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Health Assessment Exam 1 Study Guide
Health Assessment (NSG 3309)
Troy University
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Chapter 1 Health Assessment
- Nurses’ role in health assessment o ANA goals – to promote health, to prevent illness, to treat human responses to health or illness o Roles as a nurse – promote health and prevent illness, education/teaching (patient and family), community resource coordination
- What is health? o Absence of disease o Terms health and wellness have been used interchangeably to describe the state when someone is not sick, but not anymore o WHO – defines health as a state of complete physical, mental, and social well-being - Healthy People o National model for health promotion and risk reduction o Goals: illness prevention, planning, intervening, and evaluating o Types of interventions promoting healthy change: Primary intervention – preventing problems before you have them ex. immunizations, teaching about health, nutrition counseling Secondary intervention – early diagnosis, prompt treatment ex. screenings (vision, pap smear, scoliosis) Tertiary prevention – preventing further complications of an existing disease, promoting highest level of health ex. diet teaching for diabetes, exercise for obesity - Evidence based practice (EBP) o Practice based on the best available evidence, research o Minimizes intuition and personal experience o 4 steps: Identify issue based on accurate analysis of current nursing knowledge and practice Search literature for relevant research Evaluate research evidence using established criteria regarding scientific merit - What is assessment? o Health history and physical assessment o Additional necessary factors to be assessed – psychological, sociocultural, spiritual, economic, lifestyle o Because all future care is based on the health assessment it is extremely important that data is complete and accurate o This is one of the most important skills you will use as a nurse - The Nursing Process o Systematic problem solving approach to identifying and treating human responses to actual or potential health difficulties o Components of the nursing process Assessing - complete, accurate health data compilation Diagnosing – data clustering to determine patient’s condition
Planning – determining resources, targeting nursing interventions, writing plan of care Implementing – any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient outcomes Monitoring health status Prevent, resolve, and control a problem Assist with ADLs, promote optimal health and independence Evaluating – judgement of nursing care efficacy in meeting patient goals and outcomes based on patient’s responses to nursing interventions Requires knowledge of care standards, expected patient’s responses, and conceptual models and theories - Nursing vs. Medical Diagnosis o What is the difference between the two? Independent but interrelated Medical diagnosis is related to the etiology of disease Nursing diagnosis is concerned with the impact of the health problem the whole person and their response to the problem Provides a common language with which to communicate proper outcome and interventions - Type of health assessments o Emergency: life threatening or unstable situation Based on A, B, C, D, E mnemonic o Comprehensive: complete health history and physcial assessment performed Annually for outpatients and upon hospital/long term care admission o Focused: occurs in all settings, smaller scope but increased depth for specific issues ex. sprained ankle, foot fracture, etc.
- Priority Setting – what brings them here o Make a complete list of current medication, medical problems, and reason for seeking care because that will affect how you prioritize the care o Life threatening issues always take priority Circulation, airway, and breathing problems take priority over elevated temperature o Determine relationships among problems and prioritize them
- Components of the health assessment o Observe patients verbal and nonverbal communications o Maintain patient confidentiality o Purpose: collect family and personal histories of risk factors and past issues o Subjective data: patient is the primary source, therapeutic dialogue o Objective data: measurable information (vital signs, auscultation, visual appearance)
- Frameworks for health assessment o Functional assessment – focuses on functional patterns all humans share ex. nutrition, metabolism, etc. o Head-to-toe assessment – most organized, maintains modesty and efficiency ex. head and neck
Voice tone, use of touch (dominant component of physical exam, ask permission) Communicate at the patients eye level o Verbal communication skill Active listening ability to focus on patients and their perspectives, talking about difficult feelings can help patients heal, redirect interview if patients anger cannot be diffused o Other techniques of communication Restatement: restate information using patients words given to make sure you understand Reflection: echo’s patients word, focus attention on certain phrase, helps patient continue in his/her own way Elaboration: encourage patient to go on (facilitation) Silence: gives patients time to think and organize without interruption from you, gives you a chance to observe Focusing: redirect back to the topic Clarification: ask patient to clarify “tell me what you mean” Summarizing: most important findings, restate to be sure you and the patient are on the same page o Nontherapeutic responses False reassurance – promising everything is going to be okay even if you don’t know if it will, just be honest Sympathy – use empathy instead, put yourself in the patients situation Unwanted advice – don’t tell them what you would do, educate from evidence Biased questions Changes of subject Distractions Technical or over-whelming language Interrupting – listen instead
- Interviewing people with special needs o Hearing impaired: sign language o Acutely ill: make them comfortable o Under influence of street drugs or alcohol: simple and direct questions, avoid confrontation, what? How much? When? o Sexually aggressive: be professional, set boundaries, have a co-worker present o Crying: let the patient express their feelings o Angry/threatening violence: don’t take it personally, ask why, have a co worker present o Anxious: listen, address, and ease nerves o Cultural considerations: language barriers, special health practices
