HA EXAM\' 1 PDF

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Health A. Review Exam 1...

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Chapters 1-3 Assessment - 1st step of the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) - Unique from assessments done by physicians, physical therapists, etc. - Nursing assessment is holistic → looks at different components of health whereas a physician might look at just the physiological status - Medicine diagnoses the problem and prescribes a treatment - Nursing addresses how the disease process is affecting the patient ● Factors that affect health assessment= Culture, family, and community 4 Types of Assessments Initial Comprehensive

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When the patient is in the healthcare system for the first time Establish a baseline data for future providers to compare to Examining all body systems step by step in detail Involves past medical history and family history Looking at lifestyle and health practices

Ongoing or Partial

● After the initial exam is done ● Reassessment and follow up visits

Focused or Problem-Oriented

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Emergency

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You already know the patient and their problems but they’re coming in with another problem Ex. diabetic and hypertensive patient that comes in with a productive cough - start examining their cough

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Very rapid → life-threatening situation Ex. ABCs for a patient in cardiac arrest.

4 steps of Health Assessment 1. Collection of subjective data - done through an interview ❖ Pre Introductory phase ➢ Done before meeting the patient ➢ Review the medical record, biographical data, chronic diseases, medications, allergies. Educate yourself on the client and their diagnoses. Reflect on your own feelings so you don’t judge them unintentionally. ❖ Introductory phase ➢ Always refer to them by their last name. Explain what we’re doing and why we’re doing it, explaining why we’re taking notes, assuring them this is all confidential, make sure they’re comfortable and have as much privacy as they can. Establish rapport and trust ❖ Working phase - getting a complete health history

➢ Make sure they’re oriented first. Then gather biographical data, their reason for seeking care, the history of their present health concern, a past health history and family history, review all body systems for their current health problems (ex. “How do you care for [insert problem body system]?”), lifestyle and health practices, and developmental level ➢ COLDSPA - complete assessment of the sign, symptom, or health concern ■ Character ■ Onset ■ Location ■ Duration ■ Severity ■ Pattern ■ Associated symptoms ❖ Summary Phase ➢ Summarizing information obtained, validating problems and goals with the client, identifying and discussing possible plans to resolve the problem. Make sure you ask if there are any other concerns or further questions. 2. Collection of objective data - physical exam 3. Validation of data – (to prevent inaccuracies) → Make sure it’s true. If you aren’t sure of what you’re hearing/seeing/feelings, get someone else to check; can also reassess (ex: vital signs) 4. Documentation of data - so that all involved healthcare providers can see it “if you didn’t document it… you didn’t do it”

Difference between subjective and objective data Subjective Data- what the pt tells you ● ● ●

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(Gathered during the interview) Biographical information History of present health concern, experienced physical symptoms related to each body part or system Personal health history Family history Health and lifestyle practices Review of system

Do’s

Objective Data- what you observe yourself Physical characteristics- what you can see, hear, touch (measurable) ● ● ● ●

Body functions → VITALS Appearance Behavior Lab results

Don’ts

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Active listening - be at their bedside, sit down, get at eye level. Guided questioning - narrow questions to get a better answer Nonverbal communication Empathetic responses understand where they’re coming from Validation - reading the chart based on what was said, utilize any family present Reassurance Summarization Transitions Empowering the patient have them make the decision

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Provide false reassurance Give unwanted advice Use authority - ex. Saying “we have to do this” Use avoidance language - be clear and direct, don’t beat around the bush Engage in distancing Use professional jargon - if they aren’t going to know what an abbreviation/term means… use laypeople terms Use leading/biased questions - ex. “You don’t smoke, right?” vs “Do you smoke?” Talk too much - let them do the talking Interrupt - let them finish their thought process Use “why?” questions – (too aggressive/judgmental)

Verbal Communication ● ● ● ● ● ● ●

Open ended questions Closed ended questions Laundry list - list of questions we ask that they answer yes/no Rephrasing Well placed phrases Inferring Providing info

Nonverbal Communication ● ● ● ● ● ● ● ●

Appearance Demeanor Facial expression Attitude Silence Listening Posture gestures

Special considerations during interviewing for: - Gerontological variations (old people) - first assess hearing acuity. Speak slowly, face clients at all times, position yourself towards the ear that is working. It might be hard for them to open up. Be simple. - Children- Ask age appropriate questions, do age appropriate physical assessments, use age appropriate language → Talk to the child! - Cultural variations - Emotional variations

Anxious Patients

Angry Patients

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Give them simple organized info in a structured format Explain who you are, what is your role/purpose Ask simple and concise questions Avoid your own anxiety Do not hurry Decrease any external stimuli

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Approach client in calm, reassuring, in-control manner Allow client to vent their feelings Avoid any arguments with or touching the client Get help from other healthcare professionals if needed Make sure the patient has personal space so they don’t feel threatened or cornered.

Pain assessment: COLDSPA= Complete assessment of the signs, symptoms or health concern

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Character- describe the sign or symptom (feeling, appearance, sound, smell, or taste) 

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Onset- when did it begin  “When did this pain start?” Location- where is it? Does it radiate? Does it occur anywhere else?  “Where does it hurt

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Duration- how long does it last? Does it recur?  “How long does the pain last? Does it come

“What does the pain feel like?”

the most? Does it radiate or go to any other parts of your body?” and go?”

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Severity- how bad is it? How much does it bother you?  “how intense is the pain? Pattern- what make it better or worse?  “what makes your back pain worse or better? Are

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Associated symptoms- what other symptoms occur with it? How does it affect you and your daily activities  “What do you think caused it to start? Do you have any other problems

there any treatments you’ve tried that relieve the pain?”

that seem related to your back pain? How does this pain affect your life and daily activities?”

Complete Health History:  Biographic Data- name, address, phone, gender, birthday, place of birth, marital status, race or ethnic background, education level  Reasons for seeking health care  History of present health concern (using COLDSPA)  Past health history of client- problems @ birth, childhood illnesses, immunizations up to date, surgeries, accidents, allergies, prolonged pain or pain patterns, physical, emotional, or spiritual strengths/weaknesses  Review of systems for current health problems  Lifestyle and Health Practices- nutrition and weight management, activity level and exercise, sleep and rest, medications and substance use, herbal preparations, selfconcept and self-care responsibilities, social activities, relationships, values and beliefs, education and work, stress levels and coping style, environment Collecting objective data (physical assessment) Using the senses of vision, smell, and hearing to observe the conditions of various body parts, including any deviations from normal

Inspection

(color, size, location, texture, symmetry, odors, sounds)

Touching and feeling body parts with your hands to determine the following:

Palpation ● ● ● ● ●

Texture - rough/smooth Temperature - warm/cold Moisture - dry/wet Motion- stillness/vibration Consistency - soft/hard/fluid filled

Technique: - expose body parts being observed while keeping the rest of the client properly draped - comfortable room (not too hot or cold) - ALWAYS look before touching - Good lighting Types: ●

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Light (less than 1 cm)- to determine pulse, tenderness, surface skin texture, temperature and moister) Moderate (1-2cm)- to feel for easily palpable body organs and masses) Deep (2.5-5cm)- to feel very deep organs covered by thick tissue) Bimanual- for breasts and abdominal organs

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Tapping a portion of the body to elicit evidence of tenderness or sounds that vary with the density of underlying structures Eliciting pain Determining location, size, shape Determining density Detecting abnormal masses Eliciting reflexes

Types: ● Direct- we tap it immediately (ex: sinuses) ● Blunt- place a hand and bluntly punch it (kidneys)—most common ● Indirect- tap on a finger (lungs) Sounds you’ll hear ● Resonance- lungs ● Hyper-resonance- COPD patients ● Tympany- abdominal cavity ● Dullness- solid organs/tumors ● Flatness- bone

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Intensity - loud/soft Pitch - high/low Duration - length Quality - musical, crackling, raspy

Using a stethoscope: ● Diaphragm - for high pitched sounds normal heart sounds, breath sounds ● Bell - for low-pitched sounds abnormal heart sounds and bruits (abnormal loud, blowing, or murmuring)

Percussion

Auscultation

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Fingertips- for pulsations Palmar/ulnar surface- for vibratory sensations (thrills, fremitus) Dorsal surface- for temperature

