HHA EXAM 1 Review PDF

Preview

Summary

Exam 1 Review ...

Description

N3320 Holistic Health Assessment Exam 1 Study Guide This first Exam includes the 5 chapters involved in the basics of Assessment – The Nurse’s Role in Health Assessment: Collecting and Analyzing Data; Collecting Subjective Data: The Interview and Health History; Collecting Objective Data: The Physical Examination; Validating and Documenting Data, and Thinking Critically to Analyze Data and Make Informed Nursing Judgments. Chapters 6 & 8 cover Assessing Mental Status and Substance Abuse and Assessing General Status and Vital Signs Ch. 14 Assessing Skin, Hair and Nails, and Ch. 24 Assessing Musculoskeletal System are the beginning of the “body system” chapters. Know the specific Conceptual Foundations or Structure & function, Subjective data, including rationale; Objective data including technique, normal and abnormal findings Include relevant content for performing the assessments in the childbearing woman, newborns and infants, children and adolescents, and older adults.

Ch. 1 – Nurse’s Role in Health Assessment: Collecting and Analyzing Data 1. Definition of nursing by the American Nurses Association- “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities, and populations.” There is an emphasis on diagnosis and treatment which is based on accurately assessing the client. 2. Assessment in Nursing: American Nurses Association definition of assessment- Assessment is collection by the RN of comprehensive data pertinent to the patient’s health or situation. 3. Nursing: Scope and Standards of Practice: The RNThe RN must: 1. Collect data systematically and prioritize it. This will involve the patient and family. 2. Use evidence-based assessment techniques 3. Synthesize date and document findings 4. Derives a diagnosis based on the assessment date collected 4. Texas Board of Nursing: Definition of assessment and role of the RN. The comprehensive assessment done by the nurse is the first step of the nursing process. It is the initial and ongoing extensive collection, analysis and interpretation of data. Surveillance is essential in the assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. 5. Nursing Process and Assessment – ADPIE Assessment- collect objective and subjective data Diagnosis- analyze the collected date and make a judgment Planning- determine the outcome criteria and make a plan ImplementationEvaluation- Assess if the outcome criteria has been met. Make revisions as necessary 6. Nursing Process and Benner’s Model – Novice to Expert Novice- Has no experience with certain populations. Uses rules to guide performance Competent- has 2-3 years under belt; acts according to patient goals Proficient- Understands patient situation as a whole and see long term goals Expert- Makes quick clinical judgments and has an intuitive grasp of situations 7. ***Know the 4 types of assessment and examples of when each is used A. Initial comprehensive assessment- collection of subjective data about the client’s perception of health of all parts or systems, past medical history, family history, and lifestyle and health practices (admission to facility)

B. Ongoing or partial assessment- data collection that occurs after the comprehensive database is established (reassurement, shift assessment ) C. Focused/problem oriented assessment- assessment of a particular client problem, which does not cover areas not related to the problem (pain assessment) D. Emergency assessment- very rapid assessment performed in life-threatening situations (rapid, response, chest pain, ABC) 8. Steps of health assessment Collect Subjective Data Collect Objective Data Validate Assessment Data for accuracy Document Data for communication with health team 9. Preparing for the Assessment: Review this info Review client’s record first Educate yourself about diagnosis and tests Avoid premature judgments Gather supplies 10. Collection of Subjective Data – elements included Biographical Info History of present health concern Personal Health History Health and Lifestyle Practices 11. Collection of Objective data Physical traits Body functions Appearance Behavior Measurements Results of Lab Tests 12. Distinguish between subjective and objective data Subjective: (speech-client) Data elicited by and verified by the client in the interview Obtained from the client record or other health professionals Skills: effective communication, empathy, good listener “I have a headache” Objective: (observe-you) Measurement (direct or indirect) from the nurse or others Observations, physical assessment findings of nurse or other provider Skills: inspection, palpation, percussion, ascultation VS, irregular pulse, x-ray 13. Steps in Analysis of Data: Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnosis Check for defining characteristics of those diagnosis Confirm or rule out nursing diagnosis Document conclusions