- Primary and Secondary Data Sources o Patient – primary source Gives subjective data o Documentation and family members – secondary sources o Historian reliability
o Nurses role Records the information provider Notes any discrepancies Identifies additional sources to confirm history (previous health records)
- Components of a health history o Demographic data (Name, DOB, billing address, age, gender, etc.), reason for seeking care, history of present illness, past health history, current medications, indications/allergies, family history, psychosocial and lifestyle factors Reason for seeking care - chief complaint, brief statement in persons own words describing reason for visit History of present illness – OLD CARTS Onset – when did it start, specific time Location/radiation – where does it hurt Duration – how long has this been going on, as specific as possible Character – sharp, dull, throbbing, etc. Aggravating factors/associating factors – what makes it worse, have any other symptoms shown up (headache w nausea) Relieving factors – what makes it better Timing – better/worse in the morning or ate night, when did it start, frequency Severity – how bad is your pain on a scale from one to ten Past health history/childhood illnesses/past illness Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations: cause, what hospital, what treatment, how long were you there physician Operations: what hospital and physician Immunizations Obstetric history: full term, miscarriages, abortions Last examination data Allergies: to what and what happens Current medications Family history – cancer, HTN, diabetes, heart disease Genogram age and health or cause of death of relatives Psychosocial and lifestyle factors Personal, at the end of the interview Coping/stress tolerance – social, cultural, and spiritual assessment Mental health – history, medications, and alcohol and drug use Human violence Sexual history and orientation – establish a baseline and educational need Review of systems General health state
o History/physcial examination by primary health care provider o Primary providers orders o POC (plan of care) or clinical pathway o Flow sheets – vital signs, intake and output, routine assessments o Focused assessment documentation o Medication administration record (MAR) o Laboratory/diagnostic test results o Progress notes from members of care team (case note) o Narrative notes SOAP(IE) notes: subjective, objective, analysis, plan, interventions, evaluation PIE notes: problems, intervention, evaluation DAR notes: data, action, response CBE (charting by exception): outside normal limits, charting abnormalities o Consultations o Discharge or transfer summary o Home care documentation OASIS – outcome and assessment information set (federally mandated) o Long term care documentation Resident assessment instrument (RAI) – very comprehensive assessment tool o Written hand off summary
- Electronic medical record o Clinical agencies have computerized all/parts records eMAR computerized provider order entry o Permits use of automated clinical surveillance tools Detects assessment data indicating problems, requires timely input of assessment data
- Principles governing documentation o Confidentiality: keeping patients health information private Health Insurance Portability and Accountability Act (HIPPA) – requires protection of specific health information o Accuracy and completeness: must precisely reflect assessment data, legally accepted abbreviation use and corrections Logical organization Timeliness – batch charting discouraged, point-of-care documentation Conciseness Critical thinking/clinical judgement
- Verbal communication o Verbal handoff potential communication barriers Lack of Structured format Policies/standard for communication Responsibility/contact ambiguity
Relationship hierarchy questions Ethnic background differences Poor clinical decision making regarding important data Differing communication styles of doctors and nurses o Reporting Qualities of effect reporting – organized, complete, concise, respectful SBAR model: situation, background, assessment, recommendations Reporting to primary health care provider o Telephone communication o Patients rounds, conferences o Critical thinking, clinical judgement
Chapter 3 Techniques of Assessment and Safety
- Physical Examination o Skills required: inspection, palpation, percussion, and auscultation (IPPA) Abdominal IAPP Inspection – begins when you meet the person with general survey As you proceed through the exam, start assessment of each body system with inspection (maintain modesty) Always comes first Requires: good lighting, adequate exposure, occasional use of instruments Palpation - second and often confirms points you noted during inspection , lumps, deformities, rash, temp. Light palpation (1cm) first to detect surface characteristics and accustom patient to being touched Then perform deeper palpation (1-2cm) when needed o Intermittent pressure better than one continuous palpation, avoid any situation in which you could cause internal injury or pain Bimanual palpation (2-4cm) require both hands to envelop certain body parts or organs for more precise delimitation (spleen, liver, uterus, adnexa) Use finger pads for fine discrimination o Ex. pulses, small lumps, skin texture, edema Use finger palmar surfaces firmness, contour, position, size, pain, tenderness Use dorsal surface of hand temperature Percussion – tapping the persons skin with short, sharp strokes to assess underlying structures The strokes tell us the location, size, and even density of the organ by the way they sound or “percuss”
Prior to invasive procedure Before and after contact with a patient o Wear gloves When potential exists for contact with fluids Not a substitute for washing hands Change between task and procedures and when moving from contaminated to clean area Wear gown, mask, eye wear when potential for any blood or body fluid Caution: latex allergies o Standard precautions All waste and contact are potentially infectious Use with all patients
