HESI Review

The Nursing Process as a Professional Framework

  • Definition: The nursing process is a systematic and dynamic method used to collect both subjective and objective data. This is achieved through the patient interview and the physical examination (IPPA).
  • Assessment Scope: Data collection is not limited to physical health; it encompasses physiological, psychological, sociocultural, spiritual, and economic factors.
  • Case Example: Hospitalized Patient in Pain
    • Assessment factors: The nurse identifies the causes and manifestations of the pain.
    • Patient responses: The nurse documents behaviors such as the inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or requests for increased pain medication.
  • Nursing Diagnosis/Analysis:
    • This step involves identifying actual or potential health conditions or needs.
    • Examples include: anxiety, impaired nutrition, or ineffective coping.
    • Nursing diagnoses serve as the foundational basis for the nursing care plan.
  • Outcome Identification and Planning:
    • SMART Goals: Expected outcomes must be Specific, Measurable, Achievable, Relevant, and Time-bound.
    • Goals must be discussed and established with the patient.
    • Example 1: "Pt will move from bed to chair at least three times per day."
    • Example 2: "Patient will rate pain as tolerable by end of shift."
  • Implementation:
    • The nurse carries out appropriate interventions aimed at meeting the expected outcomes.
    • All interventions must be documented in the patient's record.
  • Evaluation:
    • Actual outcomes are compared against the expected outcomes (the goals).
    • The care plan is modified as needed based on the effectiveness of the interventions.

Cultural Assessment and Sensitivity

  • Cultural Responses to Pain: Silence may be a specific cultural response to pain.
  • Native American Practices:
    • Sweat lodges: Used for purification and healing.
    • Smudging: Purifying a space or person with sacred herbs.
    • Amulets: Charms worn around the neck to protect the wearer from evil spirits.
  • Health Belief Systems:
    • Hispanic Culture: May follow a "Hot/Cold" theory of disease and treatment.
    • Asian Culture: May follow the "Yin/Yang" balance theory.
  • Clinical Considerations:
    • Always assess the patient's use of herbal supplements.
    • Maintain awareness of nonverbal behaviors.
  • Key Questions for Cultural Assessment:
    • "What are your religious or spiritual preferences?"
    • "What cultural practices are important to you?"
    • "What are your health goals?"

Types of Patient Databases

  • Episodic/Focused Database:
    • Obtained for a specific problem or condition (e.g., sore throat, dysuria, surgery).
    • Subjective data is limited specifically to the current episode.
  • Complete (Total Health) Database:
    • Conducted during the first encounter with a patient.
    • Includes a complete health history and full physical examination to establish baselines.
  • Follow-up Database:
    • Used to evaluate the status of identified acute or chronic problems (e.g., assessing a new medication or post-surgery recovery).
  • Emergency Database:
    • Crucial subjective data is collected while simultaneously assessing the ABCs (Airway, Breathing, Circulation).

The Complete Health History

  • Biographical Data: Includes identifying the source of the data and assessing their reliability.
  • Chief Complaint (Reason for Seeking Care): Always document the patient's reason for the visit in their own words using quotation marks.
  • History of Present Illness (HPI): Utilizes the OPQRSTU mnemonic to explore symptoms.
  • Past Medical History: Includes illnesses, hospitalizations, and allergies.
  • Medication Reconciliation: Patients should bring in their physical medications so the nurse can assess for potential interactions.
  • Family History: Documentation of hereditary conditions.
  • Review of Systems (ROS): Subjective data and symptoms relating to each body system.
  • Functional Assessment (ADLs):
    • Covers Self-esteem/self-concept, Interpersonal relationships, and Spiritual resources.
    • Assesses Personal habits, Stress management, Work/leisure, and Sleep/rest.
    • Assesses Activity, Exercise, and Nutrition/Elimination (nutrition is particularly critical in infant assessments).

The Interview Process and Communication

  • Interview Phases: Opening phase, the Body, and the Closing phase.
  • Environmental Factors: Maintain eye level with the patient.
  • Special Population Considerations:
    • Elderly: Assess for hearing or vision impairments.
    • Language Barrier: An interpreter is always required; do not use family members.
    • Anxiety: The examiner should appear unhurried and confident.
  • Techniques:
    • Open-ended vs. Closed questions: Open-ended questions allow for narrative; closed questions for specific facts.
    • Silence: "Silence is golden"; it allows patients to express emotions.
    • Facilitators: Phrases like "Tell me more."
  • Communication Traps: Avoid "Why" questions, which can seem accusatory.
  • Documentation: It is best to document the history electronically while in the room to ensure accuracy.

