NUR 3121 Health Assessment Exam 1

What is the Nursing Process

Assessment

Diagnosis

Planning

Implementation

Evaluation

(ADPIE)

Risk-Focused Nursing Diagnosis

Clinical judgements that a problem does not yet exist; risk factors are present. The two components include (1) risk diagnostic label and (2) related factors

Risk for infection as evidenced by prolonged hospitalization, compromised immune system, invasive procedures.

Problem-Focused Nursing Diagnosis

The client's problem is present at the time of assessment. The three components include (1) nursing diagnosis, (2) related factors, and (3) defining characteristics

ineffective breastfeeding related to maternal anxiety, inadequate family support, and pacifier use as evidenced by infant crying at breast, infant unable to latch on to maternal breast correctly, and sustained infant weight loss.

Health Promotion Focused Nursing Diagnosis

The client displays a readiness to improve health. The two components are (1) nursing diagnosis and (2) defining characteristics.

Readiness for enhanced breastfeeding as evidenced by verbalized commitment to breastfeeding and expressed interest in learning proper latching techniques.

What are the aspects of clinical decision making?

best evidence from literature + patient preference + clinical expertise and experience + physical exam

Subjective data

what the patient tells you; symptoms

Objective data

information that is seen, heard, felt, or smelled by an observer; signs

Complete health assessment

Describes current and past health state and forms the baseline to measure all future changes

Focused or problem-centered database/assessment

Collect "mini" database, smaller scope and more focused on current situation than the complete database

Follow-up database/assessment

Status of all identified problems should be evaluated at regular and appropriate intervals

Emergency database/assessment

Rapid data collection, may be done along with lifesaving measures

What are the 5 tiers of Maslow's Hierarchy of Needs?

Physiological needs, safety needs, belongingness and love needs, esteem needs, and self actualization

What is first level priority in nursing?

Emergency, life threatening, and immediate.

ie. ABCs

What is second level priority in nursing?

Next in urgency, requiring attention to avoid further deterioration.

ie. pain, mental status changes, abnormal labs, elimination patterns

What is third level priority in nursing?

Important to patient's health but can be addressed after more urgent problems are addressed.

ie. mobility and living situation, edema

What are the ABC's?

airway, breathing, circulation

ROS

used to evaluate past and present state of each body system

Contact precautions

practices used to prevent spread of disease by direct or indirect contact. Wear gloves and gown.

Droplet precautions

Must be followed for a patient known or suspected to be infected with pathogens transmitted by large-particle droplets expelled during coughing, sneezing, talking, or laughing. Wear mask, gloves, and face shield or glasses.

Airborne precautions

Precautions to prevent disease transmission by airborne particles. Wear N95 mask, keep door closed, wash hands, isolation rooms

Standard precautions

recommendations that must be followed by everyone to prevent transmission of pathogenic organisms by way of blood and body fluids. Hand hygiene, ppe, sterilize equipment and environment, and sharps safety, etc.

Enteric precautions

MUST use soap and warm water after removing PPE, no hand sanitizer allowed, gown, and gloves ie. C Diff

What are two patient identifiers?

Name and DOB

What is holistic health?

Treat the whole body, mind, and spirit. Forces of nature must be maintained in balance or harmony

What are 3 things to keep in mind when using an interpreter?

Look at the patient for their response, avoid using a family member as an interpreter, take pauses

Define SBAR

Used in order to communicate with another provider quickly:

S: Situation

B: Background

A: Assessment

R: Recommendation

Situation

Identify self, site, unit, Pt identifiers, symptom onset, and symptom severity

Background

State date/time of admission, admission diagnosis, relevant medical history, lab results, and notable changes

Assessment

State suspected underlying cause and concerns

Recommendation

State recommendation and expectations

What is at risk drinking in women and in men?

Women is 8 or more drinks a week, men is 15 or more drinks a week

Nociceptive pain

pain from outside sources (burn, cut, etc.)

SMAST-G

assesses substance abuse in aging adults

CRAFF-T

assesses substance abuse in teens

TWEAK

assesses substance abuse in women (especially pregnant women)

AUDIT

general assessment of substance abuse

What is CIWA

Withdrawal Assessment for Alcohol; looks at HR, BP, sweating and hallucinations

What does it mean for a nurse to be a mandatory reporter?

You don't need proof, just suspicion

How do you document abuse?

Objectively document findings that suggest violence

General assessment

a general assessment is the study of the whole person, often involving a physical. It covers the general health state such as stature, appearance, gait, nutrition, posture, mobility, LOC, etc.

