Health Assessment Test 1

Social Determinants of Health ( SDOH )

associated with health risks and outcomes. They are proven to affect a person's health and are the effects of where people work, live, play and learn.

Health

A relative state in which a person strives to meet their potential and includes the areas of wellness with the ultimate goal of improving health. Includes the eight dimensions. It is not solely the absence of disease or eating right.

8 dimensions of health

physical, social, emotional, intellectual, spiritual, environmental, financial, occupational

Physical dimension

takes into consideration multiple areas including activity level and exercise, proper nutrition and sleep. It also looks at promoting healthy coping behaviors and identifying non healthy behaviors such as smoking, excess caffeine intake or substance abuse

Emotional dimension

is the ability to handle life and its challenges that may arise. The ability to be resilient and use coping mechanisms effectively, including strong relationships with others, are recognized.

Social dimension

is a sense of inclusiveness and connection. If a patient feels isolated, figuring out family dynamics and a potential support system are important. Providing information about self-help groups, health resources, and local organizations can promote additional avenues for socialization.

Spiritual dimension

involves a person's sense of values and beliefs. A patient may wish to speak with a spiritual advisor or may utilize meditation or some other form of self-care. Often, it is best to broach this topic and let the patient take the lead on how to handle spiritual care, as this dimension is individual.

Environmental dimension

encompasses the patient's surroundings, which may be in the home or outside and can affect health. Neighborhood safety related to violence or inside the home related to physical or sexual abuse are examples of factors to assess. Overall disorganization may negatively influence how one feels and affect health.

Intellectual dimension

is the ability to advance knowledge and is different for each person. A patient may need guidance in areas to enhance this component and suggestions might be to read, engage in a new hobby, tutor others, or learn a new language.

Financial Aspect

Finances for the basics such as shelter, food, and health care may be lacking. Insurance may not cover all facets of care or specific providers. Illness often leads to decreased income with increased costs for care and medication.

Occupational

involves the work milieu, including the type of job, relationships with coworkers, and management of stress levels. This is important in conjunction with a healthy work-life balance.

Nursing health assessment

Entails both a comprehensive health history and complete physical examination which are used to evaluate the health status of a person.

The first component of the health assessment

health history, which also incorporates the eight dimensions

The second component of health assessment

Physical examination ( Head to toe examination )

Focused examination

Is completed on a patient who has already had a comprehensive examination and is being seen for a follow up visit. Addresses focused concerns or symptoms.

Emergency assessment

A patient who presents with a new problem of a serious or critical nature would require this assessment

Purpose of health assessment

Determine a patient's health status, Determine the patient's risk factors, Determined the need for health education, Develop a nursing plan of care

Role of nurse in assessment

- Use findings and decide in which areas patient needs most care

- Deliver care across the lifespan

- Promote health and prevent disease

- Educate and counsel individuals, families, groups and communities

- Determine what affects the patients health

- Focus on health and goals of the patient

Healthy People 2030

framework that identifies risk factors, health issues, and diseases of concern in the US. Goals and objectives serve to improve the health of individuals and communities. Overall goal is to increase quality of life by creating guidelines for a healthy lifestyle.

goal of health assessment

the development of an individualized plan of care for each patient

Nursing process

Assessment

Diagnosis/Analysis

Planning

Implementation

Evaluation

Subjective data

things a person tells you about that you cannot observe through your senses; symptoms

objective data

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

OLD CART

Onset

Location

Duration

Characteristics

Aggravating factors

Relieving factors

Treatment

Steps in clinical reasoning

Identify abnormal or positive findings.

Cluster the findings.

Interpret the findings.

Make hypotheses about the nature of the patient's problem.

Test the hypotheses and establish a working nursing diagnosis.

Develop a plan agreeable to the patient.

Progress note follows what format?

