Holistic Assessment EXAM 1 Study Guide PDF

Preview

Summary

Download Holistic Assessment EXAM 1 Study Guide PDF

Description

HOLISTIC ASSESSMENT EXAM 1 STUDY GUIDE Assessment is the collection of subjective and objective data about a patient’s health. • Subjective data consist of information provided by the affected individual. • Objective data include information obtained by the health care provider through observation and inspecting, percussing, palpating, and auscultating during the physical examination. The holistic health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together. Health assessment also should consider the cultural beliefs and practices of different people. Obtaining a heritage assessment helps gather data that are accurate and meaningful and can guide culturally sensitive and appropriate care. The nursing process includes six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It is a dynamic, interactive process in which practitioners move back and forth within the steps. • Nurses apply the process differently depending on their level of time and experience. • The novice nurse has no experience with specific patient populations and uses rules to guide performance. • The proficient nurse understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it. • The expert nurse has an intuitive grasp of a clinical situation and zeroes in on the accurate solution Critical thinking is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment. The process includes identifying relevant information, gathering clinical cues, completing an assessment, and setting priorities. • First-level priority problems are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. • Second-level priority problems are next in urgency. They require prompt intervention to prevent further deterioration and may include a mental status change, acute pain, or abnormal laboratory values. • Third-level priority problems are important to the patient’s health but can be addressed after more urgent problems. Examples include lack of knowledge or family coping. • Collaborative problems are certain physiologic conditions in which the approach to treatment involves multiple disciplines • Evidence-based practice is a systematic approach to practice that uses the best evidence, the clinician’s experience, and the patient’s preferences and values to make decisions about care and treatment. • An individual’s health status is influenced by a group of personal, social, economical, and environmental factors, collectively known as determinants of health.

•Cultural care is professional health care that is culturally sensitive, appropriate, and competent. To develop cultural care, you must have knowledge of your personal heritage and the heritage of the nursing profession, the health care system, and the patient. • Culture has four characteristics. First, it is learned from birth through language acquisition and socialization. Second, it is shared by all members of the same cultural group. Third, it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. Fourth, it is dynamic and ever changing. • Ethnicity pertains to membership in a social group that claims to possess a common geographic origin, migratory status, religion, race, and language and shared values, traditions or symbols, and food preferences. One’s cultural background is a fundamental component of one’s ethnic background. • Religion is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator or ruler of the universe. •Spirituality is borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. • Socialization is the process of being raised within a culture and acquiring the characteristics of the group. Education is a form of socialization. -In times of illness, religion and spirituality may be a source of comfort for patients and their significant others. -Religion and spiritual leaders may strongly influence the perception of health, illness, and practices. Spirituality may be used to find meaning and purpose for illnesses. The process of communication includes sending and receiving information. When exchanging information, both individuals engage in verbal and nonverbal communication, which can affect the communication process. “IMPLICIT BIAS” refers to the attitudes, beliefs, or stereotypes that inform and affect our understanding, Actions, and Decisions. • operates at a Level below our conscious Awareness as opposed to “explicit Bias” which refers to beliefs and attitudes that one endorses at a conscious Level. • can be Positive or negative • Not limited to Race, can include gender, Religion, socioeconomic status, sexual orientation, age, size, etc… • Present in every Facet of Life and institution in our country (Education, Healthcare, criminal justice, hiring practices) How to approach implicit biases: • Confront your biases when they arise • Challenge others to do the same

•

Make connections with people that are different

• Internal factors are specific to the examiner. Four internal factors promote good communication: liking others, expressing empathy, the ability to listen, and self-awareness. • External factors relate mainly to the physical setting. You can foster good communication with certain external factors, such as by ensuring privacy, preventing interruptions, creating a conducive environment, arranging equal status seating, wearing appropriate attire, and documenting responses via note-taking or an electronic health record without interfering with the conversation. • The interview has three phases: an introduction, a working phase, and a closing. • During the first phase, begin the interview by introducing yourself and your role. • During the working phase, gather data. Start with open-ended questions, which ask for narrative information. •Then use closed or direct questions, which ask for specific information in short, one- or twoword answers. •Nonverbal communication is important in establishing rapport and conveying information while providing clues to understanding feelings. No matter what form is used to record the health history, plan to gather data in eight categories. • First, collect biographical data, such as the patient’s name, date of birth, occupation, primary language, and communication needs. • Second, note the source of the history, which is usually the patient but may be someone else, such as a relative or interpreter. • Third, obtain the reason for seeking care, formerly known as the chief complaint. In the patient’s own words, briefly describe the reason for the visit stating one or two symptoms or signs and their duration. • Fourth, record the present health or history of present illness. For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care. When a patient reports a symptom, perform a symptom analysis including location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, and patient’s perception. • Fifth, investigate past health events, such as illnesses, injuries, hospitalizations, surgeries, and allergies, and current prescribed and herbal medications. • Sixth, gather a family history to help detect health risks for the patient, and assist with early screening and periodic surveillance. Several questions should be added to assess spiritual resources or religion, nutritional status, and immigration status as applicable. • Seventh, perform a review of systems to evaluate the past and present health of each body system, doublecheck for significant data that may have been omitted, and assess health promotion practices.

