
S'b2ectie data
• 1nfo)mation that the client
e:pe)iences andcomm'nicates to the n')se7
E:amples+ pe)ception of pain.&a'sea, di==iness itchingsensations o) feeling ne)o's
8/15/2019 1. conceptual overview.pptx
20/28
ASSESS%E&T
S'b2ectie data• ;oe)t data(hidden$
• Symptoms –e)ceied by the client b't
can not be seen by othe)s
8/15/2019 1. conceptual overview.pptx
21/28
ASSESS%E&T
S'b2ectie data4amily membe)s o) ca)egie)s can)epo)t s'b2ectie data based on the
pe)ception of client sha)ed withthem
• 1f+ the client is e)y ill o) 'n able tocomm'nicate
• 6e>'i)ed if+ the client is infant o)child.
8/15/2019 1. conceptual overview.pptx
22/28
ASSESS%E&T
Ob2ectie 8ata• Obse)ed and meas')ed bythe p)ofessional n')se
• Oe)t 8ata o) Sign –8etected by the n')se
• ;an be seen, hea)d, felt andmeas')ed
8/15/2019 1. conceptual overview.pptx
23/28
ASSESS%E&T
Ob2ectie 8ata• &eeded to alidate
s'b2ectie data and tocomplete the data base
8/15/2019 1. conceptual overview.pptx
24/28
ASSESS%E&T
• Health assessment incl'des7". 1nte)p)etation of 3ndings
• %a/ing dete)mination abo'tall of the data collected datain the health assessment
p)ocess.
8/15/2019 1. conceptual overview.pptx
25/28
ASSESS%E&T
• Health assessment incl'des7". 1nte)p)etation of 3ndings
•
8ete)mine if the 3ndings fallwithin the no)mal ande:pected )anges in )elation
to the clients age, gende),and )ace
8/15/2019 1. conceptual overview.pptx
26/28
ASSESS%E&T
• Health assessment incl'des7". 1nte)p)etation of 3ndings
•
8ete)mine the signi3canceof the 3ndings in )elation tothe clients health stat's
and immediate and long)ange health )elated needs.
8/15/2019 1. conceptual overview.pptx
27/28
8atabase
• 1ncl'des all the pe)tinent patientinfo)mation collected by the n')seand othe) health ca)e
p)ofessionals• Enables a comp)ehensie and
e?ectie plan of ca)e to be
designed and implemented fo)the client
8/15/2019 1. conceptual overview.pptx
28/28
Assessment s. Eal'ation
Evaluation • 8ete)mines e?ectieness of
t)eatment o) ca)e
• t)eatment o) ca)e is )eiewed,the client@s )esponse tointe)ention identi3ed, and a
conside)ation as to whethe) theclient has achieed thep)edete)mined o'tcomes and
goals