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Health Assessment
- a systematic method of collecting data about a client for the purpose of determining the clients:
- 1. current and ongoing health status
- 2. predicting risks to health
- 3. identifying health promoting activities
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The nursing process: ADOPIE
- Assessment
- Diagnosis
- Outcome Identification
- Plan
- Implement
- Evaluation
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First Level Priority Problems
IMMEDIATE: airway, breathing, cardiac/circulation, vital signs
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Second level priority problems
- Immediate after treating first priority:
- mental status change
- acute pain
- acute urinary elim problems
- abnormal lab values
- risk of infection, ect.
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Third level priority problems
knowledge deficit, family coping, spiritual distress
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Subjective data
what patient says.
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objective data
what you observe, measurable
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Sign
Data observed- vital signs
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symptom
what patient tells you
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Health
dynamic state in the life cycle; internal and external environment. Influenced by biological, psychological, spiritual, and social
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Wellness
an active process wherein an individual experiences a balance in these factors: biological, psychological, spiritual, social
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Types of Data Bases (C.E.F.E.)
- Complete
- Episodic
- Follow Up
- Emergent
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Complete Data base
complete health history and physical, describes current and past health state, forms a baseline against which all future changes are measured
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Episodic data base
Problem centered. for limited or short term problem
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Follow Up data base
on going problem
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Emergent
rapid collection of data
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4 Basic elements of culture****
- Learned
- Shared
- Adapted
- Dynamic
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Acculturation
process by which an individual assumes the traits and behaviors of another culture, adapting to it, adopting its values, etc
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culture
a complex, integrated system reflecting the whole human behavior and experience
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custom
the habitual activity of a group or subgroup
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