HA Exam 1

What are the three types of assessments?

Comprehensive, focused, and emergency

Comprehensive assessment

Full examination of all body systems that is conducted in a systemic way from head to toe 

Focused assessment

assessment of either a body system or a body part that is guided by the clients presenting concern

Emergency assessment

systematic evaluation conducted to quickly identify life-threatening conditions or urgent needs in a patient or population, enabling immediate and prioritized interventions

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

uses clinical judgment to evaluate data collected to formulate the client’s problems and develop plan of care

Planning

problem solving and decision-making skills are used to prioritize outcomes and goals, and develop interventions to meet the goals

Implementation

interventions are carried out and clinical judgment is used to monitor clients profess toward achieving their goals

Evaluation

effectiveness and achievability of goals are evaluated for adjustments that may need to happen

Steps of Clinical Judgement 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 data)

• 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 on 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 then continue plan or work on next priority

• If goals are not met -> revise goal

Subjective Data

clients reason for visiting provider; what the client tells the provider

Objective Data

observations or measurements of client’s health condition

Ethical principles

• nonmaleficence

• beneficence

• autonomy

• justice

• confidentiality

• fidelity

Nonmaleficence

to do no harm

Beneficence

client’s right to make decisions

Autonomy

client’s right to make decisions

Justice

treat everyone fairly

Confidentiality

respecting the rights of the client to maintain privacy

Fidelity

faithfulness or 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

What is a stethoscope used for?

Listening to sounds of the heart, lungs, stomach, intestines, and arteries

When should the diaphragm of the stethoscope be used?

For high pitched sounds like breath, bowel, and heart sounds

When should the bell of the stethoscope be used?

For soft, low pitch sounds like extra heart sounds or memories

What is a doppler used for?

assessing circulation or pulse in feet

What is the purpose of a general survey?

Initial appraisal of a client’s overall presentation and behaviors to obtain baseline readings

What data is collected during general survey?

• appearance

• behavior

• mobility

• measurement

• vital signs

• pain level

What is assessed under appearance?

• Client’s age and gender identity

• Facial features

• Eye contact

• Skin

• Hygiene

• Body structure

• Indicators of abuse/neglect

What is assessed under behavior?

• Speech

• Mood

• Affect

• Emotional state

• Level of consciousness

What is assessed under mobility?

gait and ROM

What is assessed under measurement?

• Height

• Weight

• BMI

What is assessed under vital signs?

• Temperature

• Pulse

• Pulse symmetry

• Respirations

• Blood pressure

Expected findings for facial features

symmetrical face

Unexpected findings for facial features

• Expressionless face or “mask like” face

• Asymmetrical facial features, such as drooping eyelid or one drooping side of the mouth

• Involuntary facial movements, such as twitching or excessive blinking

• Swelling

• Lesions

Expected findings for emotional state

• Relaxed posture

• Smiling

• Responsiveness to communication

Unexpected findings for emotional state

• Restless, grimacing, or quiet, indicating pain, anxious, or upset

• Anger, distrust, depression, and sadness expressed through being uncooperative, withdrawn, or tearful

Expected findings for eye contact

direct

Unexpected findings for eye contact

• Avoidance of eye contact, indicating confusion, anxiety, or defensiveness

• Penetrating stare, communicating negative feelings

• Squinting or staring without blinking can be manifestations of an eye dysfunction

Expected findings for level of consciousness (LOC)

• Client is alert and oriented to person, place, time, and situation

• Awake or easy to arouse

• Responds appropriately to questions

Unexpected findings for level of consciousness (LOC)

• Confusion

  • Dementia – chronic, progressive

  • Delirium – acute, temporary

• Lethargy – quickly drifts off to sleep, easily awaked

• Obtundation – asleep, only arouses to loud noise, physical stimuli, incoherent

• Comatose – unconscious, no response to stimuli

Expected for speech

Fluency, pace, articulation normal

Unexpected for speech

Whispering, dysarthria, aphasia, absence, abnormal tone or pace

What is mood?

state of emotion

What is affect?

physical expression of a client's mood or how the mood appears to others

Expected findings for mood and affect

Pleasant and cooperative

Unexpected findings for mood

• Client who is smiling and laughing while talking about a difficult situation

• Client whose face remains expressionless has a flat affect, possibly indicating depression

Expected findings for grooming

• Clean clothing that fits well

• Hair and facial hair that is well-maintained

• Nails that are trimmed and clean

Unexpected findings for grooming

• Clothing that is mismatched or not buttoned correctly

• Hair that is dirty or uncombed

• Clothing that is too loose or tight

• Long sleeves on a hot day

Expected findings for odor

Natural or pleasant odors for both the body and the breath

Unexpected findings for odor

• Halitosis, or bad breath, maybe indicative of poor oral hygiene

• Unexpected breath odor, such as alcohol, fruity breath, and ammonia

• Musty body or breath odor can indicate liver disease

• Fecal breath odor can indicate vomiting

Expected findings for dental hygiene

• Lips should be smooth, moist, and darker than the color of the surrounding skin