Interviewing peds (up to 14 yo) o Validate information for reliability with the responsible significant other (e.g. parent, grandparent) o Use age appropriate language o Involve the parent when interviewing the child to achieve accurate information o Allow the child to sit with the parent or in the parents lap if desired Interviewing older adults o Remember that age affects and often slows all body systems within a person to varying degrees o Use a gentile, genuine approach o Use simple, straightforward questions in lay terms. Let them set the pace of the conversation. Be patient and listen well. Allow ample time o Introduce yourself but remember that an older client might forget your name- you may have to write it for them later in the interview (wearing a name tag might be helpful) o Use direct eye contact and sit eye level. Establish and maintain privacy o Assess hearing acuity

CHAPTER 4, 5: Validating, Documenting & Analyzing Data

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Purpose of validation= make sure subjected and objected data are reliable and accurate  METHODS: repeat assessment, clarify data with the client, verify with another health care professional, compare findings of objective and subjective data Information requiring documentation o Subjective and biographic data o Present health concern (COLDSPA) o Past health history of client o Family history o Lifestyle and health practices o Objective data Guidelines for documentation o Confidentiality o Correct spelling/grammar; phrases instead of sentences (avoid being wordy) o Avoid the word- NORMAL o Record what you see o Record the client’s understanding and perception of the problem

Critical thinking  Diagnostic reasoning= form of critical thinking where expertise comes with knowledge and experience, time and practice  Processing information using past experience, intuition, and cognitive abilities to come to conclusions or diagnoses  Using essential elements: o Keep an open mind o Use rationale to support opinions or decisions o Reflect on thoughts before reaching a conclusion o Use past clinical experiences to build knowledge o Acquire an adequate knowledge base that continues to build o Be aware of the interactions of others o Be aware of the environment ○ Verbal communication  SBAR - reporting to other health care workers ● S – situation ○ what is the client complaining of? ● B - background ○ Describe events that led up to the current situation (list medications, allergies, when it started, co-morbidities) ● A - assessment ○ State subjective and objective data you collected (COLDSPA)

● R - recommendation ○

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Suggest what you believe needs to be done for the client based on your assessment Try your best to do this face to face Allow time for receiver to ask questions Make sure they heard/understood what was said.

Steps of data analysis – done during second part of nursing process (Diagnosis) Identify abnormal data and strengths Cluster data Draw inferences Propose possible nursing diagnoses Check for defining characteristics Confirm or rule out diagnosis Document conclusions ○

Why do we need to document?  To have a chronologic source of data, treatment record, course of care  Helps with communication and preventing fragmentation, repetition, or delays in care  Gives us a basis for screening or to validate proposed diagnoses  Helps diagnose new problems  Helps us figure out the educational needs of the patient, family, and significant others  Eligibility for reimbursement, legal record of care, acuity level for staffing, contributes to epidemiological data

○ Common mistakes in documentations  Too many or too few data  Unreliable or invalid data  Insufficient number of cues available to support the diagnoses  Clustering cues that are unrelated to each other  Quickly diagnosing without hypothesizing several diagnoses  Incorrectly wording diagnostic statement Nursing Diagnosis  Wellness diagnosis- enhancement of health state o Indicated that client has the motivation to increase well-being and enhance health state  Risk Diagnosis- Patient does not currently have the problem but is vulnerable to it  Actual Diagnosis- currently experiencing the stated problem  Syndrome Nursing Diagnosis- when a cluster of nursing diagnoses are related in a way that they occur together  Collaborative problem- needs interventions from both nurse and doctor

