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Health Assessment - Exam 1
Health Assessment (NSG 3160)
Galen College of Nursing
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- Extremely accurate representation of exam 1
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Health Assessment
Exam 1
Chapter 1: Evidence-Based Assessment
● Assessment ○ Subjective: person says ○ Objective: what’s observed ● Diagnostic Reasoning ○ Process of analyzing health data and drawing conclusions to identify diagnoses ○ Four major components: ■ 1) attending to initially available cues ■ 2) formulating diagnostic hypotheses ■ 3) gathering data relative to the tentative hypotheses ■ 4) evaluating reach hypothesis w/ the new data collected ○ Cluster/ group assessment data that appear associated ■ Look for gaps in data collection ● Nursing Process ○ Assessment ■ Collect/ document data ○ Diagnosis ■ Compare, validate, and document diagnosis ○ Outcome Identification ■ Develop timeline ○ Planning ■ Document plan of care ○ Implementation ■ Collaborate with colleagues ○ Evaluation ■ Progress towards desired outcome; adjust as needed ● 1st level priority problems ○ Emergent; life-threatening ● 2nd level priority problems ○ Urgent; require prompt intervention to prevent further problems ● 3rd level priority problems ○ Can wait until more serious problems are addressed ● Evidence-based practice ○ All patients deserve to be treated with most current and best-practice techniques ● Complete (Total Health) Database ○ Current and past health state and forms baseline against which all future changes can be measured ○ Must screen for pathology and determine ways people respond to that pathology or to any health problem ● Focused/Problem-Centered Database ○ “Mini” database ○ Concerns mainly one problem, one cue complex, or one body system ● Follow-Up Database ○ Status of identified problems should be evaluated at regular, appropriate intervals ● Emergency Database ○ Urgent, rapid collection of crucial info
○ Often compiled concurrently w/ lifesaving measures
● Holistic Health ○ Views mind, body, and spirit as interdependent and functioning as a whole w/i the environment ● Health promotion: set of positive acts that we can take
Chapter 2: Cultural Assessment
● Determinants of Health and Health Disparities ○ Individuals health status is influenced by constellation of factors known as social determinants of health (SDOH) ○ Health disparity: specific type of health difference that is closely linked w/ social, economic, and/or environmental disadvanaged ○ Vulnerable populations ■ Including ethnic and racial minorities, people w/ disabilities, and LGBTQ+ ○ Lack of health insurance ○ Limited English proficiency (LEP) ● Culture-Related Concepts ○ Socialization (enculturation): process of being raised w/i a culture and acquiring the norms, values, and behaviors of that group ○ Subcultural groups ■ Share different beliefs, values and attitudes ○ Race relevant when determining disease prevelance ■ Does not typically refer to specific genetic or biologic characteristics that distinguish one group from another ○ Ethnicity ■ Religion, language, geographic location, values, food preferences, etc. ○ Acculturation ■ Process of adopting culture/behavior of the majority culture ○ Acculturative Stress ■ Losses and changes that occur when adjusting to/ integrating new system of beliefs, routines, and social roles ● Religion and Spirituality ○ Spirituality ■ Connecting to something larger than oneself ■ Belief in transcendence ○ Religion ■ Organized system of beliefs ■ Cause, nature, and purpose of the universe ■ Attendance of regular services ○ Completion of spiritual assessment = component of holistic health ● Health is defined as the balance of the person ○ Within (physical, mental, or spiritual) ○ Outside (natural, communal, or metaphysical) ● Biomedical (scientific) theory of illness ○ All events in life have a cause and effect ● Naturalistic (hollistic) ○ Forces of nature must be kept in natural balance or harmony ○ Yin/yang theory: health exists when all aspects of the person are in perfect balance
