Health Assessment Exam 1

Steps of the Nursing Process

1. Assessment

2. Analysis

3. Planning

4. Implementation

5. Evaluation

assessment

the nurse gathers information from the client through interview, physical exam, and observation

analysis

- RN analyze subjective and objective data collected during assessment using clinical judgement

- RN then collabs with client to develop client plan of care

planning

nurse prioritizes outcomes and goals and develops interventions to meet goals

implementation

- carry out interventions that have been established

- use clinical judgements to monitor client's progress toward achieving their goals

evaluation

nurse will evaluate the effectiveness and achievability of the goals and need for adjustment of the interventions

clinical judgment model

1. recognize cues (collect data)

2. analyze cues (identify problems)

3. prioritize hypothesis (competency based on nursing diagnosis)

4. generate solutions (goals)

5. take action (nursing interventions)

6. evaluate outcomes

recognize cues (collect date)

What's going on with the patient?

- review the chart (history, meds, labs, vital signs)

- perform a head-to-toe OR focused/problem-based assessment as appropriate

- talk with the patient, family, and healthcare team

- Identify subjective and objective data

analyze cues (identify problems)

What does the data mean?

- group related signs and symptoms

- identify actual or potential problems

prioritize hypothesis (competency based nursing diagnosis)

What is most important right now?

- Use ABCs and Maslow's Hierarchy

- Decide what is life-threatening vs. less urgent

generate solutions (goals)

What should improve?

- write SMART goals (specific, measurable, achievable, realistic, time-bound)

- focus on priority problems first

- include short term (< 24 hrs) and long term goals (>24 hrs)

take action (nursing interventions

What will the nurse do?

- monitor VS, LOC, I&O

- provide care (oxygen, positioning, meds)

- teach the patient and family/advocates

- collab w/ healthcare team (what can/needs to be delegated)

evaluate outcomes

Did it work?

- reassess the patient

- compare findings to baseline

- if goals are met -> continue plan or work on next priority

- if goals are not met -> revise goals or interventions

ethical principles

- nonmaleficence

- beneficence

- autonomy

- justice

- confidentiality

nonmaleficence

to do no harm

beneficence

act to promote the good of the client

autonomy

client's right to make decisions

justice

treat every fairly

confidentiality

respecting the rights of the client to maintain privacy

fidelity

faithfulness; loyalty

therapeutic communication

- do not use "we"

- do not assume

- do not ask irrelevant personal question

- do not give personal opinions

- do not give false reassurance

- do not relay disapproval

physical assessment techniques

1. inspect

2. palpate

3. percuss

4. auscultate

physical assessment techniques for abdomen

1. inspect

2. auscultate

3. percuss

4. palpate

steps of general survey

- appearance

- behavior

- body structure

- mobility

- height, weight, BMI

- VS

- pain

- indicators of abuse (bruises, overbearing guest) / neglect (overgrown nails, odor, matted hair) / human trafficking

dementia

chronic and progressive

delirium

acute and temporary

lethargy

quickly drifts off to sleep, easily awakened

obtundation

asleep, only arouses to loud noises or physical stimuli, confused, speaks one-word sentences when awake

stupor

unconscious, responds to painful stimuli, incoherent

comatose

unconscious, no response to stimuli

spasticity

- increased muscle tone

- increased passively extending a joint

rigidity

resistance to any manipulation of the joint

fasciculation

continuous, rapid twitching of muscle at rest

myoclonus

- sudden jerking of a muscle

- hiccups

- seizure activity

- falling asleep

tic

- involuntary, repetitive muscle movement

- neurologic or psychogenic cause

- grimaces, winks, shoulder shrugs

tremors

rhythmic movement of joints, at rest or purposeful movement

sources of pain

- visceral (begins in the larger internal organs, described as deep cramping, squeezing, or dull pain)

- somatic (often associated with the musculoskeletal system, described as throbbing or deep achy feeling)

- referred (felt in one area but originates elsewhere, ex. cardiac pain that is felt in left arm or neck)

PQRST pain assessment

- provocation/palliation

- quality

- region

- severity

- timing

provocation/palliation

- What were you doing when the pain started?

- What makes it better?

- What makes it worse?

- What triggers the pain?

- What relieves it?

quality

- Describe the pain.

- Is it dull or sharp?

- Is it stabbing, throbbing or cramping?

region

- Where is the pain?

- Does it radiate?

- Is it localized?

severity

- How severe is it?

- Does it interfere with activities?

- How long does it last?

timing

- What time did it start?

- How long does an episode last?

- Is it sudden or gradual onset?

- Does it occur during the day or night?

health history purpose

have a structure conversation with client to gather pertinent details about their background and current medical status

stages of health history interview

1. introduce yourself and the reason for your health history interview

2. use therapeutic communication to collect and document client data

3. thank the client for their participation, answer and questions and summarize the collected info

key elements of health history interview

P - past medical history to include pervious illnesses and state of health

L - last oral intake of liquids and food

E - events leading to illness or injury

A - allergies and types of reactions

S - symptoms or chief complain

E - each prescribed medication, OTC meds, and herbal supplements

interpret and validate

responses by repeating a summary of their responses back to them

skin layers

epidermis (top layer)

dermis (middle layer)

subcutaneous (bottom layer)

physiology of skin & nails

- protect inner body parts and organs

- body temp regulation through shivering and sweating

- sensory perception of temperature, touch, and pain

- excrete waste and toxic substances

- produce vitamin D

steps of skin assessment

1. health history interview

2. inspect skin color

3. inspect skin texture & moisture

4. inspect skin integrity

5. skin temperature

6. skin mobility and turgor

7. inspect nails

health promotion intervention

- bathing and hygiene practices

- sun exposure

- self-assessment of moles and suspicious lesions

ABCDE Rule for skin integrity

A - asymmetry

B - border (irregular)

C - color (multiple)

D - diameter (>6 mm)

E - evolving (changing rapidly)

*if 2 or more are present, risk is high and need biopsy

conjunctivae

mucus membranes that cover the surface of the eye and the inside of the eyelids

sclera

white outer layer of the eyeball

cornea

transparent layer that covers the iris and pupil

lacrimal apparatus

keeps the conjunctiva and the cornea moist and lubricated with constant irritation

iris

colored portion of the eye

tympanic membrane

ear drum

pinna/auricle

external ear

steps of head, neck, and neurological assessment

1. inspect and palpate head

2. inspect and palpate face

3. palpate temporal artery

4. palpate temporomandibular joint

5. inspect nose and test nasal patency

6. palpate frontal and then maxillary sinuses

7. percuss frontal and then maxillary sinuses

8. inspect client's mouth

9. inspect the neck

10. inspect and palpate trachea

11. inspect and palpate thyroid gland

12. palpate lymph nodes

health record

- individualized collection of health information and data bout a client's health

- identifies the health services that have been provided to the client

components of a health record

- medical history

- demographics

- vital signs

- medications

- allergies

- immunizations

- diagnoses

- treatments

- lab and radiology studies

documentation guidelines

must be clear, accurate, and concise

legal considerations regarding documentation

- can be used in any legal proceedings

- nurse must document only accurate information

- records must be kept private and confidential

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