• Gums, or gingiva, should be intact, moist, and firmly attached to the teeth in a scalloped shape

• Teeth should be intact, aligned, and smooth

Unexpected findings for dental hygiene

• Lips that are dry and cracked, indicating dehydration or excessive, licking of the lips

• Gums that are bleeding, swollen, overgrown, spongy, retracted, or discolored

• Teeth that are missing, misaligned, or broken, and are brown or dark yellow

Expected findings in body structure: posture

• Relaxed

• Straight vertical line

Unexpected findings in body structure: posture

• Slumped or rigid posture and fidgeting

• Stiff spine, and neck

• Slumped shoulders, erect, and rigid position, or bent posture

• Tripod position – arms resting on knees

Expected findings in body structure: build

• Normal height for age

• Symmetry of extremities

• Nourishment – well nourished

• Weight evenly distributed

Unexpected findings in body structure: build

• Height out of expected reference range

• Asymmetry of body part of limbs

• Uneven weight distribution

• Anorexic, obese

Expected findings in body mobility

• Smooth gait with coordinated movements and distance between feet

• Rise form and sit in chair without use of arms

• Full ROM

• No involuntary movements

Unexpected findings in body mobility

• Wide stance

• Staggering, stumbling, shuffling

• Dragging or limping

• Immobility of a leg

• Guarding

• Inability to rise or sit without using hands

Active ROM

patient can do it themselves

Passive ROM

patient needs help to do it

Assisted ROM

patient is being assisted with it

Expected findings in body mobility: ROM

• Conscious, smooth, coordinated movements

• Full mobility of joint

• Symmetrical between right and left

Unexpected findings in body mobility: ROM

• Limited ROM

• Pain with movement

• Immobility due to paralysis or injury

• Jerky, uncoordinated movements

• Hesitancy with movement

• Asymmetry of joints

• Crepitus – cracking when bone surface rub against each other

Unexpected findings of involuntary movements

• Spasticity

• Rigidity

• Fasciculation

• Myoclonus

• Tic

• Tremors

Spasticity

alteration manifested as increased muscle tone

Rigidity

alteration in muscle tone manifested as resistance to any manipulation of the joint

Fasciculation

alteration in muscle movement seen as a continuous, rapid twitching of a muscle at rest

Myoclonus

alteration and muscle movement that is seen as a sudden jerking of muscle

Tic

alteration and muscle movement characterized by involuntary, repetitive movement of a muscle group related to a neurologic or psychogenic cause

Tremors

alteration and muscle movement by opposing muscle groups that result in a rhythmic movement of one or more joints

What tools is used to measure height?

stadiometer

Expected findings in measurement: weight

influenced by genetics, exercise, diet, and fluid volume

Unexpected findings in measurement: weight

unintentional weight gain or weight loss

What is BMI used for?

To assess for healthy weight and is a preferred method for identifying total body fat over assessing body weight alone

What is the formula to calculate BMI?

weight/height x 703

Underweight BMI

<18.5

Healthy weight BMI

18.5 - 24.9

Overweight BMI

25 - 29.9

Obesity BMI

30+

What part of hypothalamus controls heat loss?

Anterior hypothalamus

What part of hypothalamus controls heat production and conservation?

Posterior hypothalamus

Vasoconstriction

conserves the core temperature and prevents heat loss through the skin by decreasing blood flow to extremities and skin

Vasodilation

Loss of heat through evaporation, radiation, conduction, and convection by widening blood vessels and increasing blood flow to skin

Expected findings in vital signs: temperature (oral)

36° to 38°C (96.8° to 100.4°F) with the average being 37°C (98.6°F)

Normal oral temperature range for older adults

35° to 36.1°C (95° to 97°F) due to less body fat

How does rectal temperature compare to oral temperature?

Usually 0.5°C and 0.9°F higher than oral temperature

Which temperature route is the most accurate for core temperature?

Rectal

How does temporal temperature compare to oral temperature?

Nearly 0.5°C and 1°F higher than oral temperature

How can temporal temperature be most accurate?

When combined forehead and behind the ear readings are obtained

How does axillary temperature compare to oral temperature?

Usually 0.5°C and 0.9°F lower than oral temperature

Which temperature route requires longer measurement time and is less accurate?

Axillary

How does tympanic temperature compare to oral temperature?

Consistent with oral temperature