Ch. 2: Collecting Subjective Data: The Interview and Health History Collecting subjective data is part of interviewing the client to obtain a nursing health history. Subjective data includes: Symptoms/feeling/perception/desire/preference/ideas/beliefs/ values Subjective data is: client’s perception Phases of the Interview are: Introductory - reviewing health record, explaining purpose, making sure client is comfortable Working - bio info, health history, review of body systems Summary & closing - identifying and discussing plans, reassuring client Nonverbal communication: Describe these elements of nonverbal communication Appearance - professional Demeanor- warm Facial expression- neutral Silence- allows reflection Listening- Active Posture- same level as client Attitude- accepting Nonverbal Communication to Avoid: inadequate eye contact, being distracted, etc Verbal Communication types(questioning): open-ended, when/how/where, listing Verbal communication to avoid: talking too much, big words, false hope Lifespan History: Review specific types of additional information, questions to ask: Functional status WILL be on the exam; Functional status is the person’s ability to carry out ● The basic activities of daily living (ADLs): Instrumental activities of daily living (IADLs): ● Instrumental activities of daily living (IADLs): activities necessary for function Cultural considerations: Box 2-2, p. 17

Emotional Variations: Box 2-3, p. 18

Complete health history: ● See Weber and Kelley Assessment Tool 2-1 to see detailed information of what is included in each category

Ch. 3: Collecting Objective Data: The Physical Examination Physical Examination: How to Preparing the physical setting Provide for comfort, warm temperature Private area free of interruption Quiet area with adequate lighting Firm examination table or bed Bed-waist height to prevent stooping/ bending (protect back)

Equipment and Tools: Review necessary equipment (Table 3-1) plus your 5 senses EQUIPMENT NEEDED- ANTICIPATE PROCEDURES/PURPOSE • Gloves, gowns, mask • Stethoscope, watch with 2nd hand, pain scale, thermometer • Tape measure, platform scale • Exam light, penlight • Mirror, wood’s light • Braden scale/fall tool • Opthalmoscope, snellen chart, pocket screener, otoscope, tuning fork • Tongue blade • Doppler device and gel • Cotton-tip applicators, cotton balls • Reflex hammer Prepare Yourself: EXAMINE YOUR THOUGHTS, ANXIETIES (TRANSMITTED TO CLIENT) PROJECT SELF-CONFIDENCE (PRACTICE COMPETENCE CONFIDENCE) PREVENT TRANSMISSION OF INFECTIOUS AGENTS CDC (CENTERS FOR DISEASE CONTROL) AND HICPAC (HOSPITAL INFECTION CONTROL PRACTICES ADVISORY COMMITTEE) UPDATED PRECAUTIONS 2007 Client Approach and Preparation- how to Establish nurse-client relationship. Explain procedure/steps of physical exam Respect client’s requests/desires; sequence may vary with age or patient acuity. Explain the importance of the exam Reassure client: “I listen in a number of places; that doesn’t mean there is a problem. Leave room/ provide privacy Provide necessary container in case of need for sample. Begin exam with less-intrusive procedures. Approach client from right-side, most exam techniques performed with right hand (even if examiner is lefthanded). Explain procedure being performed. Explain to client why position changes are necessary; be organized, minimize unnecessary position changes. Client Positioning (Know the purpose for each position used) “Sitting position” - allows for you to assess the upper extremities. Head, neck, lungs, heart “Supine position”- if they are too weak to sit up. Allows abdominal muscles to relax for easy peripheral pulse sites “Dorsal Recumbent”- easier for those with pain in back or abdomen but do not assess the abdomen because they are contracted in this position “Sims”- to assess rectal and vaginal areas “Standing” - to assess balance and gait; or male genitalia “Prone”- assess the hip joint, do not allow those with cardiac and or respiratory issues to be in this position “Knee Chest”- Rectum exam; elderly and those with respiratory/cardiac problems cannot handle this position “Lithotomy”- Vaginal, rectal exam; elderly may not be able to handle this position How to perform each assessment procedure: ● Inspection: Used the first moment you meet the client ● Palpation: Using parts of the hand to touch and feel for characteristics: ● Percussion: Involves tapping body parts to produce sound waves which enable the examiner to assess underlying structures. Know the sounds. Resonance- hollow sound;lungs Tympany- drum sound, gastric Dullness- over organs-abn pleural effusion Flatness- bone/muscle ● Auscultation: Using a stethoscope to listen to sounds not audible to the human ear. (SCOPE TO SKIN):

