뒤로Anatomy & Physiology: Patient Assessment and Nursing Models
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이 집합의 용어 (20)
Patient assessment is the process of identifying the condition, needs, abilities, and preferences of a patient. It forms the foundation for planning and evaluating care.
Comprehensive assessment evaluates the patient's complete health status; Focused assessment addresses specific concerns or symptoms related to particular body systems.
A structured rapid assessment of acutely unwell patients covering Airway, Breathing, Circulation, Disability (neurological status), and Exposure (injuries and environment).
It is a nursing model based on 12 activities of living to systematically assess a person's functioning across physical, psychological, and social areas for comprehensive care.
It focuses on assessing a person's ability to care for themselves and identifying where nursing support is needed due to self-care deficits.
Examples include Glasgow Coma Scale (GCS), Generalised Anxiety Disorder (GAD-7), Alcohol Use Disorders Identification Test (AUDIT), Body Mass Index (BMI), and MUST score for malnutrition risk.
Information reported directly by the patient or caregivers, such as symptoms, feelings, and personal experiences, e.g., pain levels or dizziness.
Measurable and observable clinical information gathered by the clinician, such as vital signs, lab results, and physical exam findings.
Patient identity, source of data, presenting complaint with history, past medical history, and holistic physical, psychological, and social needs.
Foster relationship, use open-ended questions, listen actively, ensure accuracy, respect sensitivity, involve the patient, and prioritise clinical findings.
To standardise recording, scoring, and responding to changes in physiological parameters to detect and manage clinical deterioration early.
Respiratory rate, oxygen saturation, temperature, systolic blood pressure, heart rate, level of consciousness, and supplemental oxygen use.
Situation, Background, Assessment, Recommendation; a structured tool for clear communication among healthcare staff.
Most patient safety failures are due to poor communication, which can lead to errors, misunderstandings, and compromised patient care.
1) Consider patient situation, 2) Collect information, 3) Process data, 4) Identify problems, 5) Set goals, 6) Take action, 7) Evaluate outcomes, 8) Reflect and learn.
1) Assume capacity unless proven otherwise, 2) Support decision-making, 3) Right to make unwise decisions, 4) Act in best interests if lacking capacity, 5) Use least restrictive option.
Comprehensive assessments are for new patients and cover full health status; focused assessments target specific symptoms or body systems, often for established patients.
Reduce background noise, face the patient, use hearing aids or interpreters, and speak clearly using simple language.
Engaging patients promotes shared decision-making, improves understanding, respects autonomy, and enhances care outcomes.
Alert, Voice, Pain, Unresponsive; a scale to assess level of consciousness.