Reviewer for P1

Definition of Health reasoning to formulate diagnoses based

on the assessment data and the
• Health is a relative state in which a person is
patient’s problem list.
able to live to his or her potential and includes
• Planning is devising the best course of
the “7 facets”:
action to address the patient’s
• Physical health – how the body works and diagnoses. During planning, the nurse
adapts and patient select goals for each
diagnosis in order to alleviate, decrease,
• Emotional health – positive outlook and or prevent the problems addressed in
emotions channeled in a healthy manner
the nursing diagnosis.
• Social well-being – supportive relationships • Implementation of the interventions
with family and friends can be completed by the patient, the
family, or members of the health care
• Cultural influences – favorable connections to team. The interventions should clearly
promote health relate to the nursing diagnosis and the
• Spiritual influences – living peacefully, planned goals.
morally, and ethically • Evaluation is a continuing process to
determine if the goals have been
• Environmental influences – favorable attained. The nursing care plan is
conditions to promote health revised based on the patient’s condition
• Developmental level – how one thinks, solves and whether the goals are realistic or
problems, and makes decisions appropriate for the patient.

• Health is a sum of these facets and is not • Types of Health Assessment

solely defined as the absence of disease or
eating right, but rather by the contribution of all • a. A focused or problem-oriented
dimensions. assessment is where the nurse focuses
• The nursing process is the ability of the on gathering information about the
nurse to extrapolate the findings, patient’s problem.
prioritize them, and finally formulate
and implement the plan of care is the • A follow-up history is a form of a
overall goal. focused assessment.
• Assessment – it is the first step of the
nursing process. It is the subjective and • An emergency history is the data
objective data gathered during the collection which focused on the
initial health history and physical patient’s emergent problem with a
examination and collected on each systematic prioritization of need
patient encounter. beginning with the ABCs of airway,
• Diagnosis has a nursing focus and is breathing, and circulation.
based on real or potential health
problems or human responses to health
problems. The nurse uses clinical
• Health History Format • INSPECTION

• PALPATION
•  past  present  family history
• PERCUSSION
• Types of data
• AUSCULTATION
• Subjective data are information from
the client's point of view (“symptoms”), VITAL SIGNS INCLUDES THE FF:
including feelings, perceptions, and • BLOOD PRESSURE
concerns obtained through interviews. • TEMPERATURE
• PULSE
• Objective data are observable and • RESPIRATIONS
measurable data (“signs”) obtained
WHEN ASSESSING THE HEART
through observation, physical
examination, and laboratory and FOR RATE AND RHYTHM, YOU NEED TO LISTEN IS
diagnostic testing. FOR 1 FULL MINUTE

NEUROLOGIC ASSESSMENT TOOLS INCLUDES

• SEVEN ATTRIBUTES OF A SYMPTOM
GLASGOW COMA SCALE OR GCS IT MONITORS
NEUROLOGIC FUNCTIONS
• “OLD CART”
CULTURE
• O-NSET
• ETHNICITY-an ethnic group composed of
individual who self-identify
• L-OCATION
membership with or belong to a group
with shared values, ancestry and
• D-URATION
experiences
• RACE– socially constructed concept of
• C-HARACTERISTICS SYMPTOMS
dividing people into populations or
groups on the basis of various sets
• A-SSOCIATED MANIFESTATIONS
physical characteristics

• R-ELIEVING/ EXCERBATING FACTORS SELF AWARENESS

Values are the standards we use to measure

• T-REATMENT our own and others’ beliefs and behaviors.

• MRSA STANDS FOR Methicillin-resistant Biases are the attitudes or feelings that we
Staphylococcus aureus attach to perceived differences.

• Protective barriers include: gloves, Affect -A patient's affect is defined in the

gowns, aprons, masks, and protective following terms: expansive (contagious),
eyewear euthymic (normal), constricted (limited
variation), blunted (minimal variation), and flat
• Cardinal Techniques of Examination: (no variation).
Thought process Suicidal ideation or intent-Inquiring about
suicidal ideation at each visit is always
• Record the patient's thought process
important. In addition, the interviewer
information. The process of thoughts can be
should inquire about past acts of self-harm
described with the following terms: looseness
or violence.
of association (irrelevance), flight of ideas
(change topics), racing (rapid thoughts), Insight
tangential (departure from topic with no
• Assess the patients' understanding of
return), circumstantial (being vague, i.e.,
their condition. To assess patients' insight
"beating around the bush," giving inordinately
to their illness, the interviewer may ask
long responses that only eventually answer the
patients if they need help or if they believe
stated question), word salad (nonsensical
their feelings or conditions are normal. A
responses, i.e., jabberwocky), derailment
patient's attitude toward the clinician and
(extreme irrelevance), neologism (creating new
the illness plays an important part to
words), clanging (rhyming words), punning
developing insight into their condition and
(talking in riddles), thought blocking (speech is
overall prognosis.
halted), and poverty (limited content).
Judgment
• Types of delusions
• Estimate patient's judgment based on the
• grandiose (delusions of grandeur),
history or on an imaginary scenario. To
• religious (delusions of special status
elicit responses that evaluate a patient's
with God),
judgment adequately, ask the following
• persecution (belief that someone
question: "What would you do if you
wants to cause them harm),
smelled smoke in a crowded theater?"
• erotomanic (belief that someone
(Good response is "call 911" or "get help";
famous is in love with them)
Poor response is "do nothing" or "light a
• jealousy (belief that everyone wants
cigarette").
what they have)
• thought insertion (belief that someone Impulsivity
is putting ideas or thoughts into their
mind), • Estimate the degree of the patient's
• ideas of reference (belief that impulse control. Ask the patient about
relatively ordinary or commonplace doing things without thinking or planning.
phenomenon are referring specifically Positive responses may result in follow-up
to them). questions about the frequency of which
impulsive behaviors occur and whether
Phobias: Determine if patients have any they appear to impact a patient’s
fears that cause them to avoid certain functioning (e.g., punching walls in anger,
situations. destroying property, getting into verbal
altercations, or experiencing black-out
Obsession and compulsions- Signs of
anger).
ritualistic type behaviors should be
explored further to determine the severity
of the obsession or compulsion.
Cyanosis

 Central cyanosis is best identified in the lips,

oral mucosa, and tongue.

 The lips, however, may turn blue in the cold,

and melanin in the lips may simulate cyanosis in
darker-skinned people.

Jaundice

 Jaundice may also appear in the palpebral

conjunctiva, lips, hard palate, undersurface of
the tongue, tympanic membrane, and skin.

 Press the skin over a bony prominence and

observe the color when your finger is removed.
 Jaundice suggests liver disease or excessive
hemolysis of red blood cells.

Moisture

 Note excessive dryness, sweating, and

oiliness. Skin should be dry to touch without
flaking or cracking.

 Perspiration may appear on the face, hands,

axillae, or skin folds in response to a warm
environment; increased metabolic activity, such
as fever or exercise; and anxiety or pain.

Temperature

 Use the backs of your hands to make this

assessment. In addition to identifying
generalized warmth or coolness of the skin,
note the temperature of any areas with
increased pigmentation or erythema.

 Generalized warmth in fever,

hyperthyroidism; coolness in hypothyroidism.
Local warmth of inflammation or cellulitis.