Health Assessment Exam 1 PDF

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Health Assessment Exam 1 Notes...

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Ch. 1: Introduction to Health Assessment ●

Define health and health assessment -Health: “A state of complete physical, mental, and social-well being and not merely the absence of disease or infirmity.” -Health Assessment: “The processes used to evaluate the health status of a person.” ●

Explain the components of the health assessment -Comprehensive health history: past medical, physical, psychological issues, social history, cultural history, spiritual beliefs. -Complete physical examination: head-to-toe, identify changes in patient’s body systems, unusual or abnormal findings, document all findings in clear and concise manner, collate all information with medical records. ●

What are the different facets of a patient’s health? -Spiritual, Developmental, Physical, Mental, Social, Cultural

Ch. 2: Critical Thinking ●

Identify the components of the nursing process. Assessment: gathering subjective and objective data, instrumental in devising care plan, key points and relevant pieces of information grouped, prioritized problem list, continues throughout patient encounter. Diagnosis: based on real or potential health problems, based on assessment data, sets stage for reminder of care plan, formulated based on problem Planning: chart best course to address patient’s diagnosis, nurse and patient select goals for each diagnosis, set short and long term goals, be realistic, work with patients economic means competing responsibilities, family structure, and dynamics. Implementation: completed by patient, family, or health care team, clearly relate to nursing diagnosis, individualized for each patient, modified as changes occur, support positive outcomes Evaluation: continuing process to determine if goals are met, based on patient's condition, are goals realistic, it's an ongoing process, confirm nursing care is relevant. ●

Prioritize patient problems. -List the most active and serious problems first and record date of onset, order of priority, separate lists for active and inactive problems, assign each problem a number to be referenced in health record, use list to check status in future visits, allow other health care team members to review status ●

Identify steps in developing a plan of care for patients. -Must be agreeable to patient, develop and record plan for each problem, specify what steps are needed, share assessment with patient, ask the patient for his/her opinion, patient should always be an active participant of plan, adapt and change as problem change. ●

What does OLDCARTS stand for? How does the nurse use it?

Onset Location Duration Characteristics Associated Manifestations Relieving or Exacerbating Factors Treatment Severity -This is used to assess a patient's chief complaint or pain they feel ●

Know the different phases of the nursing process and what the nurse might be doing in each of the phases. Assessment: gathering subjective and objective data, instrumental in devising care plan, key points and relevant pieces of information grouped, prioritized problem list, continues throughout patient encounter. Diagnosis: based on real or potential health problems, based on assessment data, sets stage for reminder of care plan, formulated based on problem Planning: chart best course to address patient’s diagnosis, nurse and patient select goals for each diagnosis, set short and long term goals, be realistic, work with patients economic means competing responsibilities, and family structure and dynamics. Implementation: completed by patient, family, or health care team, clearly relate to nursing diagnosis, individualized for each patient, modified as changes occur, support positive outcomes Evaluation: continuing process to determine if goals are met, based on patient's condition, are goals realistic, it's an ongoing process, confirm nursing care is relevant.

Ch. 3: Interviewing & Communication: ●

Compare different therapeutic communication techniques which are used during the patient interview. -Active listening, guided questioning, nonverbal communication, empathic response, validation, reassurance, summarization, transitions, empowering patient. ●

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Organize the phases of the nurse-patient interview. -Pre-interview: set the stage, preparation -Introduction: put patient at ease, establish trust -Working: obtain patient information, set goal -Termination: summarize and discuss goals

Discuss strategies for handling difficult patients. -Silent Patient, confusing patient, patient with altered capacity, talkative patient, crying patient, angry/disruptive patient, language barrier, low literacy, impaired hearing, impaired vision, cognitive disabilities, personal problems, and sexuality. **Need to finish filling in**

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Be able to differentiate between subjective and objective data. -Subjective data is what the patient tells you where as Objective data is what you obtain from the assessment such as BP or Temp.

Ch. 4: Health History: ●

Apply the four types of histories to appropriate settings. -Comprehensive Health Assessment: admission of new patient -Focused or Problem-Oriented Assessment: returning patient -Follow-up History: problem or treatment evaluation -Emergency History: focused on emergent problem

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Identify the components of a comprehensive health history. -Initial information, chief complaints, history of present illness, past history, family history, review of systems, health patterns ●

Organize the components of a comprehensive health history. -Initial information, chief complaints, history of present illness, past history, family history, review of systems, health patterns ●

Make sure to look if a questions ask for “health history” versus “physical exam” so you can check for the correct components of the questions/answers. -Health history: past medical, physical, psychological issues, social history, cultural history, spiritual beliefs. -Physical examination: head-to-toe, identify changes in patient’s body systems, unusual or abnormal findings, document all findings in clear and concise ●

Review the different therapeutic communication techniques: e.g. validation, continuers, etc. -Active listening, guided questioning, nonverbal communication, empathic response, validation, reassurance, summarization, transitions, empowering patient. ●

What is the working phase of an interview? What would you (the nurse) be doing during that phase? -During the working phase the nurse is obtaining information from the patient. (Taking vitals, obtaining health history, performing physical exam, etc.)

