Health Promotion and Assessment NURS 212

Unit 1 Getting Started Chapter 1 Health Assessment and the Nurse

Overview of the Nursing Process Assessment Nursing Diagnoses (pg. 6 in text) Planning Implementation Evaluation

The Assessment Definition: systematic, continuous collection of data about the health status of clients. It is a thinking, doing and feeling process which has ethical and legal ramifications. Cognitive Skills (Conscious) Reflexive Thinking (Unconscious) Scientific Method Intuition (Includes Trial & Error)

DIFFERENTIATE BETWEEN: Subjective and Objective data Primary and Secondary data.

Factors that Influence Communication Non-verbal behavior Vocal cues Personal space Touch Cultural differences Language Eye contact Feelings Touch Perceptions about a disease.

Communication Techniques (pg 10) Affirmation/Facilitation Silence Clarifying Restating Active Listening Broad or General Openings Reflection Humor Informing Redirecting Focusing Sharing Identifying Themes Sequencing Events Suggesting Presenting Summarizing

Open to page 13 in text book The Code for Nurses Open to page 13 in text book

Data Collection Techniques Interviews (Techniques on pg. 18) Introductory Phase Working Phase Termination Phase Observation Physical Assessment Inspection Technique Palpation Technique Percussion Technique Auscultation Technique

Differentiate between: Nursing assessment & Medical assessment. The goal of nursing practice is to diagnose and treat human responses to actual or potential health problems. The goal of medical practice is to diagnose and treat disease. Both are client based and should complement each other. First and most important part of the nursing process. It involves data collection, validation and clustering the data.

How to validate your findings Compare finding between subjective and objective data Talking with your client Medical records Verify finding with another health care practitioner.

Organizing Data Maslow’s Hierarchy of Needs

Prioritizing Data Top Priority Secondary Problems Third Level Problems Airway problems, Fire, Cardiac arrest, etc. Life-Threatening Secondary Problems Pain e.g. (requires prompt attention) Third Level Problems Education e.g.

Documentation of your findings PIE Problem Implementation Evaluation SOAPIE Subjective Objective Assessment/clinical judgment Plan Implementation Evaluation DAR Data Action Response

How about a break?