Be familiar with specifics of assessing childbearing women, newborns, infants, toddlers, children and adolescents, and older adults. CHILDBEARING WOMEN: FINDINGS • Identify complaints/findings of pregnancy; explain the cause • Skin: chloasma, striae, linea nigra, spider nevi • (Fundoscopic exam not addressed in this course) • BP lower 2nd trimester • Possible enlarged thyroid • Gingival hypertrophy • Nasal stuffiness • Breast changes • Increased AP diameter, slight hyperventilation • Possible systolic heart murmurs • Varicose veins, dependent edema • Lordosis of spine NEWBORNS, INFANTS • Infant- unclothed; keep warm; expose areas as needed • Never leave unattended • Initial newborn assessment/subsequent exam • Skin- eval color, birthmarks, rash • Head, weight, length measured for growth • EENT inspected • Reflexes are evaluated • Denver developmental exam assess normal/ development milestones CHILDREN AND ADOLESCENTS • Children • Assess fear/anxiety • Fear body injury or mutilation • More modest • Firm approach; exam quickly • Alter sequence, accommodate developmental needs • Least intrusive procedures first, age appropriate explanations • Use play and age-appropriate diversions, toys, to distract • Adolescents • Allow privacy • Prefer time w/o parent • Give feedback about body development, progress, expectations • Provide teaching, wellness guidelines AGE-SPECIFIC (OLDER ADULTS) • Deterioring function RT aging/Dx • Subjective data - physical exam • Keep room warm; privacy • Allow rest or limit length of exam • Assist- dressing, repositioning PRN • Assess degree of frailty • Formal v. Informal

• Assess cognitive impairment • Involve caregivers as needed • Some older clients process information more slowly

Ch. 4: Validating and Documenting Data Validation of data is the process of confirming or verifying that the subjective and objective data you collected are reliable and accurate. Steps of validating data: ● Deciding whether data requires validation ● Methods of validation ● Identification of areas for which data are missing Documentation of Data: Purpose of documentation: promotes effective communication among multidisciplinary health team members. Documenting Data: ● Subjective information from the health history ● Objective data: from the physical examination Guidelines for Documenting Data: Keep confidential all documented information in the client record If not using electronic record, document legibly or print neatly in non-erasable ink Use correct grammar and spelling Avoid wordiness that creates redundancy Use phrases instead of sentences to record data Record data findings, not how they were obtained Write entries objectively without making premature judgment Record the client’s understanding and perception or problems Avoid recording the word “normal” for normal findings Record complete information and details for all client symptoms Include additional assessment content when applicable Support objective data with specific observations obtained during the physical examination Electronic Health Record (EHR) (electronic medical record-EMR) • Know benefits, uses Databases can link to other documents and health care departments Eliminates repetition of collection of similar data Nurses are involved in selecting and developing software systems and databases Improves quality, safety, and efficiency of care while reducing disparities Must ensure privacy and security of data Assessment forms used for documentation: The type of assessment form used for documentation varies according to the facility. There are 3 typical types of printed forms: ● Initial Assessment Form: Also called the nursing admission or admission database ● Frequent or ongoing assessment form: flow charts that help staff to record and retrieve date for frequent reassessments ● Focused or specialty area assessment form: focused on one major area of the body for clients who have a particular problem Verbal communication of data, findings: Use standardized method such as SBAR

Ch. 5: Thinking Critically to Analyze Data and Make Informed Nursing Judgments Critical thinking is the way in which the nurse processes information using knowledge, past experiences,

intuition, and cognitive abilities to formulate conclusions or diagnoses. 1. Data analysis (2nd phase of the nursing process) 2. The nurse is required to use diagnostic reasoning skills to interpret data accurately 3. Critical thinking is the way the nurse processes the information 4. DO KNOW the 7 essential elements of critical thinking ● Keep an open mind. ● Use rationale to support opinions or decisions. ● Reflect on thoughts before reaching a conclusion. ● Use past clinical experiences to build knowledge. ● Acquire an adequate knowledge base that continue to build. ● Be aware of the interactions of others. ● Be aware of the environment. 5. Be able to discuss what means to group, cluster data and form hypotheses 1)Identify abnormal data and strengths- sub and onj data 2) Cluster data- identify abn findings and strengths that are related. Consider if add data needed 3)Draw inferences- consider nursing diagnosis, collab, and referral 4) Propose nursing diagnosis- actual, risk, health promotion 5) Check for defining characteristics- NANDA 6) Confirm or rule out diagnosis- validation client and other providers 7) Document conclusions 6. Know the components of the diagnostic reasoning phase 7. Distinguish between actual nursing diagnoses and risk diagnoses Actual- a problem the client is currently experiencing 1) Diagnosis (NANDA) 2) Cause (Related to) 3) Evidence (S&S) Risk nursing diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene 8. Know generally about setting priorities 1st- emergent, ABCS, life threatening 2nd- MUAAR, Prompt intervention

Ch. 6: Assessing Mental Status and Substance Abuse Mental status refers to a client’s level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability). Factors affecting mental health: Economic status, exposure to violence, etc etc Evidence Base: Know info on Dementia and Alzheimer’s Disease

●

Alzheimer’s disease compared with typical aging

●

Also focus on Box 6-3: 7 Warning Signs of Alzheimer’s Disease.

