Health Assessment Exam 1

adult respiratory rate

12-20 breaths/min

adult pulse rate

60-100 bpm

pulse volume

0= absent

up to 4+ = bounding

body temperature

97.8-99.1 degrees Fahrenheit

normal BP

below 120 and below 80 mm Hg

light palpation

about1 cm; done before deep palpation (4-5 cm)

Droplet precautions

surgical mask within 3-6 feet of the client

Complete health history

can take 30-60 minutes; pause if the client seems fatigued

Repeat BP reading

deflate the cuff and wait 1-2 minutes

chronic pain

lasting longer than 3-6 months

rectal temperature

not for infants under 2 years old

adult hypertension screening

USPSTF Grade A

abdominal exam order

inspection, auscultation, percussion, palpation

every other system exam order

inspection, palpation, percussion, auscultation

critical thinking

Purposeful, logical, reflective thinking

Analyze information and evidence, question assumptions, consider alternatives, and make logical decisions

clinical reasoning

Applies knowledge to a specific client

Connect assessment findings, interpret relevant information, and consider possible explanations

Clinical judgement

Recognizes what is happening, determines what is most important, decides what action is needed, and evaluates the client’s response

Nursing process

Assessment, diagnosis, outcomes identification, planning, implementation, evaluation

NJCMM steps

Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes

assessment

collect data: health history, physical examination findings, diagnostic and laboratory data

Diagnosis

Identify client responses and problems

Nursing diagnoses: problem-focused, health promotion, and risk

Outcomes identification

Client goals; specific, measurable outcomes; a time frame

Planning

Set priorities and choose interventions using evidence-based practice

Implementation

Coordination of care, health teaching and health promotion, carrying out the care plan

Evaluation

Were the goals met? If not, revise the care plan

SBAR

Situation, Background, Assessment, Recommendation

When is SBAR used?

handoff, transfer of care responsibility, telephone and interprofessional communication

Written and electronic tools

EHR, nursing notes, flow sheets, care plans, the medication administration record, clinical communication forms

CBE

charting by exception

SOAP

Subjective data, Objective data, Analysis of data stated as a nursing diagnosis, Plan

PIE

Problem/diagnosis, Intervention, Evaluation

Role of the nurse

first point of contact and tone-setter, establishes trust and privacy, explain the purpose and process, appear professional, use culturally responsive communication, foster a safe and comfortable environment, watch verbal and non verbal cues, use teachable moments

Role of client

active and equal participant, share concerns, symptoms and goals in their own words, ask questions, take part in decisions, and identify preferences, strengths, and barriers.

Previous experience shape their perceptions

complete (comprehensive) health history

full baseline of physical, emotional, and social health; annual physicals, initial hospital admissions

Episodic (focused, problem-oriented) health history

targeted to a specific system or acute problem: urgent care or clinic visit for a new rash

O of OLD CARTS

onset

L of OLD CARTS

location

D of OLD CARTS

Duration

C of OLD CARTS

character or quality

A of OLD CARTS

aggravating and alleviating factors

R of OLD CARTS

Radiation or relieving factors

T of OLD CARTS

Timing

S of OLD CARTS

Setting and severity

standard precautions

All clients

Hand hygiene before and after every client contact, task-specific PPE, respiratory hygiene and cough etiquette, appropriate client placement, equipment handling and environmental disinfection, safe injection practice, clean reusable instruments between clients

contact precautions

gloves when entering; gown when contact with the client or the environment is expected

C. diff: soap and water, not hand sanitizer

airborne precautions

N95 respirator; client in negative pressure Airborne Infection Isolation Room

Inspection

general survey, skin, HEENT, chest contour, musculoskeltal alignment

Palpation is used for

abdomen, peripheral pulses, lymph nodes, skin warmth, fremitus

percussion is used for

lungs and abdomen

Auscultation is used for

heart, lungs, bowel sounds, arteries

ANA Standards of Professional Nursing practice includes

Assessment

Diagnosis

Outcomes Identification

Planning

Implementation

Evaluation

Purpose of motivational interviewing

a collaborative, person-centered approach to help clients explore and identify their own motivation for health behavior change

Communication Facilitators

ensuring privacy

allocating adequate time

maintaining comfortable eye-level positioning

using plain language

nonjudgmental attitude

utilizing professional interpreters

Communication hindrances

environmental noise

interruptions

acute pain

fatigue

severe anxiety

language barriers

medical jargon

rushed pace

personal bias or judgment

Effective communication Techniques

open ended questions

focused follow up

therapeutic silence

empathy

clarification

summarizing

appropriate touch

teach back

Nurse self awareness

recognize personal assumptions

monitor tone and body language

acknowledge emotional reactions

seek clarification instead of guessing

Listening responses

silence, facilitation, reflection and restatement

clarification and perception

Action responses

Providing information and offering self, focusing and summarizing

Acknowledge feeling, clarify concern, provide information, confirm understanding

Nontherapeutic Communication

giving unasked advice, expressing approval/disapproval, false reassurance, asking “why?” in a blaming tone, minimizing concerns, excessive interrogation, using medical jargon or stereotypes

Problematic Questioning Techniques

leading questions

rapid-fire multiple questions

forced yes/no questions when qualitative detail is needed

10 characteristics of a chief complaint

OLDCARTS

Past Health History Components

childhood illnesses

chronic conditions

major hospitalizations

surgical history

obstetric history

immunization status

verified allergies

current medications

Family Health History & Genogram Construction

identifies genetic predispositions and hereditary risk patterns across three generations

Square for males, circles for females, diagonal lines for deceased relatives

Health Maintenance Activities

evaluates preventive behaviors is including routine checkups/screenings, immunization currency, nutrition, physical activity, sleep hygiene, safety practices, and substance use screening

Comprehensive review of systems

evaluates client-reported subjective systems, not objective physical examination findings

USPSTF Recommendations in Client Care

provides evidence-based recommendations (Grades A and B) to guide primary care clinicians in preventive screening, screening, counseling, and disease prevention

Pillars of Legally Defensible Documentation

FACT

FACT

Factual

Accurate

Complete

Timely

Documenting Ill Clients

Emphasizes detailed symptom analysis (HPI), rapid cue recognition, current coping strategies, and the functional impact of illness on daily living

Percussion sound: resonance in lungs

normal tissue

percussion sound: hyperresonance in lungs

over trapped air

percussion sounds: tympany in abdomen

gas-filled structures

Percussion sound: dullness in abdomen

solid organs or fluid

Diaphragm of stethoscope

flat side

high-pitched sounds (breath sounds, bowel sounds, normal S1/S2 heart sounds

Bell of stethoscope

cup side

low pitched sounds (murmurs, bruits)

cardiopulmonary distress symptoms

nasal flaring, tripod posture, cyanosis

acute pain symptoms

grimacing, guarding

Respiratory rate is altered by

age, exercise, fever, pain, anxiety, altitude, medications

What do opioids do to respiration?

depress respirations

What do bronchodilators do to respirations?

increase respiration rate

Pulse volume

0=absent to 4+=bounding

pulse sites

radical, apical, carotid, brachial, femoral, popliteal, posterior tibial, dorsalis pedis

BP Factors

age, stress, ethnicity, obesity

falsely high BP

cuff too small and placing arm below heart level

falsely low BP

cuff too large, arm above heart level

Body temperature is influenced by

circadian rhythm, age, hormones, exercise, environment, stress

oral temperature

accessible and convenient

Affected by recent ingestion of hot/cold food or smoking

Tympanic temperature

rapid core estimate

Affected by cerumen impaction

Temporal Temperature

fast and well tolerated

affected by forehead perspiration

Axillary Temperature

Safe and non invasive

less accurate skin-surface measurement

Rectal temperature

highly accurate core temperature baseline

invasive tissue perforation risks

Nociceptive pain

Often described as a burning or tingling pain

FLACC pain scale

Tool used for a pediatric or nonverbal patient

Adult hypertension USPSTF Grade

Grade A

Universal Intellectual Standards (UIS)

clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness

Stages of Interview

Stage I: joining

Stage II: working

Stage III: termination

Flatness

soft intensity, high pitch, found in muscle and bone normally

Lung flatness

severe pneumonia

Dullness percussion

moderate intensity, high pitch, normally found in organs (liver)

Lung dullness

atelectasis