• Eighth, perform a functional assessment, including activities of daily living, measuring a person’s self-care ability. • Mental status is a person’s emotional (feeling) and cognitive (knowing) function. Functioning related to mental status is inferred by assessing the individual’s consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, and perceptions. • The full mental status examination is a systematic check of emotional and cognitive functioning. Its purpose is to determine mental health strengths and coping skills and to screen for dysfunction. • The four main components of the mental status assessment are appearance, behavior, cognition, and thought processes. Think of the initials A, B, C, and T to help remember these categories. • To assess appearance, observe the patient’s posture, body movements, dress, grooming, and hygiene. • To assess behavior, evaluate level of consciousness, facial expression, speech and articulation, and mood and affect. • To assess cognitive functions, check orientation, attention span, recent memory, remote memory, and new learning. • To assess thought processes, ask questions to evaluate thought processes, thought content, and perceptions. Also screen for anxiety disorders, depression, and suicidal thoughts. • The Mini-Mental State Examination is a simplified scored assessment of cognitive functions— not mood or thought processes. The examination is used to detect dementia and delirium and to differentiate these from psychiatric mental illness. Consciousness, language, attention span, and abstract thinking all develop over time. When examining an infant or child, consider these factors from a developmental perspective. • For pediatric patients, the mental status assessment focuses on the child’s behavioral, cognitive, and psychosocial development in coping with his or her environment. • The Denver II screening test allows direct interaction with the young child to assess the mental status. • The A, B, C, T guidelines used for adults may be used for adolescents. Although mental status parameters remain mostly intact with aging, a slower response time may affect new learning. Also, age-related physical changes, such as vision or hearing deficits, may affect an older adult’s mental status. Before assessing an older adult’s mental status, check sensory status and correct deficits, if possible. • For testing consciousness in aging adults, the Glasgow Coma Scale is a useful quantitative tool. • The Mini-Cog is a new, reliable, quick instrument to screen for cognitive impairment in otherwise healthy older adults. • Alcohol is the most used and abused psychoactive drug. • Excessive alcohol use poses various risks that increase morbidity and mortality

• Substance use and abuse is a developmental concern. • To gather subjective data, ask general screening questions or use an alcohol and drug abuse tool in a private, confidential, and nonconfrontational setting. • Intimate partner violence, child abuse, and elder abuse are important health problems. Health care professionals must recognize, assess, and report these problems, even if abuse or neglect is only suspected. • The four types of intimate partner violence include: • Physical violence • Sexual violence • Threats of physical or sexual violence • Psychological or emotional abuse or coercion tactics. • In most states, child abuse and neglect includes these four definitions: • Neglect is the failure to provide for a child’s basic needs. • Physical abuse is nonaccidental physical injury. • Sexual abuse includes exploitation through prostitution or pornography. • Emotional abuse is any behavior pattern that harms a child’s emotional development or sense of self-worth. • In addition to obvious physical injuries, the health effects of violence are significant. In all types of abuse, the clinician only needs a reasonable suspicion that the individual has been maltreated to make a report to the appropriate authorities • Despite wide differences among distinct cultural groups and within any given culture, common barriers to treatments are societal stressors, legal status, lack of access to culturally responsive care, cultural values, and gender roles. • Physical examination requires the sequential use of four assessment techniques: Inspection, palpation, percussion, and auscultation. • Inspection is close, careful observation of the individual as a whole and then of each body system. Use the patient’s body as the control and compare the right and left sides of the body to determine symmetry. Inspection requires good lighting, adequate exposure, and sometimes the use of certain instruments, such as an otoscope or penlight. • Palpation is the use of touch to assess texture, temperature, moisture, and organ location and size. This technique also helps identify swelling, vibration or pulsation, rigidity or spasticity, crepitation, lumps or masses, and tenderness or pain. The fingertips are best for fine tactile discrimination. Grasping with the fingers and thumb is ideal for detecting position, shape, and consistency of an organ or mass. The backs of the hands and fingers are good for determining temperature. The base of the fingers or ulnar surface of the hand is best for assessing vibration. • Light palpation detects surface characteristics and accustoms the person to being touched. Deep palpation assesses an organ or mass deeper in a body cavity.

