Primary prevention - Addresses the needs of healthy clients to promote health and prevent disease with specific protections; decreases the risk of
... [Show More] exposure of an individual or a community to disease.
Immunization programs
Child car seat education
Nutrition and fitness activities
Health ed. in schools - Examples of Primary Prevention
Secondary prevention - Focuses on identifying illness, providing treatment, and conducting activities that help prevent a worsening health status.
Communicable disease screening and case finding
Early detection and treatment of diabetes mellitus
Exercise programs for older, frail adults - Examples of Secondary Prevention
Tertiary prevention - Aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning.
Begins after an injury or illness
Prevention of pressure ulcers after spinal cord injury
Promoting independence after traumatic brain injury
Referrals to support groups
Rehab center - Examples of Tertiary Prevention
Improve health priorities
Improve awareness and understanding of the progress involving health, disease, and disability
Apply measurable health goals at the local, state, and national level
Apply best practice to strengthen policies and improve health practice
Identify the need for research, evaluation, and date collection of health disparities - Healthy People 2020 Objectives to promote health and prevent disease among the national population; updated every 10 years
Biographical Data - Name, Gender, Address, phone number, email address, birth date, birthplace, race/ethnicity, religion, marital status, occupation, contact person, and source of data
Reason for Seeking Health Care - Chief complaint (CC) or presenting problem
History of Present illness - Conduct a symptom analysis - include OLDCARTS
Present Health Status - Focus on patient condition's (acute and chronic), medications the patient is currently taking, and allergies the patient has experienced.
Past Health History - Explore past and present conditions that may have some effect on patient's current health needs and problems.
Family History - Review of patient's blood relatives (biologic), spouse and children to identify illnesses of genetic, familial or environmental nature that may affect the patient's current or future health.
Personal and Psychosocial History - Explores a variety of topics, including any information that affects the patient's physical and mental health.
Review of Systems - Conducted to inquire about past & present health of each of the patient's body systems. Use OLDCARTS. If sufficient data has been collected about the body system in the Present Illness/Present Health status section, these questions are not repeated.
No delegation to NAP.
The RN is not only responsible for gathering data, but clustering it and using it in decision making.
The delegating nurse retains responsibility and accountability for nursing care of the client, including nursing assessment, planning, evaluation, documentation, and supervision. The delegating nurse shall assess the clinical status and stability of the client's condition; determine the type, complexity, and frequency of the nursing care needed; and delegate only those tasks that:
a. Do not require the exercise of independent nursing judgment;
b. Do not require complex observations or critical decisions with respect to the nursing task or procedure;
c. Frequently recur in the routine care of the client or group of clients;
d. Do not require repeated performance of nursing assessments;
e. Utilize a standard procedure in which the tasks or procedures can be performed according to exact, unchanging directions; and
f. Have predictable results and for which the consequences of performing the task or procedures improperly are minimal and not life threatening.
2. The delegating nurse shall also assess the training, skills, and experience of the unlicensed person and shall verify the competency of the unlicensed person to determine which tasks are appropriate for that unlicensed person and the method of supervision required. - According to the ANA Standards of Practice, what is the registered nurse's role in assessment?
Primary prevention - Prevent disease from developing through healthy lifestyle
Secondary prevention - Screening efforts to promote the detection of disease to halt the progression the disease process
Tertiary prevention - Minimizing the disability from acute or chronic disease or injury
Help the client maximize his or her health
Health promotion - Behavior motivated by the desire to increase well-being and actualize human health potential
Health protection - Behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness
Clinical prevention - Individually focused interventions such as immunization, screenings, and counseling, aimed at preventing escalation of diseases and conditions
How does QSEN relate to health assessment? - Patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, informatics
The RN is not only responsible for gathering data, but clustering it and using it in decision making.
culture - all the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, life ways, and characteristics that influence a worldview
ethnicity - characteristics that a group may share in some combination such as common geographic origin
Language and dialect, history, lifestyle, and/or religious beliefs, shared tradition and symbols, music preferences
race - genetic in origin and includes physical characteristics.
Individuals from same racial group are not necessarily the same culture.
cultural sensitivity or cultural humility - Culturally-competent care- new terminology
be culturally sensitive, don't stereotype, use a template for assessment - cultural and ethical considerations
Comprehensive
Problem-based/focused assessment
Episodic/follow-up assessment
Screening assessment - 4 types of health assessment
Components of health assessment- health history (subjective), physical exam (objective)- includes lab and dx tests, and documentation - components of health assessment [Show Less]