HA Exam 1

Introduction to Health Assessment Critical Thinking and Clinical Judgement (POWERPOINT 1)



Objectives and Readings:

Information from Bates’ Chapter 1 and 2



-Define health and health assessment.



-Explain the components of the health assessment.



-Define the nurse’s role in assessment.



-Define subjective and objective data.



-Identify appropriate subjective questions for the health history.



-Explain the Nursing Process.



Terminology Chapter 1 and 2:



-Health

-Nursing Health Assessment

-Social determinants of health (SDOH)

-Assessment

-Objective data

-Subjective data



Do I know my content?



-I can explain the following terms: social determinants of health, 8 dimensions of wellness.



-I can apply questions to determine subjective and objective data.



-I know the two major components of a health assessment.



-I can describe the components of a health history.



-I can discuss the term review of systems.








Interviewing and Communication

(POWERPOINT 2)



Learning Objectives:

Bates Chapter 3



-Describe the phases of the nurse-patient interview



-Identify environmental elements that support successful interviewing



-Identify therapeutic communication techniques used during the patient interview



-Discuss strategies for handling patients with specific needs




Knowledge Check:

Which of the following best describes the purpose of the “pre-interview” phase?

A. To summarize the patient’s concerns and plan next steps

B. To gather the patient’s full health history

C. To prepare yourself and the environment for a successful interview

D. To begin asking open-ended questions



Knowledge Check:

You’re interviewing a patient who becomes tearful when discussing their symptoms. What are two appropriate therapeutic communication techniques

you could use this moment?



Knowledge Check:

During the working phase of the nurse-patient interview, what is the most appropriate approach when a patient begins to share their story?

A. Ask specific, focused questions first to guide the conversation

B. Let the patient speak without interruption and listen actively

C. Focus on documenting over listening to ensure accuracy of records

D. Offer reassurance to help the patient feel better about their symptoms
















Questions for Review:



-In preparing to converse with a patient, especially a new one, what is the primary goal?



-What are the four phases of the patient interview and important elements of each?



-How does “disease” differ from “illness”, and why is this distinction important?



-Can you identify the appropriate therapeutic communication techniques to use in specific patient care scenarios?



-What intervention should the nurse consider when caring for a patient whose primary language is not English?



-How might the nurse adapt the patient interview to a patient with altered capacity/cognitive impairment? Angry? Crying? Visually/hearing impaired?































The Health History

(Powerpoint 3)



Learning Objectives:

Health History (Bates Chapter 4) and General Survey (Bates Chapter 7 p. 125-130)



-Explain the four types of histories and when each is used



-Describe the components of a comprehensive health history



-Identify sensitive health history topics and appropriate approaches to gather data



Knowledge Check:

Which of the following are included in the health patterns section of the health history? Select all that apply

  1. Immunizations

  2. Sleep, nutrition, exercise

  3. Medications

  4. Roles and relationships

  5. Coping/ stress tolerance



Knowledge Check:

Which of the following best describes the purpose of the Review of Systems?

  1. To document the patient’s current medications and allergies

  2. To identify genetic conditions that may affect the patient’s health

  3. To assess the presence or absence of symptoms across body systems

  4. To evaluate the patient’s coping mechanisms and stress tolerance



Knowledge Check:

Which of the following is the most appropriate approach when asking a patient about their sexual history?

  1. Wait until the patient brings up the topic to avoid unnecessary discomfort

  2. Use medical terminology to maintain a consistently professional tone

  3. Normalize questions and ask all patients regardless of age, appearance, or background

  4. Ask only if the patient is in a long-term relationship, as they are more likely to be sexually active



Knowledge Check:

A patient reports having scarlet fever when in the 2nd grade. In which area of the comprehensive health history should the nurse document this information?

  1. Past health history

  2. Review of symptoms

  3. Health patterns

  4. History of present illness







Questions for Review:



-What is the purpose of the general survey, and what are some of its components?



-What are the differences between the four types of health histories? What are some scenarios in which you might use each type?



-What are the components of a comprehensive health history?



-What is a chief report/chief complaint? What is the HPI? What is its purpose?



-What information is gathered in the past history? What information is omitted?



-What is the purpose of a family history?



-What is the purpose of the review of systems (ROS)?



-What information is gathered in the health patterns sections?



-What techniques can nurses use to gather sensitive health information?

























 Introduction to Physical Assessment: General Survey of the Patient, Positioning/Draping, General Techniques, Equipment

(POWERPOINT 4)



Learning Objectives:



The student will be able to:



-Identify key components of a general survey assessment: physical appearance, mobility and behavior



-Describe the specific body positions and why they are used.



-Discuss the four cardinal techniques of examination and their purpose.



-List the purpose for the specific instruments used






























Assessing The Integumentary System: Skin, Hair and Nails

(POWERPOINT 5)



Learning Objectives:



-Identify the procedure for the physical assessment including health history questions of

the integumentary system: Hair, Nails, Skin



-Describe the features of a skin assessment (Primary,  Secondary and vascular lesions)



-Discuss the findings for skin cancer and pressure ulcers.

~Identifying risk factors



-Explain the purpose and interpret the grading for the skin assessment tools: Braden Scale and

PUSH.































HEENT: Examination of the Head, Face, Eyes, Ears, Nose, Mouth, Neck



Readings:

Hogan-Quigley (2022) Bates Nursing Guide to Physical

Examination and Health Assessment in Nursing 3rd ed.

Chapter 10: Assessing Head and Neck

Chapter 11: Assessing Eyes

Chapter 12: Assessing Ears, Nose, Mouth and Throat

ATI: Fundamentals of Nursing: Edition 11.0

Chapter 28 – helpful for integrating HEENT and Cranial

Nerves.



HEENT/Neck Objectives:

➢Discuss the proper assessment techniques for Head,

Eyes, Ears, Nose, Mouth, and Neck.

➢Demonstrate the correct assessment techniques in the

appropriate order for the HEENT structures and Neck

➢Document the NORMAL findings for HEENT/Neck

➢Relate the concept of sensory perception to normal and

abnormal findings of the HEENT exam



Do I know my content?

For each area, think about a history question to ask?

Head: What do I inspect? What do I palpate?



Face: What do I inspect?



Eyes: What do I inspect? What do I palpate? How do I assess function? Pupil reaction, visual acuity? Terms to know?



Ears: What do I inspect? What do I palpate? How do I assess function? Otoscopic exam: What is normal?



Nose: What do I inspect? What do I palpate?



Mouth: What do I inspect? Grading of the tonsils.



Neck: What do I inspect? What do I palpate?



What are the expected findings for thyroid, lymph nodes?



Where are the lymph nodes located?