Substance Abuse: Evidence-Based Info. DO focus on the CAGE assessment tool. Box 6-1, p. 79

Subjective Health History: Assessment of mental health is INFERRED from the answers the client gives to your interview questions and from your observations of the client’s behaviors. The Case Studies and COLDSPA examples not specifically addressed on the exam. DO KNOW the Risk factors from Assessment Guide 6-1: Modified SAD PERSONS Suicide Risk Assessment. Sex Age Depression Previous attempt Ethanol abuse Rational thinking loss Social support lacking Organized plan No spouse Sickness Complete Mental Status Exam: Often incorporated into the health history. Often it is performed with a complete neurologic exam. Perform full MSE if: – Screening exam suggests anxiety or depression or cognitive impairment – Family member concern RT behavioral changes ● Memory loss ● Inappropriate social interaction – Brain lesions, aphasia Or other symptoms Elements of Mental Status Exam – Objective Data Focus on technique for assessment, expected or normal findings and abnormal findings ● Level of consciousness and mental status: (1st check hearing and vision before assuming confusion or mental disorder ● Cognitive abilities ○ SLUMs tool for dementia. ■ What day of the week is it? Remember these five words. Be familiar with the Glasgow Coma Scale Assessment Tool 6-2. Measuring Eye opening, verbal, and motor responses Score of 7 or lower = COMA Know: Box 6-1 Abnormal levels of consciousness: Lethargy, obtunded, stupor and coma. ● Lethargy: Client opens eyes, answers questions, and falls Back asleep ● Obtunded: Client opens eyes to loud voice, responds slowly With confusion, and seems unaware of environment. ● Stupor: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. ● Coma: Client remains unresponsive to all stimuli eyes stay closed. Table 6-1: KNOW the differences between Alzheimer’s, Delirium and Vascular Dementia

Ch. 8: Assessing General Status and Vital Signs: Overall Impression: Observe the client & environment before interacting with them ● Observe for significant abnormalities of Skin color, dress, hygiene, posture & gait, physical development, body build, apparentage, and gender Collecting Subjective Data for General Status and Vital Signs: NOTE: For Subjective data, pay close attention to the 2-column format that includes the RATIONALE. Often there are abnormal findings listed here; a good place to study for exam

Same as with all body systems, but also include: History of present health concern: - EX: High fevers, alterations in heartbeat, difficulty breathing, pain o Personal history: - Usual BP, awareness Of Variations Of Heartbeat, Medications Taken, allergies o Family history: - Heart disease, diabetes, thyroid disease, high blood Pressure, Cancer, etc o Lifestyle & health practices - Education, alcohol, smoking General Survey Vital Signs: Common, noninvasive physical assessment procedure that most clients are accustomed to. Vital signs reflect the status of body systems of the cardiovascular, neurological, peripheral vascular, and respiratory systems. Equipment pg 32 General Impression/Survey Does what you see match? EX: Do they look like their age? Abnormal Findings: See slides and text pg 128

● ●

Malnutrition Obesity ○ Evenly distributed (exogenous) or cushing’s disease (endogenous) ● Dwarfism/gigantism ● Acromegaly/Marfan’s syndrome ● Sexual development ● Apparent age HEENT (part of general survey) Head, Eyes, Ears, Nose and Throat Vital Signs Hands-on physical examination begins with vital signs. Order of vital signs (in adults): Temp, Pulse, Respiration, BP Techniques: Temperature: 96.0-99.9 ● Oral: 96.6 - 99.5 ● Tympanic (ear): 98.0 - 100.3 ● Temporal: 97.4°‐ 100.3° ● Axillary: 95.6° - 98.5 (1 degree lower than oral) ● Rectal: 0.7° - 1°F HIGHER than normal oral temperature range Pulse: Normal - 60-100 bpm What is a pulse - wave pro...