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HA Exam 1 - Exam 1 Blueprint
Health Assessment (NSG 121)
Herzing University
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NSG121 Health Assessment Exam 1 Study Guide
CULTIVATE A SPIRIT OF INQUIRY
The Nurse’s Role in Health Assessment To Promote health, to prevent illness, to treat human responses to health or illness, to advocate for individual, families, communities, and populations
Types of Assessments
Emergent assessment: Life Threatening, Unstable, ABCs compromised
General Survey: Begins immediately upon meeting the patient and continues throughout the assessment. No measurements are done
Focused: Patient is Stable- Based on patient’s health issues (what they are in for)
Comprehensive: Assess everything, admission, all body systems, Complete health history and physical assessment
Levels of Intervention to Promote Healthy Change Primary: Preventing Problems, Vaccines, Health Teaching, Safety Precautions Secondary: Screening to Promote the early diagnosis of health problems Mammogram, eye exams, smoking cessation, Vision Screenings, Paps
Tertiary: Focuses on preventing complications of an existing disease and promoting health to the highest level Medication, Surgical Treatment, Physical Therapy
Assessment FrameworksFunctional- Focuses on the functional patterns that all humans share -Health Perception, activity and exercise, nutrition and metabolism, sleep and rest, cognition and perception, self-perception, self-perception and self- concept, roles and relationships, stress tolerance, values and beliefs, sexuality, and reproduction
Head-to-Toe- Most organized system for gathering comprehensive physical data
Body Systems Approach- Tool for organizing data when documenting and communicating findings
Communication ProcessVerbal- Exchange of information using spoken or written word Nonverbal- Transmission of information without the use of words Electronic- Electronic medical record, email
Components of Communication o Sender- Person or group who initiates or begins the communication o Receiver- Must translate and interpret the message sent o Understanding- Was the message understood o Perception o Culture
Therapeutic Communication Caring- Encompasses your empathy for and connection with the patient o Listening, nodding, touch, following-up Empathy- Being able to see and feel the situation from the patient’s perspective rather than your own Self-Concept- Need to be aware of your own biases, values, personality, cultural background, and communication style o Don’t let these form developing a therapeutic relationship with patient Verbal and Non-Verbal Communication Skills Active Listening- Ability to focus on patients and their perspectives Reflection- Summarize the main themes of communication Elaboration- Encourages the patient to keep talking and completely describe difficulties Focusing- Use when patients are straying from a topic and need redirection Clarification- Important when the patient’s word choice or idea isn’t clear Summarizing- Review and condense most important information
Therapeutic Responses False reassurance- Giving false hope of a positive outcome when the chances are not good Sympathy- When being sympathetic, you are not being therapeutic because you are interpreting the situation as you perceive it Unwanted Advice Biased Questions Change of Subject Distractions Technical or Overwhelming Language Interrupting
Phases of interview Process
Inspect Palpate Percuss Auscultate o Abdomen Inspect Auscultate Percussion Palpation (Palpating can increase bowel sounds so it is done after auscultating
Hyper resonant Tone: Intensity... Very Loud, Pitch ., Duration.., Quality.., Location.. Lungs
Resonant Tone: Intensity.., Pitch.., Duration.., Quality... Hollow, Location.. Lungs
Tympanic Tone: Intensity.., Pitch.., Duration.., Quality.. Like, Location..
Dull Tone: Intensity.., Pitch.., Duration.., Quality... Thud, Location..
Flat Tone: Intensity.., Pitch.., Duration.., Quality.., Location..
Purpose of Documentation o To keep record of all patient assessment data and interventions o “If it’s not documented, it’s not done”
Principles of Documentation o Accuracy & Completeness- Descriptions should be as clear and precise as possible o Confidentiality- Keeping private any information pertaining to health status or care received o Organization- Entries are made chronologically o Timeliness- Point of care documentation (in room) reduces errors that can occur with batch charting o Conciseness- Be complete with documentation, but avoid unnecessary words
Documentation Formats o Narrative- Unstructured Paragraphs o SOAP(IE) o Subjective
o Objective o Analysis o Plan o Intervention o Evaluation o PIE o Problem o Intervention o Evaluation o DAR o Data o Action o Response o Charting by Exception- Abnormal assessments require a note o SBAR o Situation Identify Patient Summary of primary problem o Background Date of admission Reason for admission Recent set of vital signs Current Medications Lab Work Plan of Care o Assessment Current Nursing Assessment Most Recent Set of Vital Signs Relevant Lab Values o Recommendation What do you need from this individual Suggestions to advance the plan of care Any new/urgent needs that need follow-up Any orders need to be changed or reviewed
Unit 3 Assessment for Violence & Abuse o Put patient’s safety first o Do not question in front of friends and family (abuser could be there) o Establish rapport and ask questions simply and directly o “Do you feel safe at home?” o Do not assume who abuser is o Do not ask about police or pressing charges. This decision is up to the prosecutor
o Speech o Level of Consciousness Objective versus. Subjective Data o Objective data is observable and measurable o Subjective data is gathered from what the chart says and is based on the patient’s experience and perception Basic Theories of Pain (Gate Control Theory of Pain) o Depolarization of the nerve fiber causes gate to open o The pain stimulus passes from the peripheral to central nervous system up the afferent nerve pathway o The pain stimulus passes up the spine o The stimulus is identified as pain in the cerebral cortex o The response passes down the efferent pathways and a reaction is created
Pain Assessment (OPQRST) o Onset o Proactive/Palliative o Quality o Region/Radiation o Visceral- Abdominal Organs --> Crampy o Somatic- Muscle, Bones, Joints --> Sharp o Cutaneous- Skin o Referred- Originates from a specific site but the person experiencing it feels the pain at another site along the intervening spinal nerve o Phantom Pain-Pain in an extremity or body part that is no longer there o Severity o Numeric Pain Scale o Wong-Baker FACES Pain Scale o Timing
Considerations and Barriers to Pain Assessment o Pain-Facilitating Substances o Substance Pulse- Quickens pain substance o Bradykinin- Release at site of injury o Glutamate- Neurotransmitter o Pain Blocking Substances o Serotonin- Neurotransmitter o Opioids o Gamma- aminobutyric acid, gabapentin, pregabalin
Documenting and Reporting Pain
Vital Signs o Oral- 97-98. o Axillary- 96- 98. o Rectal- 98-100. o Tympanic- 98-100. o Temporal- 98-100. Pulse Sites o Temporal o Carotid o Apical o Brachial o Radial o Ulnar o Femoral o Popliteal o Posterior tibial o Dorsalis pedis
HA Exam 1 - Exam 1 Blueprint
Course: Health Assessment (NSG 121)
University: Herzing University
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