module 1 health assessment

define the holistic approach

looking and treating the pt as a whole person rather than just their diagnosis. this includes assessing their mental status and the affect that it has on self care, safety, and adherence to medical tx-care,

define cognition

the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses

what are the 6 domains of cognitive function

1. perceptual motor function

2. language

3. learning and memory

4. social cognition

5. complex attention

6. executive function

define mood

the way a person feels internally

define affect

observable response a person has to his or her own feelings

define euthymia

normal, healthy fluctuations in mood

how do mood spectrum disorders affect a person

it disrupts a person's ability to function normally, and puts them at increased risk for substance abuse and decreased health status

define dysthymia

depression or flat mood

what are some examples of biographical data

age, gender, culture

what is current health history

the health symptoms that caused them to go to the dr

what is past medical history

previous diagnoses, hospitalizations, or treatments

what is family history

conditions and illnesses that a pt's blood relatives have that make them genetically predisposed to getting the same

what is a family history genogram

tree that shows any health history that makes them genetically at risk

what should you ask about when discussing meds that the pt is taking

dosage, frequency, why they take meds, method of administration

what is A&O x4

alert and oriented to person, place, time, situation

what is the PHQ-9 used to screen

depression

how does PHQ-9 scoring work

each question (9 total) is scored 0-3, with 0 being not at all, and 3 being nearly every day. 27 possible points total

what are appropriate actions to take if a pt has a concerning answer on q9 (suicide and self harm)

immediate follow up and escalation

what score makes the pt considered depressed, and what score is considered severe depression

10+ = depressed

20-27 = severe depression

what does the GAD-7 screen for

anxiety

how many questions on the GAD-7

7

score interpretation ranges for GAD-7

0-4: minimal anxiety

5-9: mild anxiety

10-14: moderate anxiety

15-21: severe anxiety

score of 5+ is referral level, and a score of 10 or more is considered clinically significant which requires a follow up

what is the CAGE assessment used for

alcohol use concern assessment

What does CAGE stand for?

C- cut down (have u ever felt that u needed to cut down)

A- annoyed (have ppl annoyed u by criticizing ur drinking)

G- guilty (have u felt guilty about drinking)

E- eye-opener (have u ever needed an eye-opener drink in the morning)

what score is considered necessary for referral on CAGE screening

2 or more "yes" answers

what is the mini mental state exam (MMSE)/mini-cog assessment tool used to screen

cognitive impairment/dementia

what are the 5 main areas in the MMSE assessment

orientation (person, place, time, situation)

registration (immediate recall of words)

attention and calculations (serial 7s - count backwards from 100 in multiples of 7, spell backwards)

recall (short-term memory)

language and visuospatial skills (naming, following commands, drawing)

what are the score ranges for normal cognition, mild cognitive impairment, and severe impairment on MMSE

normal: 24-30

mild impairment: 18-23

severe impairment (REFERRAL LEVEL): 0-17

what are the 3 parts of the mini-cog administration

1. instruct the pt to remember 3 unrelated words, and then repeat them

2. ask the pt to draw a clock, and then ask them to draw the hands interpreting a time

3. ask the pt to repeat the 3 words from step 1

how does mini-cog scoring work

pt given one point for each word recalled after the clock drawing test, and 2 points for a correctly drawn clock/hands (0 for abnormal clock)

0-2 is considered high risk for cognitive impairment, while 3-5 are low risk for dementia but does not rule out cognitive impairment

when administering these assessments, you should also be analyzing the clients based on the ABCT framework. what does that stand for

appearance, behavior, cognitive function, thought process and perceptions

what should u look out for when analyzing a client's appearance during mental assessment

posture

body movements (voluntary, uncoordinated, spastic, etc)

dress (dressed appropriately for setting, season, and age?)

grooming and hygiene (cleanliness v neglect)

what should u examine when assessing a client's behavior during these assessments

level of consciousness: alert, lethargic, stuporous (near unconscious) or comatose

facial expression: appropriate to the situation? eye contact

speech: quality, pace, and articulation

mood and affect

difference btwn mood and affect

mood is how the person states that they feel internally, while affect is how they express that feeling through behaviors and other observable traits

what should u examine when assessing a client's cognitive function during these assessments

orientation

attention span

memory (recent and remote)

new learning (4 unrelated words test)

what are some examples of testing remote and recent memory

remote: historical events

- ask about their first job, or their anniversary date

recent

- ask about what they ate in the last 24 hrs

what should u examine when assessing a client's thought process and perceptions during these assessments

thought process, thought content, perceptions (hallucinations or delusions), suicidal/homicidal ideation

what should u look for when analyzing a person's thought process/content

whether the pt is making sense, and their statements are consistent and based in reality

why is assessing cognition important in infants/childrens

to ensure that they are reaching developmental milestones and behavior

why is assessing cognition important in the aging adult

confusion is not a normal part of aging

what should u do before assuming cognitive loss in an aging adult

check their sensory status (vision/hearing)

what is the importance of documentation (4)

legal and professional requirement

supports communication among healthcare team

enhances pt safety and outcomes

reflects clinical judgement

what are the principles of effective documentation

accurate, complete, timely, organized, confidential

what is subjective data

information reported by the pt or caregiver that can not be directly measured

what is objective data

information that is observed, measured, or verified by the nurse or provider

when documenting subjective data, should u use direct quotes or paraphrase

record exactly what the pt says

when documenting objective data, should u use clinical terminology

yes, and be specific and precise

why is it important to be mindful of a pt's beliefs and values

cultural beliefs and values influence perception and guide decisions, as well as make the pt feel more respected

