exam 1 health assessment

role of nurses

to listen, promote health, prevent illness, treat responses to illness, advocate

health assessment

gather information about the health status of the patient, analyzing and synthesizing those data, making judgements about nursing interventions based on the findings and evaluating patient care outcomes

purpose of health history

learn the elements of a complete health history, to interview a patient to gather data for a complete health history, analyze the patient data, and record history accurately

subjective

what the patient says

objective

what we observe

subjective data

history taking

objective data

physical finding

health history sequence

biographic data, source of history, reason for seeking care, prevent health or history of present illness, past health, family history, review of systems, functional assessment including activities of daily living

biographical data

name, contact info, date of birth, gender, race/ethnicity, occupation, language spoken

source of history

who is giving the information

judge reliability of informant and how willing he or she is to communicate

reason for seeking care

brief spontaneous statement in persons own words describing reason for visit

list symptoms

do not diagnose or infer!

questions to ask for seeking care

what brings you in today?

what symptoms are you experiencing?

is there anything else we should take care of today?

history of present illness

collect all provided data and identify 8 critical characteristics

8 critical characteristics

location, character (quality), quantity (severity), timing, setting, aggravating or relieving factors, associated factors and patients perception

mnemonics for 8 critical characteristics

OLD CARTS

which of the following is a good example of a well written chief complaint?

patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest

past medical history

childhood illness, accidents or injuries, serious or chronic illnesses, hospitalizations, surgical operations, obstetric history, immunizations, last exam, allergies, current medication

childhood illnesses

experienced or exposed to presence or absence of complications

accidents or injuries

type and nature of event, acute and/or residual deficit noted

serious or chronic illnesses

presence of comorbidities has pronounced effect

hospitalizations

types based on clinical indications, interventions, used as therapy, and length of stays along with dates of occurances

surgical operations

facility, name of health care provider, and date of procedures

OB history

relevant data r/t childbearing inclusive of GPAL, labor/delivery experience, condition of infant, and postpartum course

immunizations

correlate with CDC guidelines

last exam date

obtain last data set for commonly occurring labs/diagnostics (bloodwork, ecg, blood tests, pap)

allergies

note allergen and reaction

current medication

perform medication reconciliation

include prescribed and over the counter meds/herbal therapy

family history

highlights diseases or conditions that an individual may be at risk for as a result of genetics

tool used to standardize family history data

pedigree or genogram

review of systems: purpose

evaluate past and present states of each body system, assess that all pertinent data relative to each body system, evaluate health promotion practices, organized manner

in review of systems, DO NOT INCLUDE

objective data, only use subjective

activities of daily living

self care activities of daily living as they relate to general health status

objectively measure functional status

monitor and assess for changes over time

relevant data r/t lifestyle and type of living environment

may include “sensitive” topics and may require attention to privacy concerns

different types of screening tools to provide validation of information in regards to substance abuse

functional assessment

ADL, objective measure functional status, living environment, activity, exercise patterns, hobbies, sleep, nutrition, personal habits, intimate partner violence

activity/exercise

independent or needs assistance with feeding, bathing, dressing, toileting, walking, standing, climbing stairs

sleep

sleeping patterns, naps, sleep aids

nutrition

record 24 hr diet recall and who prepares meals

personal habits

smoking/vaping, amount and type

drinking

amount and type

intimate partner violence

do you feel safe at home? are you afraid of partner/ex partner?

which of the following is considered to be subjective

pain lasting 2 hours

first step of general survey

wash hands, put on proper PPE

general survey

physical appearance, body structure, mobility, behavior

physical appearance characteristics

age, sex, level of consciousness, skin color, facial features, overall appearance

age

person appears his or her stated age

sex

sexual development appropriate for gender and age

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 absense of distress

jaundice

skin is yellow

cyanosis

skin is blue due to lack of oxygen

erythema

skin is red/flushed

pallor

pale skin

body structure characterisitcs

stature, nutrition, symmetry in body parts, posture, position

stature

height appears within normal range for age, genetic heritage

nutrition

weight appears within normal range for height and body build, body fat distribution even

symmetry of body parts

body parts looks equal bilaterally and are in relative proportion

posture

person stands comfortably erect as appropriate for age

position

description of patients position during assessment

mobility includes

range of motion and gait

behavior

facial expressions, mood and affect, speech, dress, hygiene

measurements: weight

use a standardized balance or electronic standing scale

record in lbs or kgs

measurements: height

use wall mounted device or measuring pole on scale, person should be shoeless, standing straight looking ahead with feel and shoulders on hard surface

BMI

bmi is a practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

measurement: waist circumference

assesses body fat distribution as an indicator of health risk

waist circumference is measured at

smallest circumference below rib cage and above iliac crest

hip circumference is measured at

largest circumference of buttocks

unexpected in body weight and proportion

dwarfism, gigantism, acromegaly, anorexia nervosa, cushings syndrome, marfan syndrome, elderly

indication for emergency assessment

acute change in mental status, respiratory distress, abnormality in vital signs, diaphoresis, bleeding, seizures

anatomy focuses on

structure

physiology

focuses on function

word root

fundamental meaning of the term

prefixes and suffixes

modify the word root

combining vowels

connects other word parts

aden/o

gland

carcin/o

cancer

cardi/o

heart

chem/o

chemical

cis/o

cut

dermat/o

skin

enter/o

small intestine

gastr/o

stomach

gynec/o

female

hemat/o

blood

hydr/o

water

immun/o

immunity

laryng/o

voice box

nephr/o

kidney

neur/o

nerve

ophthalm/o

eye

ot/o

ear

path/o

disease

pulmon/o

lung

rhin/o

nose

\-algia

pain

\-cele

hernia, protrusion

\-cyte

cell

\-dynia

pain