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Nursing Skills LP2
Obtain a Health History
16
Nursing
Undergraduate 1
03/30/2014

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Cards

Term
ADPIE
Definition
Assessing
Diagnosing
Planning
Implementing
Evaluating
Term
Assessing
Definition
-collect data
-organize data
-validate data
-document data
Term
Diagnosing
Definition
-analyze data
-identify health problems, risks and strengths
-formulate diagnostic statements
Term
Planning
Definition
-prioritize problems/diagnoses
-formulate goals/desired outcomes
-select nursing interventions
-write nursing interventions
Term
Implementing
Definition
-reassess the client
-determine the nurse's need for assistance
-implement the nursing interventions
-supervise delegated care
-document nursing activities
Term
Evaluating
Definition
-collect data related to outcomes
-compare data with outcomes
-relate nursing actions to client goals/outcomes
-draw conclusions about problem status
-continue, modify, or terminate the client's care plan
Term
subjective data
Definition
symptoms or covert data
-apparent only to the person affected and can be described or verified only by that person
-subjective data include the client's sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation
Term
objective data
Definition
signs or overt data
-detectable by an observer or can be measured or tested against an accepted standard.
Term
sources of data:
primary
secondary
Definition
primary: client is primary source

secondary: family members, other support persons, health professionals, records and reports, lab and diagnostic analyses, and relevant literature
Term
Components of Health History
Definition
Biographic Data-name, address, age, sex, marital status, occupation, religious preference, health care financin

Chief Complaint or reason for visit

History of present illness

Past history-illnesses, immunizations, allergies, injuries, hospitalizations, medications

Family history of illness

Lifestyle-personal habits, diet, sleep patterns, ADLs, recreation/hobbies

Social data-family relationships, ethnic affiliation, education history, occupational history, economic status, home/neighborhood conditions

Psychological data-major stressors, usual coping pattern, communication style

Patterns of health care-health care resources client is currently using and has used in past including primary care giver, specialist, dentist, health clinic, folk practioner
Term
Data Collection Methods
Definition
Observing- a)noticing the data b) selecting, organizing and interpreting data

Interviewing-directive-nurse establishes purpose of the interview and controls the interview
-nondirective-nurse allows client to control the purpose, subject matter and pacing

Examining-physical examination or physical assessment
Term
Physical Assessment (Examination)
Definition
systematic data collection method that uses observation (senses of (sight, hearing, smell, and touch) to detect health problems. To conduct the exam the nurse uses techniques of inspection, auscultation, palpation and percussion
Term
Maslow's Hierarchy of Needs
Definition
Physiological needs (survival needs)
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
Term
cues
Definition
subjective or objective data that can be directly observed by the nurse: what the client says, or what the nurse can see, hear, feel, smell or measure.
Term
inferences
Definition
nurse's interpretations or conclusions made based on the cues
Term
Nursing Process
Definition
is a systemic, rational method of planning and providing individualized nursing care for individuals, families, communities, and groups
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