General Appearance, Mental Status, Pain ○ Assessing Mental Status

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Level of consciousness – remember: time goes first, person goes last -look at the “level of consciousness” handout—GLASGOW COMA SCALE (15=optimal level of consciousness) ● Alert ● Lethargic - severe drowsiness where the patient can be aroused by moderate stimuli but then drifts back to sleep ● Obtunded - lessened interest in the environment, slowed responses to stimulation and tends to sleep more than normal with drowsiness in between sleep states ● Stupor - only vigorous shake will arouse the individual, when undisturbed they will lapse back into being unresponsive ● Coma - unarousable unresponsiveness (7 or lower on Glasgow) (lowest possible score is 3= deep coma) ● Acute confusion state - delirium  Orientation - time, place, and person, remote memory (40 years ago) ○ Voice and Speech Problems - look at “Disorders of Speech” handout  Aphonia - can’t speak at all  Dysphonia - difficulty when speaking (hoarseness)  Dysarthria - defect in the muscular control of speech apparatus (respiration, phonation, articulation, resonance)  Aphasia – disorder in producing or understanding language ● Wernicke’s aphasia ● Can speak but the sentences make no sense. “Word salad” ● Lesion in the posterior superior temporal lobe ● Broca’s aphasia ● Can understand speech but have a really hard time expressing the words. ● Lesion in the posterior inferior frontal lobe ○ Other mental status assessment tools  Mini mental state exam (cognitive state of patients)  Saint louis university mental status exam (SLUMS) – handout o For a high school educated client o o o

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For less than high school educated o o o

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Normal= 27-30 Abnormal= 20-27 mental cognition is impaired Abnormal= 1-19  dementia Normal= 20-30 Abnormal= 14-19  mental cognition is impaired Abnormal=1-14  dementia

Montreal cognitive assessment (for older adults  3 min short assessment in primary care setting to test for cognitive impairment)

Dementia vs. Alzheimer’s  Dementia (test using CAM)

A set of symptoms associated with the loss of cognitive functioning (thinking, remembering, reasoning) so much that it interferes with daily life o Decline in memory due to disfunction/loss of brain cells o Slow onset o Progressive o NOT a part of normal aging o Alzheimer’s is a subcategory of dementia Alzheimer’s disease o Repeatedly asking the same questions o Becomes lost/disoriented in familiar places o Cannot follow directions o Is disoriented to the date or time of day o Doesn’t recognize and is confused about familiar people o Difficulty with routine tasks like paying the bills o Neglects personal safety, hygiene, and nutrition o Remember remote memory but not resent o

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Delirium= temporary change in state of mental abilities SLUMS tests dementia/Alzheimer’s (CAM and SLUMs test level of orientation, memory, speech, cognitive functions)

○ Depression questionnaire asks about sleeping patterns, feeling sad, and changes in appetite and weight

○ General survey  Apparent state of health  Level of consciousness  Facial expression  Body/breath odors  Dress, grooming, personal hygiene  Posture, gait, motor activity  Speech  Mood and affect  Vital signs ● Temperature ● Pulse ● Respirations ● Blood pressure ● Pain

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Height and weight Ideal body weights (actual weight / IBW) x 100 = % IBW o Female  100 lb for 5ft + 5 lb for every inch over 5 ft o Male  106 lb for 5ft + 6 lb for every inch over 5 ft Below 70% is malnourished 80-90% - concerning 90-109% is normal 110-119% overweight 120%+ is obese 10% over ideal body weight= overweight 20% over ideal body weight=obese

● Waist Circumference ○ Females  less than or equal to 35 inches (Females are at risk for diabetes and cardiovascular disease if greater than 35inches)

○ Males  less than or equal to 40 inches ● Waist to Hip Ratio ○ Measure the hip circumference at the largest area of the buttocks ○ Waist circumference / hip circumference= waist to hip ratio  Females  less than or equal to 0.80  Males  less than or equal to 0.90 BMI= weight (pounds) divided by height (inches) squared THEN multiply by 703  Underweight- less than 18.5  Normal- 18.5-24.9  Overweight- 25-29.9  Obese- 30+

Skin Skin has 3 layers: Epidermis, Dermis, Subcutaneous layer  Epidermal appendages o Hair o Sebaceous glands o Sweat glands o Nails

● Functions of the skin

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Protection Prevents Penetration Perception Temperature regulation Identification - fingerprints Communication- via touch Wound repair/regenerative

○ Absorption and excretion we excrete certain amount of fluids and electrolytes through the skin ○ Production of vitamin Dneed vitamin D in order to get our calcium levels together

● How to assess: Subjective Data Health History ○ Common or concerning symptoms:  Mole = nevus (plural: “nevi”)  Bruising = ecchymosis  Hair loss  Problems with n...