健 康 评 估 Health Assessment

课程描述 Course Description 是论述评估服务对象身体状态的基本原则和方法的课程 This is a course that introduces the basic principles and techniques of assessing your patient’s health status. 是学习临床护理学的基础课程 It’s a foundation course  of clinical nursing. This course introduces health assessment skills. The student will learn to distinguish normal from abnormal findings and make appropriate referrals addressing the deviations. Emphasis is placed on assessment as a part of the nursing process, health histories, the problem-oriented system, self-care and health promotion, and the holistic approach to the patient.

课程内容 Topical Outline 概述 健康史的采集 身体评估 常见症状的评估 实验室检查 器械检查 Course introduction 健康史的采集 Interviewing skills to obtain a health history 身体评估 Assessment techniques and general assessments 常见症状的评估 Assessment of common symptoms. 实验室检查 Biochemical tests/laboratory tests 器械检查 Use of basic physical assessment tools or instruments

课程目标 Course Objectives 应用沟通交流技巧，采集健康史 Communicate effectively with patients and their family members while performing health assessments. 独立对服务对象的身体、心理、社会、家庭状况作出整体评估Demonstrate personal responsibility and accountability in performing health assessments. 识别正常和异常体征并解释其临床意义 Identify normal and deviations from normal in health assessment. 解释各项检查的基本概念及临床意义 Demonstrate ability to identify risks to health for the individual.

课程安排 Teaching/Learning Methods 讲课 Lecture/Discussion 影像 Videos/ AV presentations 示教和练习 Demonstrations 临床见习 Supervised guidance in practice sessions 实习 Clinical practice

教材及教学参考书 《健康评估》姜亚芳、余丽君主编 《健康评估》 《临床护理实习指导》 《诊断学》 www.aacn.org American Assoc. Critical Care Nursing www.aann.org www.nursing2007.com Nursing 2007 www.ajnonline.com Journal of Advanced Nursing

学习效果评价 Evaluation 本课程为考试科目 体格检查 Labs ： 40% 笔试 Final Exam ： 60%:

Overview of Health Assessment 健 康 评 估 绪 论 Overview of Health Assessment

绪论 Overview 教学目标 Learning objectives 叙述健康评估的重要意义 To state the significance of health assessment 描述健康评估的内容和基本方法 To describe the content and basic methods  of health assessment 举列说明健康评估在护理程序中的应用 To illustrate the application of health assessment in nursing process

绪论续Overview-cont 教学内容：Contents 介绍健康评估的重要意义 Introducing the significance of health assessment 介绍健康评估的内容 Introducing the contents of health assessment 简单介绍健康评估的基本方法 Introducing the basic methods of health assessment 简单介绍健康评估在护理程序中的应用 Introducing the application of health assessment in nursing process

绪论续 Overview-cont 健康评估的重要意义 Significance of Health Assessment 发现服务对象所具有的促进健康的潜能 Finding the patients’ potential in health promotion.  判断服务对象的健康状况 Determining the patients’ health state. 确定护理问题 Identifying the patient’s problem.  完整、全面、正确的评估是保证高质量护理的先决条件之一 A complete, comprehensive and correct  assessment is one of the prerequisites for high-quality care.  使护理工作更加科学化 Utilize scientific methods and evidence-based research findings. 是收集资料、评估患者情况、确认护理问题和制订护理计划的重要步骤 The critical initial step in the nursing process.

绪论续 Overview-cont 健康评估的内容 content of health assessment 健康史 Health History 症状和体征 Signs and Symptoms 身体评估 Physical Examination 心理社会评估Psycho-social Assessment 实验室检查 Laboratory Tests 辅助检查 Diagnostic Examination

绪论续 Overview-cont 护士的角色功能 Role of the Nurse 分析所收集的资料 Collect and analyze data 判断服务对象的健康状况 Assess the patients’ health status 决定需提供的护理服务 Initiate nursing care plan

绪论续 Overview-cont 健康评估的基本方法 收集资料 Collecting Data 整理资料 Collating Data 分析资料 Analyzing Data/Data Analysis 提出护理问题/做出护理诊断 Identify Nursing Problem/Making Nursing Diagnosis

绪论续 Overview-cont 收集资料 Data Collection 内容 Scope 生理、心理、社会等方面 健康评估的基本方法续 收集资料 Data Collection 内容 Scope 生理、心理、社会等方面 physical, psychological, and social 来源 Sources 患者、亲友、其他医务人员、病历等 patients, significant others, health care providers, medical records 分类 Categorize 主观 subjective 客观 objective 方法 Methods 询问、谈话、观察、体格检查、辅助检查等 interview, observing, physical examination, diagnostic examination

绪论续 Overview-cont 健康评估的基本方法续 收集资料 Data Collection 主观资料 Subjective Data 患者/被评估者主诉 Patient’s chief compliant 客观资料 Objective Data 体检 Physical Examination 实验室检查 Laboratory Examination/Test 器械检查 Equipment Inspection 是一个持续不断的过程 A continuous process 

绪论续 Overview-cont 健康评估的基本方法续 整理资料 Collating Data 核实 Validation 主客观资料应相互支持 Subjective and objective data should support each other. 注意可变资料的动态变化 Pay attention to the variable data and dynamic changes 分类 Categorize 马斯洛的基本需要层次 Maslow‘s hierarchy of needs Gordon 的11个功能性健康型态 Gordon‘s 11 Functional Health Patterns

Gordon 的11个功能性健康型态（Functional Health Patterns） Health Perception and Health Management Nutrition and Metabolism Elimination Activity and Exercise Cognition and Perception Sleep and Rest Self-Perception and Self-Concept Roles and Relationships Sexuality and Reproduction Coping and Stress Tolerance Values and Belief

绪论续 Overview-cont 健康评估的基本方法续 Making Nursing Diagnosis 分析资料 Data Analysis 对比后找出异常 Identifying Abnormal by Comparison 找出相关因素 Identifying Relevant Factors  提出护理问题/护理诊断 Making Nursing Diagnosis

绪论续 Overview-cont 健康评估在护理程序中的应用 Applying health assessment in nursing process 是护理程序的开始 The first step of nursing process 评估、诊断、计划、实施、评价 assessment, diagnosis, planning, implementation, and evaluation 与护理程序的其他步骤相互作用 Interacting with other steps of nursing process 重点在服务对象的健康功能状态 Emphasis on the health status of patients. 包括收集资料和做出判断 Including data collection and diagnosis making 是不断进行的工作内容 It’s a continuous process