NUR 2092 Final Exam Study Guide Health Assessment

NUR 2092 Final Exam Study Guide Health Assessment

• Geriatrics: functional assessment-what is being tested, best approach to testing; caregiver

concerns; IADLs, ADLs; disability concerns; tools to assess

What is being tested -Identify strengths -Identify limitations – so interventions can be recognized -Independence and prevention of functional decline Best approach to testing Caregiver concerns -Decrease in attention, memory, orientation, language, planning and making decisions -Depression is not a normal change -Persistent depression – is concerning if it interferes with ADL’s -Eating IADLs Instrumental activities of daily living -measures functional abilities necessary for independent community living -includes shopping, meal preparation, house-keeping, laundry, managing finances, taking medications, and using transportation ADLs Activities of daily living -tasks necessary for self-care -measure domains of eating/feeding, bathing, grooming, dressing, toileting, walking, using stairs, and transferring Disability concerns Tools to assess -Katz Activities of Daily Living -The Lawton Instrumental Activities of Daily Living Scale -Hospital Admission Risk Profile -Geriatric Depression Scale (short form) -Inspect for lesions and moles – irregular shapes, change in size or color -Check for pressure ulcers especially sacrum, heels & trochanters -Clubbing – cardiac or pulmonary disorder -Pitting/transverse groves – peripheral vascular disease, arterial insufficiency, or diabetes -Brittleness – decreased vascular supply -Yellow or brown nails – fungal infection -Look for limited range of motion – arthritis or muscle weakness causing pain and discomfort -While assessing range of motion – watch for reports of pain, dizziness,

jerky or abnormal movements: may indicate fractured vertebrae,

Parkinson’s disease, transient ischemic attack, or stroke -Look for facial symmetry (asymmetry may indicate a stroke) -Bowel sounds; Look for hernias, pulsatile masses -Evaluate muscles for atrophy, tremors, and involuntary movements -Note warmth, swelling, tenderness, crepitus and deformities

• Cultural assessment: culturally competent care; definition of ethnicity; spirituality; concepts

such as assimilation, acculturation, etc.

Culturally competent care -Know self, understand own heritage -Identify meaning of health to someone else -Understand health care delivery system -Gain knowledge re social backgrounds of clients -Be familiar with language, resources for interpreters, resources within

community Ethnicity Associated with culture; awareness of belonging to a group in which certain characteristics differentiate from one group to another -Includes nationality, regional culture, language, ancestry

-Ex: Egyptian, Swedish, Mexican, Jewish, etc.

Spirituality -Borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life.-Comes from person’s life experiences -Attempt to find meaning and purpose of life -More abstract -Relationship of self and something larger Ethnocentrism To believe one’s own beliefs or way of life is ‘superior’; will interfere with collection and interpretation of data, your development of a plan of care may be skewed; must be aware of your own biases Acculturation Adapting to and acquiring another culture Assimilation Developing new cultural identity and becoming like the dominant culture Biculturalism Divided loyalty, identifies with two cultures

• Therapeutic communication: examples of effective and ineffective techniques e.g. clarification,

reflection, blaming, etc.

Therapeutic communications The face-to-face process of interacting that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide support and information to patients.Examples of Therapeutic communications

-Open ended questions: tell me about, how are you doing today

-Closed ended questions: do you have pain

-Facilitation: nodding yes, uh-huhh

-Encourages client to say more; shows person you are interested

-Reflection: echoes words, repeat part of what was said

-Clarification: summarize, simplify

-Useful when patient’s word choice is ambiguous and confusing -Silence: Communication that client has time to think; silence can be uncomfortable; provides you w/ chance to observe client and note nonverbal cues

-Empathy: Names a feeling and allows its expression

-Consider your body language; consider cultural differences Barriers to communication -Lack of interest or attention/lack of respect -Physical barriers: a curtain, a door, a computer, a monitor, pain, room temperature -The patient’s inability to hear you, hearing deficit, or language barrier -Language/ use of jargon, or speaking above someone’s educational level

-Safety: fear

-Psychological barriers: embarrassment, disbelief, shock, anger, fear, grief, fatigue, hostility

10 Traps of Interviewing

• Providing false assurance or reassurance
• Giving unwanted advice
• Using authority
• Using avoidance language
• Distancing
• Using professional jargon
• Using leading or biased questions
• Talking too much
• Interrupting
• Using “why” questions

-Advising, defending, disagreeing, disapproval, giving approval, reassuring, requesting an explanating

• General survey – what is included?

