N209 - Overview of Assessment

Nursing Assessment

Nursing Assessment

What is the process that evaluates or appraises the needs, preferences, and abilities of a patient?

Historical Assessment

What is a subjective assessment that includes information from the patient and family's perspective?

Physical Assessment

What is the objective assessment that includes biological (senses) and physiological aspects?

Pharmacological Assessment

What is the subjective assessment that includes what drugs the patient takes, such as Rx, OTCs, herbal remedies, illicit drugs, etc.?

Psychological Assessment

What is the objective/subjective assessment that looks at the patient's mental status, ability to cope, and support systems?

• what will the pt. need going home?

Social Assessment

What is the subjective assessment that looks at the patient's family structure, roles in the family, significant other, recreation, socioeconomic status, violence, and substance abuse?

alcohol

_______ is the most used and abused psychoactive drug

4

5

Binge Drinking = a pattern of drinking that occurs within __ drinks in women and _ drinks in men, in ab 2 hours, on the same occasion in & least 1 day in last 30 days.

14

A drink = any drink that contains __g of alcohol. One physical cup/bottle can have multiple drinks.

Alcohol Use Disorder Identification Test (AUDIT)

What test is used to determine if someone has an alcohol use disorder by assessing alcohol consumption, drinking behavior or dependence, and adverse consequences from alcohol?

• Intimate Partner Violence

• Human Trafficking

• Elder abuse

• child abuse

What are important health problems that you must recognize the signs of and asses in every pt. in regard to domestic violence?

Intimate partner violence

This occurs from any partner with whom the person has a close relationship with (including emotional connectedness &/or physical/sexual contact)?

Human Trafficking

= compelling or coercing a person to provide labor or services, or to engage in commercial sex acts

• majority affected are women/girls (75%) and children (25%)

Developmental Assessment

= assessing growth and development through life

• Erickson & Piaget

• Stages of development through life

Functional Assessment

= assessment done on OA (but applies to everyone), assessing one’s ability to perform activities of daily living (ADLs) and self-care

Activities of Daily Living (ADLs)

= tasks necessary for self-care

• e.g., bathing, grooming, eating, dressing, toileting, walking, etc.

Katz Index of ADL

• used to measure performance, evaluate treatment outcomes, and predict the need for continuing supervised care in OA

• 6 points = independent ; 0 points = very dependent

Instrumental Activities of Daily Living (IADLs)

= (life management tasks) functional abilities necessary for independent community living.

• e.g., medication management, money management, shopping, cooking, housekeeping

Timed Get Up and Go Test (TUG)

Test that has the pt. stand, walk 10 ft, turn around & walk back

• if >12 sec, they’re @ risk of falling

Sitting and Standing Test

= test that helps predict mortality

• can a person stand up from sitting on the floor w/o using hands for support

Impairment

= loss/abnormality of structure or function

• e.g., amputated leg

Disability

= lack of ability to perform activity in a way that is considered normal

• e.g., (with an amputated leg) cannot walk

Handicap

= disadvantage caused by an impairment that interferes with a person's normal role

• e.g., (with an amputated leg) cannot climb stairs

Incapacity

What is the legal term/legal disability that refers to inability to provide basic needs?

Functional Limitation

= behavior or condition that impairs a person's ability to do ADLs

Nutritional status

What is the balance b/t nutrient intake & nutrient requirements?

undernutrition

= nutritional reserves are depleted and/or inadequate to meet day-to-day needs

overnutrition

= consumption of nutrients more than body’s needs

• can lead to obesity

• is a risk factor for type II DM, heart disease, and cancer

Body Mass Index (BMI)

A marker for optimal weight for height and an indicator of obesity and undernutrition

• weight (kg)/height (m)2

Waist-to-Hip Ratio

Assesses body fat distribution as an indicator of health risk.

andriod obesity

= more fat in the upper body

gynoid obesity

= more fat in the lower body

Skinfold Thickness/ Triceps Skinfold (TSF)

Estimates the body fat stores or the extent of obesity or undernutrition

Arm Span or Total Arm Length

= nearly equivalent to height and useful in situations where height is difficult to measure

• e.g. infants & bedridden patients

Sleep Assessment

= assessment of the quality of sleep (feels rested), usual pattern and times, sleep aids, rituals, and problems.

