EXAM 1: HA

ch1-7

What is a complete Health assessment?

full head-to-toe evaluation including health history AND physical examination

What are the types of health assessment?

Focused/Problem-oriented Assessment, Follow-up history, Emergency Assessment, Comprehensive health assessment

Why are health assessment performed?

determine patient’s health status, risk factors, and need for education for developing a nursing plan of care. The sooner, the more the nurse knows of pt and can provide holistic care to ensure health promotion and quality of life.

What are the two parts of a comprehensive health assessment?

Comprehensive Health History and Complete Physical exam

What is all the subjective data part of?

Health history

What is all the objective data part of?

Complete Physical exam

When is a focused assessment done?

Appropriate for established pts, during routine or urgent visits (comprehensive health assessment already completed) and focused on a CURRENT specific concern, complain, or symptoms. RESTRICTED TO A SPECIFIC BODY SYSTEM

What is a Follow-up History Assessment?

a form of focused assessment. pt is returning to evaluate problem after treatment or intervention to check progress or response. Gather data and evaluate if plan was successful.

***second-shift nurse following up with problem

What is an emergency assessment?

Rapid, focused, and immediate. In life threating or unstable situations (ABCs)

What is a comprehensive Assessment?

a full head-to-toe exam and complete history. Done on admission, first visit to a clinic, or when a pt’s care is transferred.

What is healthy people 2030?

A campaign that occurs every 10 years to increase quality of life and create healthy lifestyle. Promotes disease prevention.

What is the role of the nurse in assessment?

Is to collect data. by focusing in verbal and non verbal cues by constantly assessing them. Ask questions ot determine health information that influences the day to day care and how it affects the person’s quality of life

What is the nursing process?

problem-solving process to identify pt problems, set goals, develop plan, implement, and evaluate outcome

What is the order of the nursing process?

1. Assessment

2. Analyze

3. Planning

4. Implement

5. Evaluate

What is clinical reasoning?

thought process of a nurse to decide what’s going on with a pt and what to do about it

What are the steps to clinical reasoning?

1. Gather Data

2. Cluster Findings

3. Interpret Findings

4. Create Hypothesis

5. Develop a Plan

What occurs in the gather data phase of clinical reasoning?

Identify abnormal or positive findings. Make list of pt symptoms, signs you observed, and lab reports.

What occurs in the cluster the findings phase of clinical reasoning?

group related assessment data together. ex/ scratchy throat and inflamed pharynx = pharynx.

What occurs in the interpreting the findings phase of clinical reasoning?

Nurse needs to tell what can be treated by the nurse. Analyze the data to evaluate the pt’s health status.

What occurs in the make a hypothesis stage of clinical reasoning?

1. Make hypotheses about the nature of pt problem.

2. Draw all knowledge about abnormalities, diseases, and issues.

3. Test the hypothesis and establish a working analysis plan.

4. Make a nursing analyses

What occurs in the develop plan phase of a clinical reasoning?

Plan reference the nursing analysis, therapy, pt education for each individual. PLANS NEED TO BE DIFF TO REFLECT PT NEEDS

What is important to do before establishing a plan for a pt?

share assessment with pt and seek out opinions, concerns, and willingness to proceed. Repeat information multiple times before they comprehend. PT MUST BE ACTIVE PARTICIPANTS IN PLAN OF CARE

Why is generating a problem list useful?

Helps summarize pt problem following Maslow’s Hierarchy of Human Needs. From most active and serious problems be listed and addressed first.

What the MOST important thing when following a problem list?

pt reason of visit IS the priority problem, not the “high risk” that has no immediate threat to life.

What is a positive responded?

When pt confirms the condition, symptom, or behaviors is present.

DOESNT MEAN GOOD

What is OLD CART?

a tool to dig deeper in the chief complaint during the history of present Ilness

What is the O in OLDCART?

Onset (when did it start?)

What is the L in OLDCART?

Location (Where is it? Does it radiate?)

What is the D in OLDCART?

Duration (How long does it last? Constat or intermittent?)

What is the C in OLDCART?

Character (What does it feel like? Sharp, dull burning?)

What is the A in OLDCART?

Associated Manifestation (Does it come with anything else?)

What is the R in OLDCART?

Relieving/Exacerbating factors (what makes it worse or better?)

What is the T in OLDCART?

Treatment (Any interventions that pt has tried)

What are the four general phases of each interview?

1. Pre-interview

2. Introduction

3. Working

4. Termination

What are some communication techniques for motivation interviewing?