■ Empathy ■ Clarification ○ 4 involve your own thoughts and feelings ■ Confrontation ■ Interpretation ■ Explanation ■ Summary ● 10 traps of interviewing ○ Proividing false assurance or reassurance ■ Acknowledge the feeling and open the door for more communication ○ Giving unwanted advice ■ If advice is based on a hunch or feeling or is your personal opinion, most likely inappropriate ○ Using authority ○ Using avoidance language ■ Not talking about uncomfortable topics doesn’t make them go away but instead makes them more frightening ○ Distancing ■ Specific language and blunt terms indicates that yout are not fearful of the disease/procedure ■ May decrease anxiety and help client cope with reality of the situation ○ Using professional jargon ■ Adjust yout vocab to ensure understanding w/o sounding condescending ○ Using leading or biased questions ■ Client feels that they risk disapproval by not answering “correctly” ○ Talking too much ■ Listen more than you talk ○ Interrupting ○ Using “why” questions ■ Implies blame and condemnation ● Nonverbal Skills ○ Open position w/ extension of large muscle groups shows relaxation, physical comfort, and willingness to share info ○ Closed position w/ arms and legs crossed looks defensive and anxious ● Ending the interview ○ Should end gracefully ○ Summary of what you have learned ● Interviewing parent/caregiver ○ Children 1 - 6 years old, focus more on caregiver ■ If child sees caregiver accepts and likes you, they will begin to relax ○ Observer child-caregiver interaction ○ Do not ignore child completely ■ Nonverbal communication is most important to children ○ Children frightened by quick or grandiose gestures ● Stages of Cognitive Development ○ Sensorimotor (birth - 2 yrs) ■ Reflexive communication, then moves through 6 stages to reach actual thinking ○ Preoperational (2 - 6 yrs) ■ Begins use of symbolic thinking
■ Imaginative play ○ Concrete Operations (7 - 11 yrs) ■ Logical thinking ○ Formal Operations (12+ yrs) ■ Abstract thinking ● Communicating w/ Different Ages ○ Infant (birth - 12 months) ■ Coos, gurgles, facial expressions, cries to identify needs ○ Toddler (12 - 36 months) ■ Telegraphic speech: combination of noun and a verb ■ Includes words that have concrete meaning ■ Struggle for control abd autonomy ○ Preschooler ( 3 - 6 years) ■ 3 - 4 word telegraphic sentences containing only essential words ■ Animistic: may imagine that unfamiliar inanimate objects can come alive and have human characteristics ○ School-Age Child (7 - 12 yrs) ■ More objective and realistic ■ How things work and why things are done ■ Can decenter and consider all sides of a situation to form a conclusion ■ Ask child about symptom first ○ Adolescent ■ Sometimes capable of mature actions, other times fall back on childhood response patterns, especially in times of stress ■ Keep respectful attitude ■ Use totally honest communication ■ Focus on adolescent first, not the problem ■ Explain every step and give rationale ■ May be more willing to give info w/o caregiver in room ○ Older Adult ■ Avoid “elderspeak” ■ Plan for longer encounters ■ Touch is important to older people ● Interviewing People w/ Special Needs ○ Hearing-Impaired ■ Ask preferred way of communication – signing, lipreading, or writing ○ People under the influence of drugs or alcohol ■ Alcohol, benzos, and opiods ● CNS depressants ● Slow brain activity ● Impair judgement, memory, intellectual performance, motor coordination ■ Cocaine, amphetamines ● Stimulate CNS ● Cause intense high, agitation, paranoid behavior ■ LSD, ketamine, PCP ● Hallucinogens ● Cause bizzare, inappropriate, sometimes violent behavior ● Accompanied by superhuman strength and insensitivity to pain ■ Ask simple, direct questions
Hematologic system Endocrine system ● Functional Assessment (ADLs) ○ Person’s self-care abilities ○ Best asked later in interview when rapport is established ○ Areas to ask about include: Self-Esteem, Self-Concept Activity/ Excerise Sleep/ Rest Nutrition/ Elimination Interpersonal Relationships/ Resources Spiritual Resources Occupational Health
Coping and Stress Management Personal Habits Alcohol Illicit or Street Drugs Enviroment/ Hazards Intimate Partner Violence
● Past Health of Children ○ Depending on age, info may be needed about mother’s ■ Prenatal status ■ Labor and delivery ■ Postnatal status ○ Developmental History ■ Growth ■ Milestones ○ The younger the child, the more detailed the nutritional history should be ● Adolescents ○ HEEADSSS ■ Home environment ■ Education and employment ■ Eating ■ Activities, peer-related ■ Drugs ■ Sexuality ■ Suicide/depression ■ Safety from injury/violence
Chapter 7: Domestic and Family Violence Assessment
● Intimate Partner Violence ○ Any partner w/ whom the person has a close relationship with ○ 4 main categories: ■ Physical violence ■ Sexual violence ■ Stalking ■ Psychological aggression ○ Also includes teen dating violence ■ Can be physical, sexual, psychological, or emotional abuse ● Child Abuse and Neglect ○ Neglect ■ Failure to provide for child’s basic needs ■ This includes prenatal drug exposure
