NUR2092 Health Assessment Exam 1 Study Guide

NUR2092 Health Assessment Exam 1 Study Guide

• Nursing Process steps- assessment, diagnosis, outcome identification, planning, implementation, evaluation • Communication: open ended questions ask for a narrative response use in following situations: to begin interview, introduce new section of interview, whenever the patient introduces a new topic. Closed ended questions ask for specific information, use in following situations: after opening narrative questions, when you need specific facts about past health problems, to move interview along. These are yes and no questions.

• Therapeutic communication techniques: active listening, communication validation,

assurance, empathy, support ▪ Keys to this are active listening, full attention, avoid interruptions, evidence of understanding, validating concerns

• Barriers to communication: the ten traps of interviewing- providing false assurance or

reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing, using professional jargon, using leading or biased questions, talking too much, interrupting, using why questions.

▪ Communication barrios: blaming, patronizing, false reassurance, failure to

listen, changing the subject or topic

• Pain:

• Types of pain: Acute pain is short term and self-limiting, often follows a predictable

trajectory, will dissipate after the injury heals. Chronic or persistent pain is diagnosed when pain continues for 6 months or longer. Chronic pain can be further divided into malignant (cancer related) and nonmalignant. Referred pain also called reflective pain, pain perceived at a location other than the site of the painful stimulus. Phantom pain: pain sensations are described as perceptions that an individual experiences relating to a limb or an organ that is not physically part of the body.

• How to assess pain: Where is your pain? When did your pain start? What does your pain

feel like? (ex: burning, sharp, stab, shooting, dull) How much pain do you have now?What makes pain better or worse? How does pain limit your activities? What does this pain mean to you? How do you act in pain, how do others know you are in pain? pick pain rating tool appropriate for patient population ( numeric scale, Wong baker, oucher, Cries)

• Initial pain assessment
• Brief pain inventory: asks patient to rate pain within past 24hours on graduated scales

(0-10)

• Short form McGill pain questionnaires: asks patient to rank list of descriptors in terms

of their intensity and to give an overall intensity rating to his or her pain

• Neuropathic pain: indicates types of pain that does not adhere to typical phases

inherent in nociceptive pain

• Nociceptive pain: the instant pain response to touching something hot, protects body

from injury

• Numeric rating scales: ask patient to choose a number that rates level of pain

o Verbal descriptor scales: have the patient use words to describe the pain

• Visual analog scales: have the patient mark the intensity of the pain on a horizontal line

from no pain to worst pain

• Physiologic changes with pain: patient can become withdrawn, act out, aggressive,

grimacing, diaphoresis, guarding, and vocalizing location of pain. Behaviors to pain are influenced by nature of pain, age, cultural and gender expectations as well.

• Alcohol and substance abuse:

• How to assess: Cage test: have you ever thought you should CUT down on drinking.

Have you ever been ANNOYED by criticism of your drinking? Have you ever felt GUILTY about your drinking? Do you drink in the morning, an EYE opener?• Domestic violence/ human trafficking: is the patient comfortable with who they are in the room? What is their behavior towards person they are with? Stall- do not let patient leave with person they are with. Follow facility protocols for reporting instance. Call 911 if in immediate danger. These screenings should be done every office visit.• Nutrition: refers to the degree of balance between nutrient intake and nutrient requirements.

• Factors that can affect nutritional status: undernutrition is when nutritional needs are

not met or depleted. Vulnerable groups are infants, children, pregnant women, recent immigrants, persons with low income, hospitalized patients, aging adults—this places the preceding people at risk for impaired growth and development, lowered resistance to infections and disease, delayed wound healing, longer hospital stays, higher health care costs. Over nutrition- is caused by consumption of nutrients in excess from what the body needs. This can lead to heart disease and hypertension, type II diabetes, stroke, gallbladder disease, sleep apnea, certain cancers, osteoarthritis

• Methods of assessing nutrition in health history: knowing what the patient typically

eats, what do they drink, what is their religion? Admission nutrition screening tool.Dietary history and clinical information. Physical examination for clinical signs, anthropometric measures, lab tests.▪ 24hr recall ▪ Food frequency questionnaires ▪ Food diary ▪ During hospitalization, documentation of nutritional intake can best be achieved through calorie counts of nutrients consumed or infused ▪ Subjective data: Eating patterns, usual weight, changes in appetite, taste, smell chewing, swallowing, recent surgery, trauma, burns, infection, chronic illnesses, vomiting, diarrhea, constipation, food allergies or intolerances, medications or nutritional supplements, self-care behaviors, alcohol or illegal drug use, exercise and activity patterns

o Issues that affect nutrition status across the lifespan:

o How to calculate BMI: kilograms divided by meters

• Vital signs:

• Normal vital signs: Normal oral temp is 96.4-99.1F, pulse is 60-100, respirations 12-20,

BP 120/80, o2- 90-100% on RA

• Abnormal vital signs- temp < 96.4 or <99.1F, pulse is <60 or <100, resps <12 >25, BP

>130/90 or < 90/60, <90% on RA with no respiratory disease

• How to take temp, pulse, BP- vitals are best taken when the patient is relaxed, no

earwax in ear, pulse on wrist- pretend taking pulse when taking respirations so patient does not change breathing pattern. Bp with arm heart level.

• What affects vital signs (ex: stress, drinking something hot, positioning, wrong size

cuff, etc) – if they drank something hot the oral temp will read wrong will read higher. If the cuff is too big the bp will read too low, if the cuff is too big the bp will read too high.If the patient is stressed the HR and BP will be elevated. If the arm is positioned wrong the reading won’t be accurate.

• Diastolic vs systolic and what is being assessed : systolic pressure maximum pressure

felt on artery during left ventricular contraction or systole, Diastolic pressure elastic recoil or resting pressure that blood exerts constantly between each contraction

• Pulse characteristics ; is it week or full, rate rhythm force elasticity, regular irregular
• Respirations and terms- normal is relaxed, regular, automatic, and silent , Orthopenic-

shortness of breath when laying down, Eupenic- normal good breathing, tachypnea- fast breathing, bradypneic- slow breathing, positional is just allowing for the best chest expansion

• Temperature methods and accuracy: normal temp is influenced by the following:

diurnal cycle, menstruation cycle in women, exercise, and age.

▪ Methods are: oral, rectal, tympanic, axillary. Axillary is least accurate

whereas oral or tympanic are most reliable

• Blood pressure- measures the pressure in your blood vessels when your heart beats
• Different positions for taking blood pressure: sitting, standing, laying (changes in

these are orthostatic changes)

o Normal range for respirations: 12-18

• Pulse oximeter: is best placed on pointer finger opposite of blood pressure cuff, it is

unable to read through gel or acrylic nail polish

• History, interviewing, assessment, types:

• Types of assessments ( episodic screening, problem centered, etc)- complete total

health database: includes complete health history and full physical examination.Describes current and past health state and forms baseline to measure all future changes yields first diagnosis. Episodic or problem centered database: for limited or short term problems, collect mini-database, smaller scope and more focused than complete database, concerns mainly one problem, one cue complex, or one body system, history and examination follow direction of presenting concern. Follow up database: status of all identified problems should be evaluated at regular and appropriate intervals, note changes that have occurred, evaluate whether problem is getting better or worse, identify coping strategies being used. Emergency database: rapid collection of data, often compiled concurrently with life saving measures, diasnosis must be rapid and comprehensive in nature

• Type of data/components of a health history- Subjective data for health assessment(is

what the client says). Objective data is the signs perceived by examiner through physical

examination. Skills preformed in this order: Inspection, palpation, percussion,

auscultation.

• Signs vs symptoms –symptoms: are subjective sensation person feels from disorder,

what a person says is reason for seeking care is recorded and enclosed in quotation

marks to indicate persons exact words. Signs: objective abnormally that can be detected on physical examination or in laboratory reports

• PQRSTU- P- provocative or pallitative. What brings it on? What were you doing when

you first noticed it? What makes it better? Worse? Q-Quality or quantitiy. How does it look, feel, sound, how intense/severe is it? R- region or radiation where is it does it spread anywhere? S- Severity scale how bad is it on a scale from 1-10. Is it getting better, worse, staying the same. T- timing, onset, exactly when did it occur, duration hwo long did it last, frequency how often does it occur? U- understand patients perception of the problem.What do you think it means

• Part of a general inspection- consider your emotional state and that of the person being

examined. Patient is usually anxious due to the anticipation of being examined. You need good lighting, adequate exposure, occasional use of instruments like otoscopes, ophthalmoscope, penlight, or nasal and vaginal specula to enlarge the view.• Equipment: how and when to use various tools (ex: pulse oximeter, thermometers, stethoscope, etc)

• Thermometer: need to know what the body temperature can be indicative of infection,

food digestion, heat loss etc, can be taken oral, temporal, axillary, rectal, tympanic

• Pulse oximeter: noninvasive method to assess arterial oxygen saturation, attaches to

persons finger or earlobe

• Stethoscope: to listen to heart and lungs, bowel sounds, take a manual blood pressure.

• Assessment techniques:

• Complete total health database: includes complete health history and full physical

examination. Describes current and past health state and forms baseline to measure all future changes yields first diagnosis. Episodic or problem centered database: for limited or short term problems, collect mini-database, smaller scope and more focused than complete database, concerns mainly one problem, one cue complex, or one body system, history and examination follow direction of presenting concern. Follow up database: status of all identified problems should be evaluated at regular and appropriate intervals, note changes that have occurred, evaluate whether problem is getting better or worse, and identify coping strategies being used. Emergency database: rapid collection of data, often compiled concurrently with life saving measures, diagnosis must be rapid and comprehensive in nature

• Mental status:

• Delirium vs dementia

▪ Delirium is a short period of time, rapid speech, inappropriate and rambling, can occur as part of a medical condition, such as a systemic infection ▪ Dementia- long term, slowly comes on

• Orientation and what can affect it- discern orientation through course of interview or

ask for it directly using tact. Time: day of week, date, year, season. Place: where person lives, address, phone number, present location, type of building, name of city and state.Person, own name, age, who examiner is, type of worker.

• Expected age related changes- there are baseline vision and hearing changes due to the

aging process, may take longer to respond and process information. But their general