Cultural Assessment

=an assessment of cultural beliefs, customs and background.

focus assessment

This assessment is used in addition to a complete assessment and hones into an area of dysfunction or problem and in detail.

• promoting health

• preventing problems through developmental assessments

What is the focus of assessments of pediatric populations?

• promote wellness and independence

• provide the highest quality of life

What is the focus of assessments of older adult (OA) populations?

The Mini-Cog

A 3-item recall test and a clock-drawing test.

Folstein’s Mini-Mental State Examination (MMSE)

A test for orientation, recall, attention, calculation, language, and visual-spatial skill.

LGBTQ

• transgender females to males may still need a pap smear and gynecological assessments.

• transgender males to females may still need a prostate exam.

Assessments of this special population may be needed that are not apparent. What is an example?

director/ power of attorney

= type of advanced directive that allows you to choose who will make decisions on your behalf if you are incapacitated.

living will/instruction directive

= type of advanced directive that provides specific instructions for how your representative should make decisions.

advanced directive

= a legal document signed by a competent person to provide guidance for medical and health-care decisions in the even that they become incompetent to make such decisions.

health care proxy

= Someone to make health decisions if you are incapacitated.

this is a disease process (i.e., cancer)

Why might unintentional weight loss greater than 10 lbs be a cause for concern?

vision worsens with age (OA can experience cataracts, glaucoma, and macular degeneration).

every 2 years

Why is it important for routine eye screenings to be done after 40? How often should they be done?

hard of hearing

H.O.H (when documenting)

hearing loss

What can be a major obstacle in assessing OAs that can lead to inaccurate data collection?

<18.5

18.5-24.9

25-29.9

30-39.9

>40

BMI Interpretation:

_____ = underweight

____ - _____ = normal weight

____ - _____ = overweight

___ - ___ = obesity

_____ = extreme obesity

10%

What percentage of people over 65 have Alzheimer’s?

50%

What percentage of people over 85 have Alzheimer’s?

caregivers burden

the perceived strain by the person who cares for an elderly, chronically ill, or disabled person.

Myths of aging (common but not necessarily “normal”)

• confusion/delirium is normal

• the body’s reaction to medications is constant

  • polypharmacy

  • dec. liver and kidney function

• falling is normal

• OA drinks less and gets dehydrated

• urinary incontinence is normal

half

More than _____ of Americans age 12 and up use alcohol and many abuse it

7 to 8 hours

How many hours of sleep per night should an adult get?

Abrasion

What is a wound caused by rubbing the skin or mucous membrane?

Avulsion

What is the tearing away of a structure or part?

Bruise

What is the superficial discoloration caused by a hemorrhage into the tissue from ruptured blood vessels beneath the skin surface (aka contusion)?

Ecchymosis

What is a hemorrhagic spot or blotch, larger than petechia, in the skin and mucous membranes, forming a nonelevated, rounded, or irregular blue or purplish patch?

Hematoma

What is a localized collection of extravasated blood, usually clotted in an organ, space, or tissue?

Hemorrhage

What is the escape of blood from a ruptured vessel, which can be internal, external, and/or into the skin or other organ?

Incision

What is a cut or wound made by a sharp instrument; the act of cutting?

Laceration

What is a wound produced by the tearing and/or splitting of body tissue?

Lesion

What is a broad term referring to any pathological or traumatic discontinuity of tissue or loss of function of a part?

Patterned injury

What is an injury caused by an object that leaves a distinct pattern on the skin and/or organ or an injury caused by a unique mechanism of injury?

• distinct pattern: whipped with an extension cord

• mechanism of injury: immersion burns to the hands and feet

pattern of injuries

usually bruises and fractures in various stages of healing

Petechiae

What are minute, pinpoint, nonraised, perfectly round purplish-red spots caused by intradermal or submucous hemorrhage, which later turn blue or yellow?

Puncture

What is the act of piercing or penetrating with a pointed object or instrument?

Stab wound

What is a penetrating, sharp, cutting injury that is deeper than it is wide?

Traumatic alopecia

What is the loss of hair by pulling, yanking or other traumatic means?

Wound

= a general term referring to a bodily injury caused by physical means