Ch. 5:Spiritual and Cultural Assessment ●

Explain why culture is important in the health assessment process. - Culture is the system of shared ideas, rules, and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people. ●

Differentiate cultural competency from cultural humility. -Cultural Competence: Set of skills necessary to care for people of different cultures

-Cultural Humility: Process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners ●

Apply knowledge of the difference between spirituality and religion. -Spirituality is “all behaviors that give meaning to life and provide strength to the individual” while Religion is a system of beliefs or a practice of worship. ●

Explain why the patient's spiritual needs should be assessed. -Spiritual distress may be a response to illness or health issues.

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FYI. Females at age 14 and up can seek reproductive-related care (birth control, etc.) without a parent’s consent.

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Review the connection between nutrition and culture -Different cultures have a number of different eating habits. For example Orthodox Jew and Muslims do not eat pork, Hindus do not eat beef, Jainism is strictly vegetarian, etc. Culture may influence food preparation, number of meals, types of herbs used, food beliefs, etc.

Ch. 6: Physical Examination: ●

Identify the components of the physical examination. -General survey, assessment of vital signs, body measurements, head-to-toe system examination, establish a baseline. ●

Describe the equipment for performing a physical examination. -scale, stadiometer, ophthalmoscope, otoscope, snellen chart, near vision chart, penlight, tongue depressor, ruler, thermometer, exam gloves, gauze pads, watch with second hand, sphygmomanometer, stethoscope, reflex hammer, tuning fork, q-tips, cotton, two test tubes, paper and pen. (Neuro you need penlight, snellen chart, newspaper, ophthalmoscope, cotton swab, tongue blades, gloves, scents, tuning fork. Skin you need ruler and natural light) ●

Know Auscultation, palpation, inspection, and percussion and what each is used to detect. -Auscultation is listening to the internal sounds of the body with the stethoscope -Palpation is using tactile pressure to examine the size, consistency, texture, location, and tenderness of an organ or body part -Inspection is closely observing details -Percussion is evoking sound wave or dullness to assess the condition of the thorax or abdomen. ●

What is the process for physical exam? (e.g. privacy, wash hands, etc.) -provide privacy, hand hygiene, have patient sit down and start with the general survey, vital signs, and skin. Continue to HEENT (head eyes ears nose and throat), neck, back, posterior thorax and lungs followed by anterior thorax and lungs. Have the patient stay sitting

and examine breasts, axillae, and epitrochlear nodes. Ask the patient to lie down and check the cardiovascular system. To inspect and palpate the precordium, have patient roll partly to left side, then sit, lean forward and exhale while you listen for murmur of aortic regurgitation. Have patient lie back down to palpate and inspect the breasts and abdomen. Keep patient supine as you look at the lower extremities and musculoskeletal system. Have the patient sit while you assess the nervous system (mental status, cranial nerves, motor and sensory system, and reflexes.) Have patient stand to check peripheral vascular system and alignment of spine legs and feet along with their gait and balance. **I got this straight from the slides, so if it doesn’t make sense check those out again**

Ch. 7: General Survey, Vital Signs, and Pain: ●

Identify the components of the general survey. -First impression, nonverbal cues, look at general appearance (frail, fit, or robust, looks age, happy/unhappy, fatigued/rested, awake alert & responsive, oriented facial expression, odors such as alcohol, acetone, uremia, fruity) apparent state of health, demeanor, facial affect or expression (pain, anxiety or depression) grooming (buttons, hair, clothing), posture or gait (restless or quiet, fast movements, changes positions often, preferred posture), skin, personal hygiene, tattoos or piercings. ●

Create appropriate subjective questions based on initial observations.

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Prepare to measure blood pressure, pulse, respirations, and temperature.