SOAP

Subjective, objective, assessment, plan

motivational interviewing

Evidence-based method of therapeutic communication that enhances the nurse- patient relationship and the patients understanding of their health needs

Phases of interviewing

pre-interview, introduction, working, termination

Pre interview

Setting the stage for a smooth interview

- Self reflection

- Reviewing patient record

- Setting interview goals

- Reviewing own clinical behavior and appearance

Introduction of interview

Putting the patient at ease and establishing trust

- Greeting the patient and establishing rapport

- Establishing the agenda for the interview

working part of the interview

Obtaining patient information

- Inviting the patient's story

- Identifying and responding to emotional cues

- Expanding and clarifying patients story

- Generating and testing diagnostic hypotheses

- Negotiating a plan, include further evaluation, treatment, education and self management support and prevention

Termination of interview

- Summarizing important points

- Discussing plan of care

NURS

Naming

Understanding

Respecting

Supporting

FIFE

Patients FEELINGS

IDEAS

FUNCTION

EXPECTATIONS about the problem

Techniques of Skilled Interviewing

active listening, guided questioning, non verbal communication, empathetic responses, validation, reassurance, partnering, summarization, transitions, empowering the patients

The Cone

- Open ended questions to hear the " Story of the symptom" in patient's own words

- More specific questions to elicit the " Seven features of every symptom"

- the yes or no questions or " Pertinent positives or negatives " from the relevant of the review of systems

OARS

Open-ended questions

Affirmations

Reflective listening

Summaries

comprehensive assessment

Provides nurse with full picture of patient's health status, as well as health promotion and risk reduction needs. Head to toe assessment

Key elements of the history of present illness

- Seven attributes of each principal symptom

- Self- Treatment for the symptom by the patient or family

- Past occurrences of the symptom(s)

- Pertinent positives or negatives from review of systems

- Risk factors or other pertinent information related to the symptom

Key elements of the past history

allergies, medications, childhood illnesses, adult illnesses, health maintenance

AUDIT-C

Brief reliable test to identify individuals with alcohol use disorders or dependence

Cultural assessment

A systematic, comprehensive examination of individuals, families, groups and communities regarding their health related cultural beliefs, values and practices

Ethnicity

An ethnic group composed of " Individuals who self identify membership with or belong to a group with share values, ancestry and experiences

Race

a socially constructed concept of dividing people into populations or groups on the basis of various sets of physical characteristics, usually based on genetic ancestry

Culture

a system of shared ideas, rules, meanings that influences how we view the world, experience it emotionally and behave in relation to others

3 dimensions of cultural humility

1) Self-awareness

2) Respectful communication

3) Collaborative partnerships

RESPECT

Rapport

Empathy

Support

Partnership

Explanations

Cultural Competence

Trust

Spiritual assessment

Aspect of humanity that refers to the way individuals seek and express meaning and the purpose and the way they experience their connections to the moment, the self, others, nature and the significant or sacred

Cultural competence

recognizes the need for a set of skills necessary to care for people of different cultures

cultural bond syndrome

Illness identifies by a culture but have no corresponding illness in western medicine

Bias

A preference or an inclination, especially one that inhibits impartial judgment, for example, the attitudes or feelings that we attach to perceived differences in other cultures

Prejudice

A disapproving or negative attitude that is not rooted in fact or accurate information

stereotype

A uniform image of one group that is believed by another group; a fixed, overgeneralized belief about a particular group or class of people

Cultural assessment

culture and language

Spirituality

Nutrition

Reason for hospitalization

Family

Nursing care

Spiritual assessment

Concept of god or deity

Sources of hope and strength

Religious practices

Relation between spiritual beliefs and health

Physical Examination

A process to obtain objective data from the patient. The purpose is to determine changes in a patient's health status and plan how to respond to a problem as well as promote healthy lifestyles and well-being

preparing for the physical exam

Reflect on your approach

Adjust lighting and environment

Make patient comfortable

Check equipment

Choose the sequence of examination

The physical examination relies on four classic techniques

Inspection, palpation, percussion and auscultation

Sequence of examination

Maximize the patient's comfort

Maintain patient safety

Avoid unnecessary changes in position

Enhance clinical accuracy and efficiency

In general move "head to toe"

General survey

Overall appearance and apparent age

Level of consciousness

Facial features and expressions

Demeanor and affect

Posture

Gait

Motor activity

Speech

Skin color and lesions

Dress and personal hygiene

Vital signs

are objective measurements and are completed as part of the initial step in assessment, especially in emergent situations. These include bp and pulse

Systole

pressure within the walls of arteries when the left ventricle is contracting

Auscultatory gap

A silent interval that may be present between the systolic and diastolic pressures

