NUR2092: Health Assessment Final Exam Review

NUR2092: Health Assessment Final Exam Review

Evidence Based Practice: a systematic approach emphasizing the best research evidence, the clinician's experience, patient preferences and values, physical examination, and assessment to make decisions about care

• clinical decision-making that integrates the best available research with clinical expertise

and patient characteristics and preferences

Health History:

1. Biographic data: name, address, phone #, DOB, age, gender, occupation

• Reason for seeking care: the patient’s chief complaint (signs and symptoms)

3. Present Health or History of Present Illness: how the pt feels right now

• Past Health: past health of the pt could have residual effects on current health state

(childhood illness/surgeries/injuries/operations)

• Medication reconciliation: complete list of medications (OTC+ herbs) (name, dose,

schedule, often, side effects)

• Family History: highlight diseases+ conditions for which the it can be at high risk

(genogram)

• Review of Systems: evaluate the past + present health state of each body part (asking)
• Functional Assessment ADL’s: measures ones self-care ability to care for themselves.

- Source of history:

o Pt: primary- Patient herself, who seems reliable

o Son or daughter: secondary- Patients son, John Ramirez, who seems reliable

• Reason for seeking care- Chief Complaint “Chest pains for 2 hours”

o History of Present Illness: HPI

▪ Location ▪ Quality ▪ Severity ▪ Timing ▪ Setting ▪ Aggravating or Relieving factors ▪ Associated Factors ▪ Patients Perspective

Pain Assessment: the 5

th vital sign, is subjective data (collect the HPI)

• Visceral pain (organ)
• Somatic pain (muscular/skeletal)
• Referred (pain where pain is not)

o Acute pain: come and go (guarding, moaning/yelling, vital sign change)

• Chronic pain: longer than 6 months of pain (change in app, holding self-up bc of

bad back)

• Nociceptive pain: develops when functioning and intact nerve fibers in the periphery and

the CNS are stimulated. It is triggered by events outside the nervous system from actual or potential tissue damage. Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation

• Pain scales for pts who are nonverbal or speak a different language

Vital Signs:

o Temperature: oral, rectal (most accurate), tympanic (ear), temporal, axillary

• Pulse: Tachycardia: >100 normal response to stress, Bradycardia: <60, Normal:

60- 100

▪ 0 = absent 1+ = weak 2+ = normal 3+ = increased Bounding (heart is pounding or racing)

o Respirations: Inspiration/Expiration

• B/P/systolic/diastolic: Hypertension: 180-209/110-119

o O2 Sat: 90-100, 98 and above is good (on finger)

• Pain

Nursing Process:

1) Assessment- collect data: exam, health history

2) Diagnosis: compare normal versus abnormal

3) Outcome Identification: expected outcome individualized to person

4) Planning: develop outcomes, interventions

5) Implementation: research, teaching + health promotion

6) Evaluation: plan, progress toward outcomes

Culture: shared attitudes, beliefs, roles, norms and values that occur among those who speak a particular language or live in a geographic location Religion: organized system of beliefs concerning the cause, nature and purpose of the universe, belief in a divine or superhuman power to be obeyed + worshipped as creators + rulers of the universe (whole, together) Spirituality: born out of each persons unique life experience, his/her personal effect to find purpose + meaning in life (more individual) (tree hugger) Communication Techniques: asking open ended questions, closed or direct, silence, clarification (understanding), repeating

General Survey: study of the whole person, begins with the 1

st moment of encounter, helps to form a global impression of the person (behavior, physical appearance, body structure, mobility)( wt/ht w/in normal range (BMI),body parts equal bilat, stands erect, gait coordinated, maintains eye contact, appropriate expressions, comfortable, cooperative, speech clear) Purpose of Health Assessment: plan of care that identifies the specific needs of a client + how they need to b addressed. Gathering info about the health status of the pt, analyzing + synthesizing that data, making judgements about nursing interventions based on the findings + evaluating pt care outcomes

Objective data: info gathered by healthcare team, factual + descriptive (SIGNS)

Subjective data: what the pt says about him/her (SYMPTOMS)

Physical Assessment skills:

• Inspection: concentrated watching, use all senses, good lighting, color, shape, symmetry,

position, odors from skin, breath, wound (always comes 1 st

• (watching)
• Palpation: confirms points noted during inspection, light and deep touch, back of hand