Level of consciousness

person alert and oriented, attends to your questions and responds appropriately

Skin color

color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion

Facial features

symmetric with movement

Overall appearance

provide general statement r/t presence or absence of distress

Stature

height appears within normal range for age, genetic heritage

Nutrition

weight appears within normal range for height and build

Symmetry

body parts look equal bilaterally and are in relative proportion

Posture

person stands comfortably erect as appropriate for age

Position

description of patient's position during assessment

Mobility

gait, range of motion

Palpation is used to assess:

Texture, temperature, moisture, organs, swelling, rigidity spasticity, presence of lumps/masses/tenderness/pain

Percussion is used to:

Map location and size of organs, signaling density of a structure by a characteristic note, detecting a superficial abnormal mass, eliciting pain if underlying structure is inflamed, eliciting deep tendon reflex using hammer

What are the basic principles of auscultation

Eliminate extra noise.

Keep environment warm and warm your stethoscope.

Avoid listening over hairy body areas.

Never listen through a patient's gown or clothing.

Avoid your own artifact.

When assessing the abdominal region....

Auscultate BEFORE palpation

What are the vital signs?

Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, and pain

What are the aspects of pulse?

Rate = numerical; tachy/bradycardia, or within normal

Rhythm = tempo; regular/irregular/regularly irregular

Force = strength; weak/normal/bounding

0 = no pulse

1+ = weak, thready

2+ = normal

3+ = full, bounding

Mean Arterial Pressure (MAP)

[(2 x diastolic) + systolic] / 3

What is physiologic pain?

The body's response to tissue damage or injury.

What is mental pain?

Emotional/psychological; includes distress, anxiety, depression.

What is functional pain?

Pain that affects a person's ability to perform daily tasks; limits mobility

What are the components of PQRST?

Provoked

Quality

Radiates

Severity

Time

HEEADSSS for adolescents

Home Environment

Education and Employment

Eating

Activities

Drugs

Sexuality

Suicide/Depression

Safety

Functional assessment

used to determine ability of Pt to complete ADLs

Describe cutaneous pain

on skin surfaces; sharp/burning sensation

Describe referred pain

Pain that is experienced in an area other than the body part that is the source of the pain; can come from internal organs

What are some objective findings in response to pain?

Grimacing, frowning, clenched jaw, guarding, restlessness, agitation, moaning, groaning, crying, increased HR/BP, diaphoresis, altered gait, dilated pupils, increased respirations, muscle tension

Inspection is

visual examination of the body

Palpation is

to examine by touch

Percussion is

tapping on a surface to assess the underlying structure

Auscultation is

Listening with a stethoscope

What is the test used to assess mental health status?

Appearance (posture, dress)

Behavior (mood/attitude, speech, facials)

Cognition (orientation, attention, memory, new learning)

Thought process (thought content, perceptions, hallucinations, reality awareness)

What are the pros and cons to the FACES pain assessment tool?

It is simple and easy to use but it is subjective for interpretation and doesn't work for those who are visually impaired

What are the pros and cons of a NRS pain scale?

It is quantitative and easy to track over time, but hard for those who are cognitively impaired or with language barriers

What is the pain scale used in those with advanced dementia?

PAIN-AD; looks at breathing, vocalization, facial expression, body language, consolability. Each indicator is scored 0-2 and then the total score is 1-10.

What are ways to promote patient safety through communication?

Ask me 3: what's my problem, what do I need to do, why is it important for me to do this?

Teach back: ensuring a patient understands their treatment plan and can teach it back to you (ie. Will you tell me how you would explain your treatment plan to your spouse?)

Use plain language

What is the correct order of observation techniques in a general assessment?

Inspection, palpation, percussion, auscultation

Oral Temp

Make sure Pt hasn't smoked or drank 15 minutes before taking. 96.4F - 99.1F

Rectal Temp

Best for infants and most accurate. 0.7F - 1F higher than oral

BP

120/80 - 90/60

Pulse

60-100bpm

Respirations

12-20 breaths/min, no dyspnea, quiet, regular rhythm, and normal thoracic movement

Orthostatic BP

BP measured when Pt goes from supine to sitting to standing. The BP is measured after the Pt stays in each position for about 3-5 minutes.

Orthostatic hypotension is when there is a decrease in systolic BP by 20mmHg or a decrease in diastolic BP by 10mmHg or more.

Pulse Oximetry

95-100%

Components of health hx

Chief complaint ("What brings you here today?")

Hx of present illness ("When did symptoms begin?")

Medical hx ("What chronic diseases do you have?")

Family hx ("What illnesses run in your family?")

Personal and social hx ("How many cigarettes do you smoke a week?")

ROS (systemic assessment of body systems)

Neuropathic pain

pain from damage to internal (shingles, upset stomach, etc.)