Open-ended question, affirmation, reflective listening, summarize and teach back

What is the purpose of a health history interview?

to establish rapport, gather information, and offer information

Why use open-ended questions technique?

to invite the pt to tell their OWN story in their OWN words. AVOID WHY, seems judgmental to pt. Use “tell me about…”

Why use affirmation technique?

To affirm when the pt reveals a healthy habit or good decision

Why use reflective listening technique?

to ensure you understand the correct meaning of pt statement or emotion. Reflect back to statement or feeling you heard “it sounds like you are feeling…”

Why use summarize and teach back techniques?

Ask pt to repeat plan made to reinforce it and make sure they understand it.

What are the most important history taking approaches?

1. Adjust Environment

2. Establish the Agenda

3. Interview 1st question for every system

4. Find professional medical interpreter if pt speaks different language

What is part of adjusting the environment?

• Make setting private and comfortable as much as possible

• Ask permission to pull privacy curtains shut.

• Suggest moving to a empty room instead of waiting area

• reduce noise level as much as possible

• if watching tv, ask to lower volume or turn off

• adjust room temp. for pt needs

What is part of establishing the agenda in an interview?

• begin with open-ended questions, ex: “what concerns bring you here today?”

  Helps pt to express any possible concern and not restrict the pt to a problem.

What are three parts of a female reproductive history?

Menstrual history, obstetric history, and sexual history

***REMEMBER

When should you ask the pt their sexual history?

At the end, or if pt comes with sexual problem, it is appropriate to follow their lead with questions relating to the issue.

Can a interpreter for the pt be a family member or friend?

No, it is not only hazardous, but also confidentiality and cultural norms may be violated.

What occurs during the pre-interview?

Setting the stage by:

• self-reflection

• review patient record

• setting interview goals

• reviewing own clinical behavior and appearance

What occurs during the introduction of an interview?

Putting pt at ease and establish trust

• greet pt and establish rapport

• establish the agenda of interview

What occurs during the working phase of an interview?

Obtain pt information

• invite pt’s story

• identify and respond to emotional cues

• expand and clarify the pt’s story

• generate and test diagnostic hypotheses

• negotiate a plan, with further evaluation, treatment, education, and self-management support & prevention

What occurs in the termination phase of an interview?

• summarize important points

• discuss plan of care

What does a comprehensive health assessment include?

pt’s current health problem, past history, family history, body system review, and health pattern.

What is the purpose of a comprehensive health assessment?

provides a basis for assessing pt concerns, health status, risk factors, and health promotion. provides nurse with full pt’s health statues, and health promotion and risk reduction needs.

What are the 7 components of a comprehensive adult health history?

1. Identifying data and source

2. Chief Complaint (CC)

3. History of Present Illness (HPI)

4. Past History

5. Family History

6. Review of systems

7. Health Patterns & Personal/Social

When is a comprehensive health assessment completed?

In the admission of a new pt to a clinic, hospital, long-term care facility, or visiting nurse agency.

What about allergies should be noted?

the allergen (meds, foods, insects, env. factors) and the specific reaction to each (rash, nausea, anaphylaxis..)

What about medication should be noted?

the name, dose, route, and frequency. ALSO list home remedies, nonprescription OTC, vitamins, mineral, herbal supplements, oral contraceptives, and borrowed medicines.

In health history, what goes under identify data?

• age, date of birth, gender, occupation, relationship status, education, language

• source of the history

In health history, what goes under reliability?

Note if pt or source appears reliable when giving history.

• may vary depending on source’s memory, trust, and mood

• if judged unreliable, provide reason why

In health history, what goes under chief complaint?

the one or more symptoms or concerns causing pt to seek care

In health history, what goes under history of present illness?

• elaborate CC; describe how each symptom developed

• include pt’s thoughts and feelings about illness

• pull relevant portions of review of systems

• may include; medications, allergies, and habits of smoking and alchohol use

In health history, what goes under past history?

• list of childhood illnesses

• list of adult illnesses w/dates for at least 3 categories: medical, surgical, psychiatric

• health maintenances practices: immunizations, screening tests, lifestyle issues, and home safety

• risk factors

In health history, what goes under family history?

• outline of age and health or age and cause of death of: siblings, parents, grandparents, and children

• document presence of absence of specific illnesses in family (hypertension, coronary artery disease…)

In health history, what goes under review of systems?

presence or absence of common symptoms related to each major body system

In health history, what goes under health patterns?

personal and social history

What occurs during the Mental health History?

• be sensitive to reports of mood changes or symptoms

• Two opening screening questions: “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

• If the patient seems depressed, also ask about thoughts of suicide: “Have you ever thought about hurting yourself or ending your life?”

REMEMBER: explain what you are going to do and why to elderly, may be afraid is they don’t know the type of question you will ask.

