Health Assesment Exam Basics (copy)

What does a skilled interviewer do?

-creates relationship w px to get accurate info
-creates trust w px
-teaches px about health
-builds rapport w px
-discusses health promotion w px

What are internal communication factors?

-respect for others control over health
-empathy
-active listening
-self-awareness

What are external communication factors?

-privacy
-no interruptions
-quiet, comfortable space

How can you enhance therapeutic communication?

-adressing the px
-active listening
-establish trust
-be assertive
-restate/validate info
-interpret body language
-explore issues
-use silence
-summarize convo

What are barriers to therapeutic communication?

-Asking too many questions
-Fire-hosing information
-Asking why
-Changing the subject inappropriately
-Failing to probe
-Expressing approval or disapproval
-Offering advice
-Providing false reassurance
-Stereotyping
-Using patronizing language

What are the steps of the nursing process?

-Assessment
-Diagnosis
-Planning
-Implementation
-Evaluation

What is subjective data?

What the px tells you aka symptoms

What is objective data?

What you observe and can measure aka signs

What is a primary source?

directly from px

What is a secondary source?

info obtained from someone else

What is the difference between medical and nursing assessment?

nursing focuses on px response to health and medical focuses on diagnoses of disease

What are the four steps of health assessment?

1. health history
2. physical
3. clinical reasoning
4. documenting/communicating findings

What is OLD CARTS?

Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Related Symptoms
Treatment
Severity

What do you use OLD CARTS for?

Assessing history of present illness

How do you close an interview?

-summarize main concerns
-explain next steps
-begin clinical reasoning process

When do you begin inspection?

Immediately

What does inspection require?

good lighting, adequate exposure, occasional use of instruments

What is palpation?

Applies your sense of touch to assess texture, temperature, moisture, organ location and size, and any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.

When do you use fingertips to palpate?

skin texture, swelling, pulsation, masses

When do you use finger and thumb to palpate?

detect position, shape and consistency of organs and masses

When do you use dorsal of hands to palpate?

detect body temp

When do you use base of fingers/ulnar surface of hand to palpate?

detect vibration

What do you use light palpation for?

light palpation to detect surface characteristics

What do you use bimanual palpation for?

using both hands to envelop certain body parts for precise delimination

What is percussion?

tapping skin with short, sharp strokes to assess underlying structures

What is percussion used for?

used to evaluate the size, borders of organs, density, masses and used to assess tenderness

What is amplitude?

intensity, loud or soft sound

What is pitch?

frequency of vibration, low or high sound

What is quality?

timbre, the musical, clear, hollow, muffled, dull

What is duration?

length, short or long sound

What is the basic principle?

air= long, deep, loud sound, increased vibration
solid= short, high, soft sound, decreased vibration

What sound are lungs?

resonant

What sound are lungs overfilled with air?

hyperresonant

What sound are stomach/intestines?

tympany

What sound are liver/spleen?

dull

What sound are flat?

muscle/bone

What is auscultation?

listening to sounds

When do you use the diaphragm?

high pitched sounds

What are examples of high pitched sounds?

bowel, breath, normal heart

When do you use the bell?

low pitched sounds

What are examples of lower pitched sounds?

murmurs/extra heart sounds

What is the single most important way to reduce microbial transmission?

hand hygiene

How can you reduce anxiety in your px and yourself?

-practice, observe, organize your system, maintain privacy, chat/visit, put everything back and keep call light nearby

What is a general survey?

study of the whole person; structure, physical appearance, mobility, behavior

What do we look for in physical appearance?

-age(looks age), sex/gender, level of consciousness, orientation, skin(good color), facial symmetry, distress

What do we test in mental assessments?

-level of consciousness, orientation, cognition, and thought proccess

What do we look for in body structure?

-stature, nutrition, symmetry, posture, obvious physical deformities

What do we look for in mobility?

-gait: foot placement, arm swing, coordinated, assistance?, no involuntary movement

What do we look for in behavior?

-facial expression, affect, speech, personal hygiene, appropriate culture

How do we assess weight/height?

-use standard scale
-weigh same time of day
-record weight in kg/lbs
-compare previous weight w current
-record height in inch/meters
-BMI

What is the average body temp range?

97F-100.8F

What influences body temp?

-age, sex, exercise, stress, menstrual cycle, circadian rhythm

What are we looking for in radial pulse rate?

-50 to 95 bpm
-regular even tempo

What are we looking for in radial pulse force?

-weak or full, bounding or thready
-3 point scale

What is the three point force scale?

-3+ full, bounding, easily palpitated, hard to obliterate
-2+ "Normal", easily palpated
-1+ weak, thready, barely felt
-0 absent

What is bilateral equality?

compare both sides for equal force

What are we looking for in an apical pulse?

-regular even tempo

What are we looking for in respiration?

-normal, silent, relaxed
-12 to 20 breaths per min

What is pulse pressure?

difference between systolic and diastolic pressure

What is mean arterial pressure (MAP)?

average pressure in the arteries throughout the cardiac cycle

What is average BP?

120/80 mmHg

What are the steps of orthostatic vital signs?

-rest supine for 2-3 mins, take baseline BP/P
-repeat sitting then standing
-record BP using even #s
-record arm, position, cuff size

What are the HOPE questions?

H: sources of hope, meaning, comfort, peace, Love
O: organized religion
P: personal spirituality & practices
E: effect on medical care & end of life practices