○ Physical abuse ■ Nonaccidental physical injury ○ Sexual abuse ○ Emotional abuse ● Elder Abuse and Neglect ○ Includes both intentional acts and failure to act by caregiver or trusted person ○ Physcial abuse ○ Sexual abuse or abusive sexual contact ○ Neglect ○ Financial abuse or exploitation ● Health Effects of violence ○ Significant immediate and long term effects ○ Abuse victims have significantly more: ■ Depression ■ Suicidality ■ PTSD ■ Problems w/ substance abuse ● Documentation ○ Must include: ■ Detailed, unbiased progress notes ■ Injury maps ■ Photographic documentation (prior written consent should be obtained) ○ Do not sanitize words reportedly heard by victim ○ Do not speculate ○ When documenting child abuse or neglect, use the words the child has given to describe how their injury occured ● Subjective Data ○ All women on childbearing age (14 - 46 yrs) should be screened for IPV ○ You do not need to prove abuse to file report ○ HITS tool can be used to screen for teen dating violence ○ Watch interaction between child and caregiver ● Objective Data ○ Thorough head-to-toe exam is imperative for any patient w/ suspected or known abuse ○ Color of bruises (and ecchymoses) generally progress from ■ Purple-blue ■ Bluish-green ■ Greenish-brown ■ Brownish-yellw ○ Patients w/ suspected elder abuse should have the following labs drawn: ■ CBC w/ platelet level ■ BUN, creatinine, protein, albumin ■ Serum liver function tests ■ Coag panel ■ UA ○ Bruising in atypical places on infants and children (buttocks, hand, feet, abdomen and ears) should raise concern
Chapter 9: General Survey and Measurement
● Physcial Appearance ○ Age – should look their age ○ Sex – development appropriate for age and sex ○ Level of consciousness – alert and oriented to person, place, time, and situation ○ Skin color – color tone even; pigmentation varying w/ genetic background ○ Facial features – symmetric w/ movement ○ Overall appearance – no signs of acute distress ● Body Structure ○ Stature – height w/i normal range for age, genetic heritage ○ Nutrition – w/i normal range for height and body build; even body fat distribution ○ Symmetry – body parts look equal bilaterally; proportionate ○ Posture – stands comfortably erect as appropriate for age ○ Position – sits comfortably ○ Body build, contour – proportions are ■ Arm span (fingertip to fingertip) = height ■ Crown to pubis = pubis to sole (roughly) ● Mobility ○ Gait – walk is smooth, even; can maintain balance ○ Range of motion – full mobility of each joint; no involuntary movement ● Behavior ○ Facial expression – maintains eye contact; expression appropriate for situation ○ Mood and affect – comfortable and cooperative ○ Speech – articulation is clear, understandable ○ Speech pattern – fluent w/ even pace ○ Dress – looks clean, appropriate for climate ○ Personal hygiene – clean and groomed ● Weight ○ Remove shoes and heavy outer clothing ● Height ○ Shoeless, standing straight ● BMI ○ Underweight <18 kg/m² ○ Normal weight 18 - 24 kg/m² ○ Overweight 25 - 29 kg/m² ○ Obesity (class 1) 30 - 34 kg/m² ○ Obesity (class 2) 35 - 39 kg/m² ○ Extreme obesity (class 3) ≥ 40 kg/m² ○ To calculate: ■ BMI = (weight (lbs) / height (in)) / 703 ■ BMI = weight (kg) / height (m²) ● Waist Circumference ○ Greater risk for developing DM, HTN and other complications if too large ● Aging Adult ○ Physical appearance – sharper body contour; angular facial features; redistributed body proportions ○ Posture – general flexion ■ Kyphosis (humpback) common ○ Gait – use wider base to compensate for diminished balance
○ Weight – decreases; distribution of fat changes (deposits in abdomen and hips) ○ Height – shorter due to thinning of vertebral disks, individual vertebrae
Chapter 10: Vital Signs
● Temperature ○ Oral – 98 normal; ranges 96 - 99. ○ Rectal temp most accurate, considered core temp ● Pulse ○ Stroke volume ■ Amount of blood pumped into the aorta ■ 70 mL in adult ○ Normal range 50 to 95 beats/min ○ Bradycardia < 50 bpm ○ Tachycardia > 95 bpm ○ Force ■ 3+ – full, bounding ■ 2+ – normal ■ 1+ – weak, thready ■ 0 – absent ● Respirations ○ 10 - 20 respirations/ min ● Blood Pressure ○ Systolic – max pressure felt on artery during left ventricular contraction ○ Diastolic – elastic recoil (resting) pressure blood exerts constantly b/t contraction ○ Mean arterial pressure (MAP) – pressure forcing blood into tissues averaged over the cardiac cycle ■ MAP = [(2x diastolic) + systolic] / 3 ○ Normal BP – <120/< ● Aging Adult ○ Temperature – less likely to have fever, greater risk of hypothermia ○ Pulse – 50 - 95 bpm; rhythm may be slightly irregular ○ Respirations – decreased inspiratory volume; shallower; increased rate ○ Blood pressure – aorta and major arteries tend to harden; systolic pressure increases ● Oxygen Saturation ○ Attach to persons finger, forehead, or earlobe ○ Compares ratio of light emitted w/ light absorbed; converts ration into percentage of O₂ saturation ○ Normal – >92% ● Doppler Technique ○ Used to locate peripheral pulse sites
Health Assessment - Exam 1
Course: Health Assessment (NSG 3160)
University: Galen College of Nursing
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