(dorsal aspect) to assess temp, fingers to assess texture, moisture, area of tenderness, deep=5-8cm, light=1cm (feeling)

• Percussion: tapping the person with short, sharp strokes, mapping out locations + size of

organs, signaling density, detecting abnormal, deep tendon reflexes, sounds produced by striking area, bell--low pitched sounds such as heart murmur, diaphragm--high pitched resp sounds (tapping)

• Auscultation: listening to sounds produced by the body with the stethoscope (listening)

Cardiac Assessment:

1. Blood Pressure: observe pt 1

st then assess vitals

o Systolic BP: pressure generated by the LV during systole, when the LV ejects

blood into the aorta + the arterial tree

• Diastolic BP: pressure generated by blood remaining in the arterial tree during

diastole, when the ventricles are relaxed

2. Exam Face: color, orbital edema, anxiety

3. Vessels of Neck:

a. Inspect: JVP (R Atrial Pressure)

• Palpate
• Auscultate for Bruits
• Pulses: Carotid pulse: one at a time, “brisk” “Delayed” or “Bounding”
• Heart

a. Inspect: anterior chest for any lesions, masses or tenderness

• Apical pulse or PMI

b. Palpate: finger pads for heaves or lifts

• Ball of the hand for thrills or turbulence
• Auscultate: listening while sitting + lying, using the diaphragm + bell: listen for

murmurs

• Aortic, Pulmonic, Erbs point, Tricuspid, Mitral area (apical pulse is)

ii. Identify S1(lub, heard at the apex: mitral area (bottom)) and S2 (dup,

heard at the base: pulmonic area (top))

• S1 (lub)- tricuspid and mitral valves (atrioventricular valves)

closing and is the beginning of Systole (CONTRACTION OF THE HEART, LV pumps blood into the aorta)

• S2 (dub)- aortic and pulmonic valves (semilunar valves) closing

and is the end of systole/ beginning of Diastole (RELAXATION OF THE HEART, blood moves from RARV + LALV)

3. Heart Murmurs: have a longer duration, attributed to turbulent

blood flow (extra sound) “lub, dub, dub).

6. Inspect Extremities:

a. Arms: size, symmetry, color, clubbing, pulses (brachial, radial, ulnar)

• Legs: size, symmetry, color, pulses (femoral, popliteal, dorsalis pedis, posterior

tibial)

• Feel for the Temporal, external Carotids + aortic pulses
• Pitting edema (0-4 scale)
• Characteristics of Pulses: rate, rhythm, volume, force, tension, form, equality,

condition of arterial wall, radio-femoral delay

Peripheral vascular assessment:

• Arterial Insufficiency: lack of blood flow to lower extremities, leads to gangrene because

of decreased blood flow, skin is shiny, loss of hair, nails thickened, ridged

• Venous Insufficiency: often painful, veins cannot pump blood back to heart, edema

present

• Capillary Refill: monitor dehydration + the amount of blood flow to tissue. If good blood

flow to the nail bed, a pink color should return in <2 seconds after pressure is removed

o Clubbing: normal 160 degrees, curved 160 degrees or less, early clubbing 180

degrees

• Edema: edema is fluid accumulating in the interstitial spaces; it is not present normally

Assessment of the Skin: LOOK AT OTHER HANDOUT

- Inspect: ABCDE of moles, edema, color, texture, bruising, lesions, mobility

• Palpate: temperature: dorsal part of hand, moisture, lesion: note color, elevation, size,

location, shape, any exudate, turgor

o Skin Cancer: wear sunscreen, clothing, teach self-skin exam

o Documentation examples: Color pink, skin warm and moist. Nails without

clubbing or cyanosis. No suspicious nevi. No rash.

Skin Lesions: HANDOUT FROM EXAM 2

Pressure Ulcers:

- Stage 1: skin intact, appears red, unbroken

• Stage 2: partial thickness skin erosion w loss of epidermis, dermis looks like a blister

- Stage 3: extending into subcutaneous tissue + resembling a crater, cannot see

muscle/bone

• Stage 4: ulcer involves all skin layers, extends into supporting tissue, exposes

muscle/bone

Hair Assessment:

- Inspect: rashes, bugs, color, distribution

- Palpate: texture, masses, tenderness, scalp lesions

Nail Assessment:

- Inspect: color, shape, clubbing, ridges, lesions

- Palpate: capillary refill

Neck Assessment: