Mod 1-3 Health Assessment

What are the 2 key goals of health assessment?

Normal vs Abnormal

Patient Centered Care

What is nursing ADPIE?

Assessment

Diagnosis

Planning

Implementation

Evaluation

What are the components of the subjective data?

(think, what would you ask during the HPI documentation?)

— Onset

– Location

– Duration

– Intensity

– Quality/Description

– Alleviating/Aggravating factors

– Pain management goal

– Functional goal

What are the components of objective data?

Physiological effects of pain — Stress response & muscle tension

Inadequately treated pain — Nausea, diaphoresis

Observable behavioral responses — vocalizations

Subjective vs Objective data

Subjective is what the patient/family member reports

Objective is what the nurse sees and assesses

In a SOAP note, what is included in the Subjective?

CC, HPI, PMH & PSH, ROS, current meds, allergies

In a SOAP note, what is included in the Objective?

VS, PE findings, Labs, Imaging, diagnostic, documentation of other clinicians

Open vs Closed Q’s

Open — any response

Closed — yes or no

OLDCARTS

O: Onset

L: Location

D: Duration

C: Character

A: Alleviating/Aggravating

R: Radiation

T: Timing

S: Severity

OPQRST

O: Onset

P: Provocative or palliative

Q: Quality

R: Region, radiation

S: Severity

T: Timing

Supine

Sims

Lithotomy

Dorsal Recumbent

Prone

Knee-chest

Psychomotor skills (NEED TO KNOW)

Inspection

Percussion

Palpation

Auscultation

Why is there a specific order to the psychomotor skill?

Because palpation can change the way you hear things in the body

3 types of percussion techniques

Direct

Indirect

Indirect fist (blunt)

JCAHO standards

Assess/reassess pain regularly

Name the 5 levels of consciousness

Alert

Confusion

Drowsiness

Stupor

Comatose

The ____ the score, the more alert a person is on the Glasgow Coma scale

HIGHER

Mini-mental exam Q’s

Object recognition

Serial 7’s or simple math

Spelling — forward or backwards

Following written directions

Copying a sentence or a picture of a clock or house

Telling meaning of a phrase

Non-modifiable factors

Age

Gender/s3x

Family history

Environmental (changeable) factors

Support systems, housing, healthcare accessibility, literacy

Metabolic issues/associated physiological processes

Parkinson’s, cancer, HIV/AIDs, chronic conditions

ABCT (objective data)

Appearance

Behavior

Cognitive function

Thought processes and perceptions