What should you ask about illicit drug usage?

• ask open questions: “Have you ever used any drugs other than those required for medical reasons?”

• Start specific naming the substances

• ask patterns of use (last use, how often, substances used, amount, modes)

• Ask if in control, any bad reactions, accidents, injuries, arrest, job or family problems, have tried to quit?

What should be gathered for health patterns?

Personal/social history and daily living routines that may influence health and illness

ex: current stressors, what they do to reduce stress

What is cultural competence?

recognizing the need for a set of skills necessary to care for people of different cultures.

What is cultural humility?

process that requires humility as individuals engage in self-reflection and self-critique.

• examining cultural beliefs and systems of pt and nurses to locate cultural dissonance that contribute to pt’s health outcomes.

• **remove power imbalance and have mutual respect

What are the dimensions of cultural humility?

1. Self-awareness

2. Respectful communication

3. Collaborative partnerships

In cultural humility, what does the self-awareness dimension mean?

to learn about your own biases, since we all have them

In cultural humility, what does respectful communication dimension mean?

to work to eliminate assumptions about what is “normal”. Learn directly from pts, they are the experts on their own cultures, needs, and illnesses.

In cultural humility, what does the collaborative partnerships dimension mean?

to build your pt relationships on respect and mutually acceptable plans

What is spiritual assessment?

the sources of hope and strength to a pt

How do you ask a pt about their spirituality?

“Who is the most important person to you?”; “To whom do you turn when you need help? Are they available?”

What is the difference between spirituality and religion?

Spirituality is “all behaviors that give life and strength to the individual”; while religion is a system of beliefs or a practice of worship.

Hiking, praying, singing, reading, and meditating is an example of spirituality or religion?

Spirituality

Attending church or a place of worship is an example of spirituality or religion?

Religion

What is a bias?

preference, tendency, or judgment that is unfair or one-sided

Making assumptions about someone based on their group or identity.

• Example: Assuming an older adult cannot learn new technology.

Is an example of?

Bias

• Judging behavior based on your own cultural norms.

• Example: Thinking a patient’s way of expressing pain is “exaggerated” because it’s different from your culture.

Is an example of?

Bias

How can a nurse demonstrate nursing presence?

• Observe nonverbal cues

• Key nursing action; listen, not talk

• Encourage the pt to express feelings/concerns

• DO NOT offer advice or solutions

  • INSTEAD: help pt identify problem and resources used in the past to cope w/problems.

What is physical examination?

to obtain objective data from the pt.

What should be done to the bed during examination?

adjust to convenient height and lower the bed when you are finished

What should be done to the environment?

arrange to provide good lighting and a quiet environment. if the tv interferes, politely ask pt to lower. remember to thank pt when leaving.

what is tangential lighting?

Light that is optimal for inspecting as it casts light across body surfaces that shows contours, elevations, and depression. **perpendicular

good for: the jugular venous pulse, thyroid gland, apical impulse

What are the cardinal techniques of examination?

Inspection, palpation, percussion, and auscultation.

ALWAYS in this order, except abdomen

What is the order of cardinal techniques of examination for abdomen? and why?

inspection, auscultation, percussion, and palpation. To not increase bowel motility with palpation.

What is palpation?

tactile pressure from the palmar fingers or finger pads to asses areas of skin elevation, depression, warmth, tenderness, lymph nodes, pulses, contours and sizes of organs and masses.

what is percussion?

involves tapping body parts to produce sound waves that enable the examiner to asses the density of underlying structures.

What are the general goals of examination?

1. Maximizing pt’s comfort

2. Maintain pt safe

3. Avoid unnecessary changes in position

4. Enhancing clinical accuracy and efficiency

How can you maintain pt’s safety?

by initial washing of hands, fall prevention techniques, cleaning equipment.

How can you enhance clinical accuracy and efficiency?

move from “head to toe”, avoid examining pt’s feet before checking face/mouth

What is the ophthalmoscope for?

aid in assessing the red reflex of the eyes and inner structure of the eye such as the retina

What is the otoscope for?

aids to assess tympanic membrane and external ear canal

What is the stethoscope for?

to listen to heart sounds, bowel sounds, bruits, and breath sounds

What is the reflex hammer for?

aids in assessing deep tendon reflexes (DTR)

What is the tunning fork for?

aids in assessing hearing loss

What is the purpose the general survey?

it gives a quick impression of the pt’s general health and well-being before diving into a detailed assessment

What factors do you check for in a general survery?

general appearance, apparent state of health, nutritional status, demeanor, facial expression or affect, grooming, posture, gait, LOC.