clinical judgement in documentation

interpret findings, identify patterns, prioritize concerns, and suppiort decision

what do you document in a general survey (4)

pt's appearance, behavior, level of consciousness, and distress

what do u document in terms of mental status (4)

orientation, mood/affect, thought processes, cognition

what does the SOAP format stand for

subjective

objective

assessment

plan

what should narrative documentation be

chronological, descriptive, and flexible

what are the pros of electronic health records

accessibility, communication, accuracy, and security

what do you do when documenting abnormal findings

describe deviations

include location/severity/size

compare to norms

what documentation errors should be avoided

using unapproved abbreviations

correcting late entries

no blanks

what should you do to exhibit cultural competence when documenting

respect beliefs

avoid bias

include pt perspective

what is person-centered care

providing care that includes the pt as an active participant in choices concerning their health, rather than a passive receiver

what are the components of cjmm (6)

1. recognize cues

2. analyze cues

3. prioritize hypotheses

4. generate solutions

5. take action

6. evaluate outcomes

what should be considered during the general survey of cjmm (5)

appearance, behavior, mobility, body structure, and safety considerations (distress, fall risk, level of consciousness changes)

what are the five components of a vital signs interview

BP, pulse, respirations, temperature, and BMI

what are the methods of measuring temperature

oral, tympanic (ear), and temporal (forehead)

what are the values for tachycardia and bradycardia

tachycardia: over 100bpm

bradycardia: under 60bpm

normal bp range of values

90-120 systolic pressure

60-80 diastolic pressure

ranges for hypertension (elevated bp)

130-139 systolic pressure

What are the ranges for a hypertensive crisis (extreme high bp)What are

>180/120

what is orthostatic hypotension

if their bp drops when they stand, which can lead to dizziness, momentary vision loss, nausea, and vertigo

what might a weak pulse indicate

perfusion issues

what is assessed in a pulse assessment (3)

rate, rhythm, and strength

normal pulse value range

60-100 beats per min

what is assessed in respirations (3)

rate, depth, effort (labored or nah)

normal respiration value range

12-20 breaths/min

normal temperature ranges, and what being above/below it indicates

96.4-99.1 degrees fahrenheit

high temp: fever or infection

low temp: hypothermia, which is an emergency

alert and oriented x4 components

person (aware of their identity)

place: recognizing their environment and where they are

time: knowing date, year, time currently

situation: understanding why they are there

get 1 point for their score for each of the components they understand

normal o2 sats range

95-100% on room air

3 measures of infection control

hand hygiene, ppe, equipment cleaning

how many identifiers necessary for patient identification, and what are they

name and DOB

what is a pain goal

a goal of how much they want their pain to improve, help create a realistic goal

What is a functional goal?

what functions they want to be able to do with their pain level (perform adls, sit, climb, stand, shop, etc.)

what does sbar stand for

situation, background, assessment, reccomendation

primary prevention

preventing diseases before occurrence (ie. immunizations, nutrition education)

secondary prevention

early detection and screening for health promblems and prompting treatment to prevent firther complications (ie. BP checks, mammograms, scoliosis, screening)

Tertiary Prevention

managing established disease to prevent further complications and promoting health to the highest level (DM care)

what does adipie stand for

assess, diagnose, identify outcomes, plan care, implement care, evaluate outcomes

what is an assessment

collecting info abt a pt's health status

subjective data

information the pt or guests of the pt tell you about their history

objective data

lab values, and other information that you yourself gathered

what are the two components of an assessment

health history (interview)

physical (hands-on) assessment

what are the 3 types of assessment

emergency and urgent, comprehensive, focused

what is a comprehensive exam

includes complete health history and physical assessment, and includes all body systems and areas (typically head-to-toe format)

- ie. school admission, first-time admit at a facility, sports physicals, annual exam

what is a focused exam?

specific to patient concerns and symptoms at the time of assessment

what is an emergency and urgent assessment

involves a life-threatening or unstable situation

determines level of urgency using ABCDE assessment

what does ABCDE stand for and during which assessment is it used

used during emergency and urgent assessment

Airway (with cervical spine protection if an injury is suspected)

Breathing: rate and depth, use of accessory muscles

Circulation: pulse rate and rhythm, skin color

Disability: level of consciousness, pupils, movement

Exposure

what is a functional assessment

A functional assessment focuses on functional patterns that all humans share. Nurses often use the functional patterns to collect subjective data.

what are some of the functional patterns measured in a functional assessment

health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

what is a head to toe assessment

Most organized system for gathering comprehensive physical data.

what is the body systems approach for health assessment

logical tool for organizing data that promotes critical thinking and allows you to analyze. basically clustering similar data gathered in head to toe and gunctional assessments, and reogranizing it in a way that allows you to draw conclusions.

what are some examples of demographic data

data on age, marital status, ssn, income, race, address, occupation and education

define therapeutic communication

purposeful communication used to develop a relationship with patients by exhibiting caring and empathy. this is important because building a relationship makes pt more likely to disclose info to u.

what are social determinants in health history

assessing environment, occupation, support systems, safety, accessibility to resources, and other things that can play a factor into a person's wellbeing