Health Assessment - Final Exam

3 levels of prevention

1. primary
2. secondary
3. tertiary

primary level of prevention (with example)

health promotion strategies, such as annual physical exams and vaccines

secondary level of prevention (with example)

early screenings, detection, and treatment of diseases, such as colonoscopy to screen for colon cancer

tertiary level of prevention (with example)

restoration of health after/during illness or disease, such diabetic disease educational program

Healthy People 2030 (____ and ____ based framework)

science and research

Healthy People 2030 (updated how often and by who?)

every 10 years by the U.S. Department of Health and Human Services

Healthy People 2030 - identifies ____ and _______ for diseases

health and risk factors

U.S. Preventive Services Task Force (USPSTF) - goal

use evidence-based medicine to improve the health of all Americans; provides evidence-based recommendations about clinical preventive services

Patient Protection and Affordable Care Act

provides higher-quality, safer, more affordable and accessible care; health care insurance increases accessibility to health care; nurses have a leading role to assess, teach, and advocate

components of health history - reason for seeking care (what you would say)

what brings you in today?

components of a health history - biographical data (examples)

name, age/DOB, address, gender, race, religion, language, marital status, occupation, health insurance, allergies

components of health history - medications/immunizations

vitamins, OTC drugs, prescription drugs, herbal/nonherbal substances, vaccines

components of health history - past history/family history

childhood illnesses, adult illnesses (chronic/STIs), accidents/injuries, hospitalizations, surgeries, mental/emotional illnesses

components of health history - psychosocial assessment

focus on social determinants of health, such as access to education, occupation, housing, finances, exercise, sleep, safety, substance use, coping, abuse, sexuality

components of health history - functional assessment

does the patient have the ability to complete ADLs smoothly and effectively ?

components of health history - cultural/spiritual (what to ask)

are there any cultural or spiritual needs that may help me to provide the best care?

component of health history - review of systems

what is your perceived state of health? when was your last physical exam?

components of health history - mental health/cognitive

orientation, registration, attention/calculation, recall, language; feelings of depression?

3 phases of the interview

1. introductory (introduce/meet patient)
2. working (health history/problems/questions)
3. summarization (clarification/summarizing information/goals)

talking with hearing-impaired patients

-assess level of hearing impairment
-best way to communicate?
-hearing aids = ON
-background noise = DOWN
-face patient/speak slowly, using short sentences
-use written communication if speech is not effective
-confirm understanding/hearing
-NEVER shout

talking with visually impaired patients

-introduce/explain procedure
-ask how much pt. can see
-ask permission before touching
-be descriptive about directions
-tell patient when leaving

talking with aphasiac patients

-environment = QUIET
-communicate one question at a time
-speak slowly/clearly
-be honest (do NOT pretend to understand)
-do not rush
-write questions/use pictures

talking with cognitively impaired patients

-simple focused questions
-repeat/rephrase questions if needed
-sit in front/make eye contact
-speak slowly and clearly
-communicate one question at a time
-talk with secondary sources if unreliable

talking with aggressive or challenging patients

-be calm/reassuring; empathetic
-listen/stay focuses
-ARGUE = NO
-speak softly/simple sentences
-reflective statements, such as "I can understand why you feel this way"
-reassure confidentiality/safety
-be alert and sensitive to nonverbal communication
-keep out of striking distance
-avoid cornering the patient

low health literacy is more prevalent among who? (4)

1. older adults
2. minority populations
3. low socioeconomic status individuals
4. medically underserved people

comprehensive health history

looks at the WHOLE patient and reviews all body systems; TAKES TIME

focused (problem-based) health history

focuses specifically on an acute problem or symptom that the patient is experiencing; a patient within the emergency room will get his type of health history

follow-up health history

occurs after a patient has been seen and concentrates on new data since the last history

which health history technique would be used to assess a CURRENT, present illness?

focused/problem based health history

4 Ps for assessing sexual history

1. partners
2. practices
3. protection
4. past STIs

how to provide patient education when obtaining a health history?

-use simple terms
-avoid medical jargon
-use 4-6th grade level education
-ex: instead of saying systolic/diastolic, say top number over bottom number

can an obese person be malnourished?