• Percussion is tapping the patient’s skin with short, sharp strokes to assess underlying structures. This technique is used to assess the location, size, and density of an organ; detect a fairly superficial abnormal mass; or elicit a deep tendon reflex. • Each percussion sound has four components. Amplitude is the sound’s intensity, which may be loud or soft. Pitch or frequency describes the number of vibrations per second. Quality (or timbre) is the subjective difference resulting from a sound’s distinctive overtones. Duration is the length of time the note lingers. • Auscultation is listening to sounds produced by the body, usually using a stethoscope. The heart, blood vessels, lungs, and abdomen are commonly auscultated areas. Use the stethoscope’s diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds. Use the stethoscope’s bell for soft, low-pitched sounds, such as extra heart sounds or murmurs. • The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. It covers four areas: physical appearance, body structure, mobility, and behavior. Changes in any area may indicate illness. • Physical appearance includes an assessment of the person’s age, sex, level of consciousness, skin color, facial features, and overall appearance. • Body structure addresses stature, nutrition, symmetry, posture, position, body build or contour, and any obvious deformities. • Mobility is concerned with gait, range of motion, and the presence of involuntary movement. • Behavior considers facial expression, mood and affect, speech, dress, and personal hygiene. • Several developmental considerations apply to the general survey: • For a child, observe interactions with the accompanying adult. Unexpected behavior on the part of the adult or child may be clues to child abuse, mental illness, or a developmental disability or disorder. • For an aging adult, be aware that posture, appearance, and mobility may change. By the eighth decade, spinal flexion may occur as well as an angulation of features and a redistribution of body proportions. The gait may have a wider base to compensate for changes in balance. • Various routes of temperature measurement reflect the body’s core temperature. • The oral route is accurate and the most convenient. • The rectal route is the most accurate route, and the result is as close to core temperature as possible without using more invasive measures. • The tympanic route senses infrared emissions of the eardrum, so it is an accurate measurement of core temperature. • The temporal artery thermometer uses infrared emissions from the temporal artery and provides an average of multiple readings. There are conflicting reports regarding its accuracy. • When palpating a peripheral pulse, assess three qualities: rate, rhythm, and force. • In an adult at rest, the rate normally ranges from 50 to 95 beats per minute but varies with age and gender. • The pulse rhythm normally has an even, regular tempo.

• The force of the pulse shows the strength of the heart’s stroke volume. • Blood pressure is the force of the blood pushing against the blood vessel walls. • Systolic pressure is the maximum pressure felt on the artery during left ventricular contraction (or systole). • A cuff that is too narrow yields a falsely high pressure because it takes extra pressure to compress the artery. A cuff that is too wide yields a falsely low pressure. • Pain develops by nociceptive and neuropathic processing. • Nociceptive pain develops when functioning and intact nerve fibers in the peripheral and central nervous systems are stimulated. It starts outside the nervous system from actual or potential tissue damage. Nociception occurs in four phases: transduction, transmission, perception, and modulation. This pain typically is predictable and time limited based on the extent of the injury. • Neuropathic pain does not adhere to typical and predictable phases. It implies an abnormal processing of the pain message as a result of an injury of the nerve fibers. It is sustained on a neurochemical level. • Physical pain sources are based on their origin. • Visceral pain originates from larger internal organs, such as the stomach, intestines, gallbladder, and pancreas. • Somatic pain originates from musculoskeletal tissues or the body surface. • Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone. • Cutaneous pain is derived from the skin and subcutaneous tissues. • Referred pain is felt at a particular site but originates from another location. • Pain can also be classified by its duration. • Acute pain is short-term and self-limiting, often follows a predictable track, and dissipates after the injury heals. Acute pain has a self-protective purpose; it warns of actual or threatened tissue damage. • Chronic (persistent) pain continues for 6 months or longer. • Breakthrough pain is a transient spike in pain level in an otherwise controlled pain syndrome or the result of incident or episodic pain. Developmental and cross-cultural care related to pain includes these points: • Infants have the same capacity for pain as adults but are at high risk for undertreatment of pain because they are nonverbal. Preterm infants lack inhibitory neurotransmitters and are more sensitive to painful stimuli. • Although pain is common in older adults, it is not a normal process of aging. Pain indicates pathology or injury and should be investigated. • Genetic differences between men and women may account for differences in pain perception • The subjective report is the most reliable indicator of pain. On the initial pain assessment, the clinician should ask questions about pain and discomfort, location of pain, whether pain limits the patient’s function or activities, and how the patient usually reacts when in pain....