- Information
- AI Chat
Health Assessment Exam 1
Health Assessment (NURS 3120)
Idaho State University
Preview text
Ch. 1: Introduction to Health Assessment Define health and health assessment state of complete physical, mental, and being and not merely the absence of disease or Assessment: processes used to evaluate the health status of a Explain the components of the health assessment health history: past medical, physical, psychological issues, social history, cultural history, spiritual beliefs. physical examination: identify changes in body systems, unusual or abnormal findings, document all findings in clear and concise manner, collate all information with medical records. What are the different facets of a health? Developmental, Physical, Mental, Social, Cultural Ch. 2: Critical Thinking Identify the components of the nursing process. Assessment: gathering subjective and objective data, instrumental in devising care plan, key points and relevant pieces of information grouped, prioritized problem list, continues throughout patient encounter. Diagnosis: based on real or potential health problems, based on assessment data, sets stage for reminder of care plan, formulated based on problem Planning: chart best course to address diagnosis, nurse and patient select goals for each diagnosis, set short and long term goals, be realistic, work with patients economic means competing responsibilities, family structure, and dynamics. Implementation: completed patient, family, or health care team, clearly relate to nursing diagnosis, individualized for each patient, modified as changes occur, support positive outcomes Evaluation: continuing process to determine if goals are met, based on condition, are goals realistic, an ongoing process, confirm nursing care is relevant. Prioritize patient problems. the most active and serious problems first and record date of onset, order of priority, separate lists for active and inactive problems, assign each problem a number to be referenced in health record, use list to check status in future visits, allow other health care team members to review status Identify steps in developing a plan of care for patients. be agreeable to patient, develop and record plan for each problem, specify what steps are needed, share assessment with patient, ask the patient for opinion, patient should always be an active participant of plan, adapt and change as problem change. What does OLDCARTS stand for? How does the nurse use it? Onset Location Duration Characteristics Associated Manifestations Relieving or Exacerbating Factors Treatment Severity is used to assess a chief complaint or pain they feel Know the different phases of the nursing process and what the nurse might be doing in each of the phases. Assessment: gathering subjective and objective data, instrumental in devising care plan, key points and relevant pieces of information grouped, prioritized problem list, continues throughout patient encounter. Diagnosis: based on real or potential health problems, based on assessment data, sets stage for reminder of care plan, formulated based on problem Planning: chart best course to address diagnosis, nurse and patient select goals for each diagnosis, set short and long term goals, be realistic, work with patients economic means competing responsibilities, and family structure and dynamics. Implementation: completed patient, family, or health care team, clearly relate to nursing diagnosis, individualized for each patient, modified as changes occur, support positive outcomes Evaluation: continuing process to determine if goals are met, based on condition, are goals realistic, an ongoing process, confirm nursing care is relevant. Ch. 3: Interviewing Communication: Compare different therapeutic communication techniques which are used during the patient interview. listening, guided questioning, nonverbal communication, empathic response, validation, reassurance, summarization, transitions, empowering patient. Organize the phases of the interview. set the stage, preparation put patient at ease, establish trust obtain patient information, set goal summarize and discuss goals Discuss strategies for handling difficult patients. Patient, confusing patient, patient with altered capacity, talkative patient, crying patient, patient, language barrier, low literacy, impaired hearing, impaired vision, cognitive disabilities, personal problems, and sexuality. to finish filling Humility: Process that requires humility as individuals continually engage in and as lifelong learners and reflective practitioners Apply knowledge of the difference between spirituality and religion. is behaviors that give meaning to life and provide strength to the while Religion is a system of beliefs or a practice of worship. Explain why the spiritual needs should be assessed. distress may be a response to illness or health issues. FYI. Females at age 14 and up can seek care (birth control, etc.) without a consent. Review the connection between nutrition and culture cultures have a number of different eating habits. For example Orthodox Jew and Muslims do not eat pork, Hindus do not eat beef, Jainism is strictly vegetarian, etc. Culture may influence food preparation, number of meals, types of herbs used, food beliefs, etc. Ch. 6: Physical Examination: Identify the components of the physical examination. survey, assessment of vital signs, body measurements, system examination, establish a baseline. Describe the equipment for performing a physical examination. stadiometer, ophthalmoscope, otoscope, snellen chart, near vision chart, penlight, tongue depressor, ruler, thermometer, exam