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Discuss variations in vital signs and the possible causes. -Blood pressure: Higher readings result from a cuff too small or too tight, the arm is below heart level or not supported, inflating or deflating the cuff too quickly. Lower readings result from cuff too large, repeating assessment too quickly, inaccurate level of inflation, pressing stethoscope too tightly against pulse. -Temperature: foods, drink and smoke can affect readings. -Exercise can affect reading of pulse, temp, blood pressure, and respirations

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Evaluate the different types of pain. -Acute: occurs suddenly with recent injury or illness -Chronic: pain that persists for more than 3-6 months, recurring at intervals -Nociceptive or Somatic: related to tissue damage -Neuropathic: related to direct injury to PNS or CNS -Psychogenic: many factors that influence pain -Idiopathic: pain without identifiable etiology.

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What is the process of assessing pulse, respirations, BP, and temp? Things like asking about hot liquids before taking the temp. Hint: look for words like after in these questions.

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Know the differences in temperature via the different routes (oral, tympanic, axillary, etc.) -Oral: 37 C, Rectal: 37.4 C, Axillary: 36 C, Tympanic: 36.5 C

Ch. 8: Nutrition ●

Interpret nutrition history and physical examination assessment findings regarding the nutritional status of an individual. E.g. if a person has elevated BP, what nutrition changes might you teach about -To help lower hypertension as well as reduced risks educate patient on regular and frequent exercise, decreased sodium intake, increased potassium intake, and maintenance of a health weight. ●

Identify persons at risk for malnutrition or overnutrition -Malnutrition: older adults, hospitalized patients, eating disorders, illnesses that increase nutritional needs such as cancer, HIV, kidney failure, respiratory disorders -Overnutrition: Obese patients *look in book for more** ●

Differentiate between normal and abnormal nutrition assessment findings – e.g. if a person’s blood work shows anemia, what might you instruct the person to eat? -instruct them to add more iron to their diet -Normal: height, weight, body mass index, and abdominal circumference appropriate for

age -Abnormal *look in book** ●

What are the concerning signs of anorexia nervosa and bulimia? -Anorexia nervosa: Extreme weight loss, afraid of appearing fat, -Bulimia: overeating twice a week, dread of fatness but may be obese, preoccupied with eating alternating with periods of starvation. ●

What puts a patient at risk of malnutrition? -Immobile patient, impaired swallowing, feeding tubes, inability to absorb nutrients from GI tract, vomiting and diarrhea, increased metabolic needs, allergies to food, anorexia and other similar eating disorders

Ch. 9: Integumentary: ●

Identify the structures of the skin, nails, and hair. -Skin: Epidermis (cellular which forms melanin and keratin and horny layers which contains dead keratinized cells, ducts of sweat glands and hair shaft), Dermis (hair follicle, sweat gland, muscle to erect hair shaft, sebaceous gland), and Subcutaneous or adipose tissue (veins, nerves, and arteries). -Nail: Nail plate, lunula, cuticle -Hair: follicle and shaft

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Apply knowledge of the functions of the integumentary system. For example, if the barrier function of the skin was interrupted, what would the patient look like? What might cause that?

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Identify risk factors for pressure ulcers. – What kind of information is on the Braden scale? What is a “good” or “bad” Braden scale score? What does “shearing” mean in terms of skin integrity? -The Braden scale assess Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. The higher the number the better the score on the Braden scale. Risk factors include all those on the Braden Scale along with sustained compression obliterating arteriolar and capillary blood flow to skin 19-23: Not at risk 15-18: mild risk 13-14: moderate risk 10-12: high risk 9 or lower: very high risk ●

Identify risk factors for skin cancer. – Know the ABCDEs for Melanoma screening. A asymmetry of one side of the mole compared to the other B irregular borders, especially ragger, notched, or blurred C variation or change in color, especially black or blue D diameter >6mm or different from others, especially if changing, itching, or bleeding E evolving, a mole or skin lesion that looks different from the rest or is changing in size, shape, or color. -Risks of skin cancer: history of previous melanoma, over 50, mole changing, Ultraviolet radiation exposure, light eye or skin color, severe blistering as child ●

Analyze integumentary examination for completeness. -SKIN: Color, Moisture, Temperature, Texture, Mobility & Turgor, Edema, and Lesions. -HAIR: Quantity, Distribution, Texture, Color -NAIL: Color, Shape, Texture, Firmly Attached

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Accurately compare primary, secondary, and vascular lesions – Know macule, papule, pustule, vesicle. -Macule: flat -Papule: raised -Pustule: containing pus (zit) -Vesicle: clear fluid (blister)

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What information should be documented about a skin lesion? -Anatomic locations and distributions, patterns and shapes, types of lesions, colors, elevation, size

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Note: most of the words in the exam questions matter. If the question gives you a patient age, or a setting (hospital versus home), these are often relevant when selecting the correct answer. There are ALWAYS some ‘Select all that apply’ questions on 3120 exams....