Substance Abuse and Violence Screening

  • Substance Abuse:
    • Standard assessment for all adolescents and adults.
    • Biological Markers: Elevated GGT levels can indicate chronic alcohol abuse.
    • Clinical Risks: Alcoholics are at higher risk for hypertension (HTN) and cardiac arrhythmias such as atrial fibrillation (Afib).
    • Commonly Abused Opioids: Methadone, hydrocodone, and oxycodone.
  • Abuse and Domestic Violence:
    • Assess for potential abuse at every encounter.
    • Scripting: "Because domestic violence is so common, we are asking everyone the following questions."
    • Mandatory Reporting: Healthcare providers are mandatory reporters; only suspicion is required to file a report.

Physical Assessment: General Principles and Measurements

  • Process: Follow a systematic process (usually head-to-toe) that minimizes patient movement. Maintain professionalism, calmness, and confidence.
  • IPPA Sequence:
    1. Inspection: Always first. Includes observation using senses and good lighting. Note color, shape, symmetry, position, odors, and sounds.
    2. Palpation:
      • Use dorsa (back) of hands for temperature.
      • Assess painful areas last.
      • Light Palpation: 1−2 cm1-2\,cm deep; for texture, tenderness, moisture, and superficial masses.
      • Deep Palpation: About 5 cm5\,cm (2 in2\,in) deep; for internal organs and masses. Includes bimanual pressure.
    3. Percussion: Determines the density of underlying structures.
      • Tympany: Heard over air/bowels.
      • Resonance: Normal adult lungs.
      • Hyperresonance: Booming sound; emphysema or pneumothorax (normal in children's lungs).
      • Dullness: Over organs (liver, spleen) or a distended bladder.
      • Flatness: Over muscle or bone.
    4. Auscultation:
      • Diaphragm: For high-pitched sounds (heart, lungs, bowels). Hold firmly.
      • Bell: For low-pitched tones (extra heart sounds, murmurs, bruits). Hold lightly.
  • Growth and Measurements:
    • Pediatrics: Height, weight, head circumference, and chest circumference (Head is typically 2 cm2\,cm larger than chest until age 6 months6\,months to 2 years2\,years).
    • Growth Charts: Record on CDC charts; outside <5th<5^{th} or >95th>95^{th} percentile is a risk factor.
    • Weight Conversion: 1 kg=2.2 lbs1\,kg = 2.2\,lbs.
    • BMI Categories:
      • Underweight: <18.5<18.5
      • Normal: 18.5−24.918.5 - 24.9
      • Overweight: 25−29.925 - 29.9
      • Obese: 30−39.930 - 39.9
      • Extreme/Morbid Obesity: 40+40+

Vital Signs

  • Temperature:
    • Normal Range: 35.8−37.3oC35.8 - 37.3^{o}C (96.4−99.1oF96.4 - 99.1^{o}F).
    • Fever: Elevated if >38oC>38^{o}C (100.5oF100.5^{o}F).
    • Accuracy: Rectal is most accurate (0.5o0.5^{o} higher) but used for comatose or critical patients.
    • Hyperthermia: >41.1oC>41.1^{o}C (106oF106^{o}F); seen in infection, thyroid storm.
    • Hypothermia: <35.0oC<35.0^{o}C (95oF95^{o}F); seen in shock or exposure.
  • Pulse:
    • Normal Adult Range: 50−100 bpm50 - 100\,bpm (traditional range is 60−10060 - 100).
    • Force Scale: Measured from 00 to 3+3+.
    • Pulse Deficit: Difference between apical and radial pulses; common in heart failure and AFib.
  • Respirations:
    • Normal Adult Range: 10−2010 - 20 breaths per minute.
    • Abnormalities: Use of accessory muscles, retractions, or tripod positioning (common in COPD).
  • Blood Pressure (BP):
    • Normal Adult: <120/80 mmHg<120/80\,mmHg.
    • Systolic (SBP): Peak pressure during left ventricular contraction.
    • Diastolic (DBP): Constant pressure during left ventricular relaxation.
    • Influencing Factors: Cardiac output, volume, viscosity, vessel elasticity, and Peripheral Vascular Resistance (PVR).
    • Korotkoff Sounds: Types 1 through 5 heard during manual readings.
  • Lifespan Variations:
    • Infants: Lower BP, higher HR and RR.
    • Pregnancy: Lower BP due to peripheral vasodilation.
    • Aging Adults: Increased SBP (arteriosclerosis) leading to wider pulse pressure; lower base temperature; more shallow breathing due to calcified costal cartilages.

Mental Status and Neurological Assessment

  • Mental Health (ABCT): Appearance, Behavior, Cognition, Thought Processes.
  • Level of Consciousness (LOC): Must assess LOC first.
    • Delirious: Restless, confused.
    • Lethargic/Somnolent: Drowsy, common post-op.
    • Stuporous/Semi-coma: Requires vigorous stimulation.
    • Comatose: No response to stimuli.
  • Glasgow Coma Scale (GCS): Ratings for Eye Opening, Motor Response, and Verbal Response.
    • Score Range: 3−153 - 15.
    • <7<7 indicates severe neurological damage.
  • Cognition Tests:
    • Orientation: Person, Place, Time, Situation (A&O x4).
    • New Learning: 4 Unrelated Words test.
    • Abstract Reasoning: Interpreting proverbs (e.g., "People in glass houses don't throw stones").
  • Screens: GAD-7 (Anxiety) and PHQ-9 (Depression).
  • Cranial Nerves (CN):
    • CN I (Olfactory): Smell.
    • CN II (Optic): Vision (Snellen, Confrontation).
    • CN III, IV, VI (Oculomotor, Trochlear, Abducens): EOMs, PERRLA, Ptosis.
    • CN V (Trigeminal): Mastication, facial sensation.
    • CN VII (Facial): Symmetry, taste (sweet/salty).
    • CN VIII (Acoustic): Hearing (Whisper test).
    • CN IX & X (Glossopharyngeal, Vagus): Gag reflex, swallowing, "Ahhh" (uvula rise).
    • CN XI (Spinal Accessory): Shrug shoulders, head rotation.
    • CN XII (Hypoglossal): Tongue protrusion.
  • Motor and Sensory:
    • Cerebellum: Gait, Romberg test, Rapid Alternating Movements (RAMs), Finger-to-nose.
    • Sensory: Sharp/dull pain, vibration (first sensation lost in peripheral neuropathy).
    • Reflexes (DTRs): 00 to 4+4+ scale. 2+2+ is normal. 4+4+ is hyperreflexia (Upper Motor Neuron lesion). 00 or 1+1+ is hyporeflexia (Lower Motor Neuron lesion).

Integumentary System

  • Skin Inspection:
    • Color Changes: Pallor (anemia), Cyanosis (hypoxia), Erythema (inflammation/fever/edema), Jaundice (liver disease, first seen in sclera/palate).
    • Temperature: Localized coolness indicates impaired arterial circulation.
    • Turgor: Indicates hydration. Test on sternum/subclavicular for adults; abdomen for infants. Tenting is abnormal.
  • Lesions (ABCDE): Asymmetry, Border irregularity, Color variation, Diameter (>6 mm>6\,mm), Elevation/Evolution.
    • Macule: Flat, <1 cm<1\,cm (freckle).
    • Papule: Raised, <1 cm<1\,cm (wart).
    • Vesicle: Fluid-filled, <1 cm<1\,cm (herpes, chicken pox).
    • Wheal: Mosquito bite.
    • Petechiae: Tiny red pinpoints; usually indicates a clotting disorder.
  • Hair: Check for texture/distention. Alopecia types include toxic, areata, and traumatic. Hirsutism is male-pattern hair on females.
  • Nails:
    • Clubbing: Angle >180 degrees>180\,degrees. Indicates chronic hypoxia (COPD, heart failure).
    • Capillary Refill: Should be <2 seconds<2\,seconds. Best indicator of peripheral perfusion.
  • Pressure Ulcers: Stages I-IV. Braden Scale (range 9−239 - 23) assesses risk; lower score equals higher risk (<9<9 is severe risk).

HEENT (Head, Eyes, Ears, Nose, Throat)

  • Eyes:
    • Visual Acuity: Snellen chart. 20/20020/200 is legal blindness.
    • Accommodation: Pupils constrict and eyes converge when looking at a near object.
    • Abnormals: Ptosis (drooping), Fixed/dilated (increased ICP), Pinpoint (opiates).
    • Emergency: Retinal detachment (sudden flashes/curtain vision).
  • Ears:
    • Otoscope: Pull pinna up and back (<3 years<3\,years pull down).
    • Tympany (TM): Should be pearly grey with a cone of light.
    • Hearing Loss: Conductive (physical blockage/scarring) vs. Sensorineural (nerve damage, ototoxic drugs like aspirin or loop diuretics).
  • Nose: Epistaxis (nosebleed). Allergic rhinitis (pale/violet turbinates).
  • Mouth/Neck:
    • Thyroid: Palpate using posterior approach; note logic of the "Adam's Apple" (thyroid cartilage).
    • Lymph Nodes: Normal are movable, soft, and nontender. Cancerous nodes are hard, fixed, unilateral, and nontender.
    • Oral Lesion: Any lesion persisting >2 weeks>2\,weeks is concerning for cancer.