General Survey -Begins with first contact -General impression of client (age, sex, loc, skin color, facial features) -Physical appearance/hygiene (facial expression, speech, dress, hygiene) -Body structure (stature, nutrition, symmetry, posture, position, body build) -Body movement (gait, range of motion, assistive devices, involuntary, movements) -Emotional and mental status and behavior (mood/affect, speech, appropriate behavior for setting)

Temperature Normal range: 97.8°F to 99.1°F/average 98.6°F

Heart rate Normal: 50-90 beats per minute.

-Bradycardia: A resting heart rate less than 50 beats/min

-Tachycardia: A more rapid heartbeat, defined as over 95 beats/min or over 100

beats/min.Respiratory rate Normal: 10-20 breaths per minute; relaxed, regular, automatic, and silent

Blood pressure Normal: 90/60 mm/Hg to 120/80 mm/Hg.

5. Nutrition: Dietary assessment; abnormal eating patterns

Dietary assessment An in-depth evaluation of both objective and subjective data related to an individual's food and nutrient intake, lifestyle, and medical history. Once the data on an individual is collected and organized, the practitioner can assess and evaluate the nutritional status of that person.• Food and fluid intake (24 hour recall is always the first thing done) • Nutritional status and risk factors • Anthropometric measurements, biochemical tests, and nutrition-focused questions • Swallowing assessment prn • Ask questions about nutritional health (ex: what are the important components of a healthy diet, what are the risk factors for poor diet, any questions about weight loss/gain?) *Nutritional status: refers to the degree of balance between nutrient intake and nutrient requirements (over nutrition, undernutrition, weight loss problems, weight gain problems, difficulty chewing/swallowing, obesity, anorexia nervosa, binge eating, bulimia) Abnormal eating patterns -Overnutrition: overweight or obesity; can lead to obesity and risk factor for: heart disease, hypertension, type 2 diabetes, stroke, gallbladder disease, sleep apnea, certain

cancers, osteoarthritis -Undernutrition: occurs when nutritional reserves are depleted or when nutrient intake

is inadequate to meet day-to-day needs or added metabolic demands; risk for:

impaired growth and development, lowered resistance to infection and disease, delayed wound healing, longer hospital stays, higher health care cost

-Obesity: greater energy intake than energy expenditure; caused by genetics,

overeating, and inactivity; excessive adipose tissue on face, neck, trunk, and extremities; overweight- bmi greater than 25; obesity- bmi greater than 30

-Hyperlipidemia: elevated serum lipids

-Anorexia Nervosa: refusing to eat; extreme thinness; other symptoms of protein

calorie malnutrition

-Binge eating: consumption of large quantities; feels of being out of control

-Bulimia: recurrent binge-and-purge eating cycles; electrolyte imbalances; chronic irritation or erosion of pharynx, esophagus, and teeth

• Skin: staging of decubitus ulcers, primary skin lesions like nodules, pustules, etc.; common skin

lesions, for ex. Psoriasis, contact dermatitis; signs of malignant skin lesions; color differences seen in dark skinned individuals; lesion configurations

Skin Functions Protection, prevents penetration, perception, temperature regulation, identification, wound repair, communication, absorption and excretion, and vitamin d production Stages of decubitus ulcers

-Stage 1: Red, unbroken skin

-Stage 2: Partial thickness erosion, loss of epidermis or also dermis

-Stage 3: Full thickness, extends into subcu tissue, looks like a crater

-Stage 4: Full thickness, all skin layers, exposed muscle, bone, tendon; may have slough or eschar Primary skin lesions

Primary (original lesion: mole, freckle, cyst)

Secondary (results from changes or trauma to original lesion: scar, melanoma)

Vascular (involve some part of vascular system: spider angioma, ecchymosis)

-Macule: Flat, less than 1cm, color change.; freckle, flat mole

-Papule: Raised, solid, less than 1cm; wart

-Patch: More than 1cm, papules coalesce; psoriasis

-Vesicles: Elevated with fluid, up to 1cm; herpes zoster

-Bulla: More than 1 cm; burn

-Pustule: Raised, filled with pus; acne

-Nodule: Raised, solid, larger than 1cm; fibroma

-Tumor: Larger than a few cm elevated; lipoma

-Wheal: Superficial, raised, erythematous, transient; allergic reaction

Common skin lesions -Psoriasis: Chronic, inflammatory, plaques, overactive immune system, especially elbows, knees, scalp -Atopic Dermatitis (Eczema): Dry, itchy, hypersensitivity, common. Triggers may be soaps, cold weather, seasonal allergies Signs of malignant skin lesions -Asymmetry, Border irregularity, Color, Diameter ¼ in or 6mm -Evolution (change) Color differences seen in dark skinned individuals -hypo or hyperpigmentation Lesion configurations Discrete (bug bite), Linear (scratch), Pinpoint (rash), Grouped (herpes), Zosteriform, Polycyclic, Annular (ringworm), Confluent (hives)