gloves, gauze pads, watch with second hand, sphygmomanometer, stethoscope, reflex hammer, tuning fork, cotton, two test tubes, paper and pen. (Neuro you need penlight, snellen chart, newspaper, ophthalmoscope, cotton swab, tongue blades, gloves, scents, tuning fork. Skin you need ruler and natural light) Know Auscultation, palpation, inspection, and percussion and what each is used to detect. is listening to the internal sounds of the body with the stethoscope is using tactile pressure to examine the size, consistency, texture, location, and tenderness of an organ or body part is closely observing details is evoking sound wave or dullness to assess the condition of the thorax or abdomen. What is the process for physical exam? (e. privacy, wash hands, etc.) privacy, hand hygiene, have patient sit down and start with the general survey, vital signs, and skin. Continue to HEENT (head eyes ears nose and throat), neck, back, posterior thorax and lungs followed anterior thorax and lungs. Have the patient stay sitting and examine breasts, axillae, and epitrochlear nodes. Ask the patient to lie down and check the cardiovascular system. To inspect and palpate the precordium, have patient roll partly to left side, then sit, lean forward and exhale while you listen for murmur of aortic regurgitation. Have patient lie back down to palpate and inspect the breasts and abdomen. Keep patient supine as you look at the lower extremities and musculoskeletal system. Have the patient sit while you assess the nervous system (mental status, cranial nerves, motor and sensory system, and reflexes.) Have patient stand to check peripheral vascular system and alignment of spine legs and feet along with their gait and balance. got this straight from the slides, so if it make sense check those out Ch. 7: General Survey, Vital Signs, and Pain: Identify the components of the general survey. impression, nonverbal cues, look at general appearance (frail, fit, or robust, looks age, awake alert responsive, oriented facial expression, odors such as alcohol, acetone, uremia, fruity) apparent state of health, demeanor, facial affect or expression (pain, anxiety or depression) grooming (buttons, hair, clothing), posture or gait (restless or quiet, fast movements, changes positions often, preferred posture), skin, personal hygiene, tattoos or piercings. Create appropriate subjective questions based on initial observations. Prepare to measure blood pressure, pulse, respirations, and temperature. Discuss variations in vital signs and the possible causes. pressure: Higher readings result from a cuff too small or too tight, the arm is below heart level or not supported, inflating or deflating the cuff too quickly. Lower readings result from cuff too large, repeating assessment too quickly, inaccurate level of inflation, pressing stethoscope too tightly against pulse. foods, drink and smoke can affect readings. can affect reading of pulse, temp, blood pressure, and respirations Evaluate the different types of pain. occurs suddenly with recent injury or illness pain that persists for more than months, recurring at intervals or Somatic: related to tissue damage related to direct injury to PNS or CNS many factors that influence pain pain without identifiable etiology. What is the process of assessing pulse, respirations, BP, and temp? Things like asking about hot liquids before taking the temp. Hint: look for words like after in these questions. Apply knowledge of the functions of the integumentary system. For example, if the barrier function of the skin was interrupted, what would the patient look like? What might cause that? Identify risk factors for pressure ulcers. What kind of information is on the Braden scale? What is a or Braden scale score? What does mean in terms of skin integrity? Braden scale assess Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. The higher the number the better the score on the Braden scale. Risk factors include all those on the Braden Scale along with sustained compression obliterating arteriolar and capillary blood flow to skin Not at risk mild risk moderate risk high risk 9 or lower: very high risk Identify risk factors for skin cancer. Know the ABCDEs for Melanoma screening. A asymmetry of one side of the mole compared to the other B irregular borders, especially ragger, notched, or blurred C variation or change in color, especially black or blue D diameter or different from others, especially if changing, itching, or bleeding E evolving, a mole or skin lesion that looks different from the rest or is changing in size, shape, or color. of skin cancer: history of previous melanoma, over 50, mole changing, Ultraviolet radiation exposure, light eye or skin color, severe blistering as child Analyze integumentary examination for completeness. Color, Moisture, Temperature, Texture, Mobility Turgor, Edema, and Lesions. Quantity, Distribution, Texture, Color Color, Shape, Texture, Firmly Attached Accurately compare primary, secondary, and vascular lesions Know macule, papule, pustule, vesicle. flat raised containing pus (zit) clear fluid (blister) What information should be documented about a skin lesion? locations and distributions, patterns and shapes, types of lesions, colors, elevation, size Note: most of the words in the exam questions matter. If the question gives you a patient age, or a setting (hospital versus home), these are often relevant when selecting the correct answer. There are ALWAYS some all that questions on 3120 exams.
Health Assessment Exam 1
Course: Health Assessment (NURS 3120)
University: Idaho State University
- Discover more from:
