健 康 评 估

1. 健 康 评 估 Health Assessment

2. 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 courseof 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.

3. 课程内容 Topical Outline • 概述 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

4. 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.

5. 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

6. 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

7. 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%:

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

9. 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

10. 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

11. 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’ healthstate. • 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.

12. 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 SignsandSymptoms • 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

13. 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 Assessthe patients’ health status • 决定需提供的护理服务 Initiate nursing care plan

14. 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

15. 绪论续 Overview-cont • 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

16. 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

17. 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

18. 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

19. 绪论续 Overview-cont • 健康评估的基本方法续 • 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

20. 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 Emphasison 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