YES!!!

nutrigenetics vs. nutrigenomics

nutrigenetics - your GENES affect how your body responds to food
nutrigenomics - what you EAT affects how your genes behave

5 components of a nutrition assessment

1. assessment of diet influences
2. physical assessment
3. anthropometric measurements
4. lab diagnostics (albumin, electrolytes, etc)
5. food intake

nutrition assessment - assessment of diet influences (examples)

culture/religion, finances, physical activity, mental health, transportation, medications, education, allergies/intolerances, vitamins/supplements

nutrition assessment - physical assessment (what is WASTING?)

when a person has a low weight for their height

nutrition assessment - physical assessment (what is STUNTING?)

when a person has a low height for their age

nutrition assessment - physical assessment (what is UNDERWEIGHT?)

when a person has a low weight for their age

signs of malnutrition (malnourishment)

1. depression/lack of energy
2. memory issues/dementia
3. sick often; bruise easily, and wounds heal slowly
4. no appetite; food in fridge is expired
5. weight loss; loose fitting clothes; muscle weakness

nutrition assessment - lab diagnostics (what 4 things to look at)

complete blood count (CBC), vitamins, protein, triglycerides

nutrition assessment - food intake (3 ways to assess)

1. 24-hour diet recall
2. three-day diary
3. direct observation

3 anthropometric measurements

1. height
2. weight
3. BMI

BMI (ranges)

underweight = LESS than 18.5
normal = 18.5-24.9
overweight = 25-29.9
obese = 30-34.9
extremely obese = MORE than 35

assessment techniques - purpose of INSPECTION

to look and examine the physical aspects of the body, posture, appearance, and behavior

direct vs. indirect INSPECTION

direct = carefully observing a specific area or whole person; see, smell, hear; looking at posturing/gait

indirect = using specific equipment to improve visualization of an area (such as scopes and cameras)

assessment techniques - purpose of LIGHT PALPATION

to feel and touch for surface characteristics

assessment techniques - purpose of DEEP PALPATION

to assess for masses, location of internal organs, and tenderness

assessment techniques - purpose of PERCUSSION

to evaluate the size, consistency, and borders of body organs, and the presence or absence of fluid in body areas

purpose of indirect fist percussion?

to assess organ tenderness, usually CVA tenderness for a kidney infection

assessment techniques - purpose of AUSCULTATION

to listen to sound produced by the body

assessment techniques (CORRECT ORDER (not abdominal))

inspection, palpation, percussion, auscultation

assessment techniques (CORRECT ORDER for ABDOMINAL assessment)

inspection, auscultation, percussion palpation

normal temperature ranges (oral, tympanic, temporal, rectal)

-oral = 36-37.9 C (96.8-100 F)
-tympanic = 36.8-37.8 C (98.2-100 F)
-temporal/rectal = 37.1 - 38.1 C (98.7 - 100.5 F)

acute pain

sudden and sharp pain, resulting from nociceptor activation due to damaged tissues; resolves once damaged is repaired

chronic pain

pain that lasts longer than 3 months or past the time of normal healing

intractable pain

constant pain, resistant to treatment or incurable

intermittent pain

pain that comes and goes

how to assess pain (mnemonic)

OLDCHARTS

primary skin lesion

occur in reaction to the external or internal environment; may be present at birth or develop during an individuals lifetime

secondary skin lesion

progressive changes in primary lesions, trauma, or injury to the primary lesion

inspection/palpation of skin - what to check for

hygiene, color, temperature, thickness, turgor, moisture, nevi/rashes/lesions/scars/masses, tattoos/piercings

capillary refill

color returns to nailbed after pressure is applied to it UNDER 3 seconds

maxillary and frontal sinuses (which assessment technique is used?)

palpation, to assess for tenderness or pain

4 types of headaches

1. sinus
2. tension
3. migraine
4. cluster

normal findings for lips

symmetric, upper lip is everted, pink, moist, no swelling or cracking of skin

normal findings for teeth

color white to ivory, 32-28 teeth present, clean, free of debris, smooth edges, no cracked teeth
- ASK ABOUT DENTURES!!

normal findings for buccal mucosa

pink, smooth, moist, no lesions, swelling, or bleeding, tight margin around each tooth, no tenderness with palpation

why do we need to assess the trachea?

to check for shift/deviation; MAKE SURE IT IS MIDLINE!!

palpation of the ear (4 parts); assessing what?