Respiratory and Cardiovascular Assessment

  • Respiratory:
    • AP to Transverse Diameter: Should be 1:21:2. 1:11:1 is a barrel chest (Emphysema).
    • Tactile Fremitus: "99" test. Increased over consolidation (Pneumonia); decreased with air/fluid (Pneumothorax/Effusion).
    • Breath Sounds: Vesicular (peripheral), Bronchovesicular (major airways), Tracheal (over trachea).
    • Adventitious Sounds:
      • Crackles: Fluid (Pneumonia/HF).
      • Wheezes: Narrowed airways (Asthma/Bronchitis).
      • Stridor: Upper airway obstruction (Croup/Anaphylaxis) - emergency.
  • Cardiovascular:
    • Landmarks (APETM): Aortic, Pulmonic, Erb's point, Tricuspid, Mitral.
    • S1 and S2: S1 is loudest at the apex (M/T valves close); S2 is loudest at the base (A/P valves close).
    • S3 (Ventricular Gallop): Early sign of heart failure.
    • S4 (Atrial Gallop): Pathologic in HTN or CAD.
    • Jugular Venous Distention (JVD): Indicates right-sided heart failure. Should not be visible at 45 degrees45\,degrees head of bed.
    • Peripheral Vascular:
      • Arterial Insufficiency: Cool, pale, hairless skin; pain with activity/elevation.
      • Venous Insufficiency: Warm, brown discoloration, edema; pain relieved by elevation.

Gastrointestinal and Genitourinary Systems

  • Abdominal Sequence: Inspection, Auscultation, Percussion, Palpation. (Always auscultate before palpating to avoid altering bowel sounds).
  • Bowel Sounds: Must listen for full 5 minutes5\,minutes before confirming absence.
  • Palpation/Percussion Landmarks:
    • McBurney's Point: RLQ; associated with appendicitis.
    • Murphy's Sign: Inspiratory arrest; associated with Cholecystitis.
    • CVA Tenderness: Indicates kidney inflammation.
  • Organ Characteristics: Normal liver size is 6−12 cm6 - 12\,cm. Spleen is not normally palpable unless enlarged (do not palpate if rigid/tender).
  • Breast/GU:
    • Breast: BSE should be 4-7 days after the menstrual cycle starts.
    • BPH: Symptoms include hesitancy, urgency, and nocturia.
    • Female GU: Menorrhagia (heavy periods); Amenorrhea (lack of periods).

Laboratory values

  • Hematocrit and Hemoglobin (H&H):
    • Normal Hgb: ∼12.5−17.5 g/dL\sim 12.5 - 17.5\,g/dL
    • Normal Hct: ∼37−52%\sim 37 - 52\%
  • Prothrombin Time (PT): 11−13.5 seconds11 - 13.5\,seconds (Elevated with anticoagulants).
  • Prealbumin: Most accurate indicator of current malnutrition.
  • BUN and Creatinine: Elevations indicate kidney disease.
  • Uric Acid: Elevated in Gout cases.

Questions & Discussion

  • Stage of nursing process to determine efficacy? Evaluation.
  • History approach for 6-week post-op hysterectomy? Collect information about the client's activities since surgery.
  • Best question for medication use evaluation? "What medications have you used for your cough?"
  • Documentation for "body-wracking dry cough"? Describe having a "body-wracking dry cough" of 6 weeks duration.
  • Priority for "heart attack" triage? Ask a nurse to start a focused assessment of this patient now.
  • Infection reduction action during assessment? Perform hand hygiene.
  • Light palpation technique? Using fingertips to feel for temperature (Note: The slide suggests Nurse B using fingertips for temperature for light palpation, though usually dorsa of the hand is specified elsewhere. Ensure correct pressure of 1−2 cm1-2\,cm).
  • Abdominal sound for gas/distention? Tympany.
  • Action for non-palpable pedal pulses? Use a Doppler to detect the presence of the pulses.
  • Priority assessment for head injury? Level of alertness.
  • Complication of strep pharyngitis with muffled voice? Peritonsillar abscess.
  • H&H relevance? Low Hemoglobin often indicates anemia and fatigue. Decreasing counts indicate active bleeding.