Diastole

the pressure in the arteries when the heart muscle rests and refills with blood

Types of pain

Nociceptive or somatic pain

Neuropathic pain

Psychogenic and idiopathic pain

When evaluating the efficacy of treatment, focus on the four A's to monitor patient outcomes

Analgesia

Activities of daily living

Adverse effects

Aberrant drug related behaviors

The skin

1. provides a barrier protecting body

2. Regulates body temp

3. Synthesizes vitamin D

4. Allows sensory perception

5. Provides nonverbal communication

6. Provides identity

7. Allows wound repair

8. Allows excretion of metabolic wastes

Epidermis

Thin, devoid of blood vessels, and divided into two layers : Horny layer and cellular layer

Dermis

Well supplied with blood. Contains connective tissue, sebaceous glands, sweat glands, and hair follicles.

The color of healthy skin depends primarily on

Melanin, carotene, oxyhemoglobin and deoxyhemoglobin

Vellus hair

short, fine, pale hair ("peach fuzz") that replaces lanugo

Terminal hair

Long, coarse, pigmented hair found on the scalp, legs, arms, and bodies of males and females.

Sebaceous glands

secrete sebum (oil) into the hair follicles where the hair shafts pass through the dermis. Connects underlying structures

Sweat glands

eccrine glands ( Widely distributed, open directly on surface, help control body temperature) and apocrine glands ( In axillary and genital areas, open into hair follicles, stimulated by emotional stress, responsible for adult body odor)

Purpose of integumentary history

Diseases of the skin

Systemic diseases that have skin manifestations

Physical abuse

Risk for pressure ulcer formation

Risk for skin cancer

Need for health promotion education regarding the skin

Common or concerning symptoms

rash, nonhealing lesions, moles, growths, lesions, bruising, hair loss, nail changes

Jaundice

yellowing of the skin, deposition of bilirubin, easier to observe in sclera, nails, palms, soles

Cyanosis

Bluish color in skin, lack of oxygen ( Central ) and lack of blood flow ( Peripheral )

Nails

Protect distal ends of fingers and toes. Nail plate, lunula and cuticle

Skin assessment

color, moisture, temperature, texture, turgor, vascularity, edema, lesions

Lesion

a circumscribed area of pathologically altered tissue

Macule

less than 1 cm flat colored spot on the skin ( Freckle)

Papule

Small bump or pimple

Vesicle

Small blister containing serous fluid

nevus

mole or birthmark

Lesion assessment

Color, size, elevation, number, texture, type of skin lesions, shape and pattern, anatomic location and distribution

Nails assessment

Inspect and palpate fingernails and toenails.

Note color, shape, and any lesions.

Should be pink with white lunulae

Smooth and firm in texture

Rounded in shape

Health promotion and counseling for skin

- Skin cancer prevention

- Risk factors for skin cancers

- Avoidance of excessive sun exposure and artificial tanning lamps

- Use of sunscreen

basal cell carcinoma

Basal level of epidermis

80% of skin cancers, rarely metastasize

squamous cell carcinoma

Upper layer of epidermis

16% of skin cancers, can metastasize

Melanoma

Arise from melanocytes in epidermis

4% of skin cancers, most lethal

ABCDEFG for melanoma

asymmetry. borders, color, diameter, evolving, elevated, firm, growing

Common or concerning symptoms of the head

headache

head injury

head or neck surgery

traumatic brain injury

look for SNOOP

Systemic signs, symptoms or illness

Neurologic deficits

Onset

Other associated conditions

Prior history

Traumatic brain injury

Blow to head or piercing head injury that interferes with brain function

Not all injuries to head result in brain injury.

May be mild to severe

May be time lapse between injury and manifestation of symptoms

Headache

Most common complaint

Need to rule out life threatening causes : Meningitis, subdural, tumor

Four categories : Tension, migraine, cluster, chronic daily

scalp assessment

Part hair in several places and look for scaling, lumps, nevi, or other lesions.

Skull assessment

Note any deformities. depressions, lumps or tenderness

Face assessment

Look for asymmetry, involuntary movements, edema, and masses

palpebral fissure

opening between eyelids