1. auricles (pinna)
2. tragus
3. earlobes
4. mastoid process
-ASSESSING for tenderness

conductive hearing loss (sound is not conducted through ______ to ______/_____ of the middle ear)

outer ear canal to the eardrum/tiny bones (ossicles) of the middle ear

conductive hearing loss (is it reversible?)

YES

conductive hearing loss (how can it come about?)

sound blocked by earwax/other foreign material; middle ear space impacted with fluid, infection, or bone abnormality; eardrum may be injured

sensorineural hearing loss (considered _______ hearing loss)

INNER EAR

sensorineural hearing loss (occurs when?)

there is damage to the inner ear (cochlea), or nerve pathways from inner ear to brain

sensorineural hearing loss (how speech may sound)

unclear or muffled

what is the most common type of permanent hearing loss?

sensorineural hearing loss

Weber test

assesses unilateral hearing loss/functioning of cranial nerve VIII; strike tuning fork and place on midline of patients head and ask patient which side he or she hears it louder, or if they are equal (normal)

Rinne Test

strike tuning fork, and place base on mastoid process; tell pt. to indicate when they can't hear it anymore, of which signals the doctor to place the tuning fork perpendicular to ear canal for the patient to listen

Rinne test (normal finding (aka POSITIVE finding))

AIR conduction is heard TWICE AS LONG as bone conduction

ears - health history questions

-surgery?
-difficulty hearing words? communicating? hearing the television (use of closed captioning?
-background noise affect ability to hear?
-have hearing loss? when did it start?
-been exposed to loud noises?
-have you had hearing tested?
-wear hearing aids? have a cochlear implant?
-have ear pain? discharge? tinnitus? vertigo?

1 kg = ? lb

2.2 lb

pulse deficit equation

apical pulse - radial pulse

pulse pressure equation

systolic BP - diastolic BP

assessing the 6 cardinal positions of gaze tests which cranial nerves?

3, 4, 6

6 cardinal positions of gaze

1. up/right
2. right
3. down/right
4. up/left
5. left
6. down/left

confrontation test (assesses what?)

peripheral vision

strategies for maintaining healthy vision

-encourage a comprehensive eye exam
-encourage eating a healthy diet rich in fruits/veggies, esp dark leafy greens; fish high in omega-3 fatty acids like salmon, tuna, and halibut
-wear protective eyewear!!
-protect eyes from ultraviolet rays
-give eyes a rest
-clean hands/contact lenses properly

palpation of the thorax (what to check)

-surface characteristics
-temperature
-moisture
-tenderness
-symmetrical expansion
-tactile fremitus (vibrations created from vocal cords)

auscultation of lungs (order)

top to bottom, while comparing side to side

patient education healthy lungs

-do NOT smoke
-avoid exposure to pollutants outside
-prevent infection by performing hand hygiene often
-get vaccinated every year for the flu
-EXERCISE

peripheral vascular system - equipment needed

-stethoscope
-gloves
-doppler stethoscope
-doppler gel
-measuring tape
-PPE (if needed)
-tangential lighting

how to inspect/palpate vertebral column

have patient bend forward and then feel down their spine for any irregularities

musculoskeletal assessment (sequence)

inspection, palpation, assessing ROM, assessing strength

ROM of ankle (which movements)

dorsiflexion/plantar flexion

ROM of foot (which movements)

inversion/eversion

how to assess sensory function

-nurse performs techniques to assess for loss in function to sensory nerves
-done when examiner has detected sensory loss or it's known that the patient has spinal cord disease

assessing pronator drift

assesses motor function/proprioception; have patient extend both arms out with palms up; have patient close eyes and observe arms for change in position for 20-30 seconds
-normal = negative (no change in position)

assessing signs of stroke (BEFAST)

Balance - sudden loss of balance
Eyes - sudden loss of vision in one or both eyes
Face - is one side of face drooping?
Arms - does one arm droop down? ask them to raise both arms
Speech - does their speech sound strange?
Time - TIME IS BRAIN! get help ASAP

2 steps of assessing the female breast

inspection and palpation

4 positions for inspecting female breast

1. arms hanging at side
2. arms over head
3. hands on hips
4. leaning forward