- Vital signs and general survey o Urgent assessment Indicators of an urgent situation – extreme anxiety, acute distress, pallor cyanosis, mental status change Interventions begin while continuing the assessment Rapid response team may be called for An acute change in mental status Stridor Respiration < 10 or > 32 bpm Oxygen saturation < 91 % Pulse < 55 bpm or > 120 bpm Systolic BP < 100 mm Hg or > 170 mm Hg Temperature < 35 C or > 39 C New onset chest pain Agitation Restlessness o General Survey – a study of a whole person Covers general health state and any obvious physical characteristics Intro for physical exam, should give an overall impression Launch a general survey the moment you first encounter a patient What do you notice about them? Mood, gait, slumping, eye contact, smile, etc. As you proceed through the health history, measurements, and vital signs make note of these four areas Physical appearance hygiene, dress, skin color, development, facial expressions, level of consciousness, speech Body structure Mobility posture, range of motion, and gait Behavior Assess
Physical appearance – over all appearance, hygiene, dress, skin color, body structure, development, behavior, facial expressions, level of consciousness, speech Mobility – posture, range or motion, gait
- Anthropometric measurements – height and weight o Remove shoes and heavy clothing, record weight in kg and pounds, show person how his or her weight matches to recommended range for height o Infants and children Weight: weigh infant on balance scale .... By 2 or 3 years use up right scale Length: until age 1 measure infants body length supine by using horizontal measuring board .... For age 3 or 3 measure by standing child against pole on platform scale or back flat against a ruler tatped to the wall
- Older adults general survey o Physical appearance – body contour sharper, more angular features, body proportions redistributed o Posture – general flexion o Gait – wider base to compensate for diminished balance, arms held out, shorter more uneven steps o Weight – decreases during 80s and 90s even with good nutrition, subcut fat lost from face and periphery, additional fat on abdomen and hips
- Abnormal findings in body height and proportion o Gigantism – increased GH in childhood o Acromegaly (hyperpituitarism) – increased GH in adulthood o Achondroplastic dwarfism – kyphosis in back o Anorexia nervosa
- Vital signs o Before measuring vital signs Have patient rest a least 5 minutes Assure patient has not eaten, drank, or smoked at least 30 min before measurement Remove clothing constrictive to upper arm Patient may be sitting or standing o Vital signs include Temperature – normal is 97 to 98 depending on route Rectal, temporal artery 0.1-0 > oral Axillary 1 < oral Rectal is most accurate Diurnal cycle – down in AM up In PM Thermometer types: electronic, disposable, tympanic, temporal artery Blood pressure – force of blood pushing against side of the vessel Systolic pressure: max pressure felt on an artery during left ventricular contraction or systole Diastolic pressure: elastic recoil, or resting pressure that blood exerts constantly between each contraction
3+ full, bounding 2+ normal 1+ weak, thready 0 absent o Elasticity Pain o Oxygen saturation – percentage to which hemoglobin is filled with O 2 Normal is 95-99% < 85% inadequate oxygenation, possible emergency 85-89% possibly acceptable for those with specific chronic conditions Emphysema o Vital signs in infants/children and older adults Infants and children Temp: select appropriate type for situation Pulse: apical pulse is generally easier, count for full minute Respirations: should be done observing abdominal movement due to diaphragmatic use BP: generally not until age 3, use pediatric cuff and steth Older adults Temp: less likely to have fever but at greater risk for hypothermia, temp is less reliable Pulse: range is generally the same but often irregular Respirations: decrease in vital capacity and inspiratory reserve volume BP: BP increases, difficult to distinguish expected aging values from abnormal hypertension
Chapter 6 Pain Assessment
- Pain – complex and subjective experience that originates from the CNS, PNS, or both o Peripheral nervous system Two main types of nerve fibers: A-delta, C-delta fibers Nociceptors: specialized nerve endings designed to detect painful sensations Transmit sensations to CNS, can be stimulated directly be trauma or secondarily by chemical mediators released from the site of tissue damage o Classification of pain Nociceptive pain: develop when nerve fibers in the CNS and PNS are functioning and intact, starts outside the nervous system from actual or potential tissue damage Neuropathic pain: message that has been sent to the brain has been damaged resulting in abnormal processing of the pain difficult to treat Diabetes mellitus, herpes zoster (shingles), trigeminal neuralgia, phantom limb pain o Types of pain Acute pain: signals tissue damage
Musculoskeletal pain Visceral pain – abd organs crampy, gnawing Somatic pain – tissue, bones/joints sharp Cutaneous pain – skin layers burning, sharp Referred pain: originates at one location felt at a different location cardiac, phantom limb Complex regional pain syndrome surgery, crush-type injury Chronic pain: no known cause or treatment, pain continuing 6 months or longer Neuropathic pain: a more constant stimulus Peripheral sensitization result of inflammation process non painful touch/pressure becomes painful Neuronal windup hypersensitivity in areas not usually painful Central sensitization persisting pain remembered by spinal nerves after peripheral stimulation ceases
- Pain – Subjective Data o Pain is always subjective, and whatever the experiencing person says it is o Initial pain assessment Where is your pain? When did it start? Is it constant, does it come and go? What does it feel like? burning, stabbing, aching, throbbing, cramping, sharp, itching, dull How much pain are you in? scales What makes it better/worse? include all interventions How does it limit your function/ADLs? How would others know you were in pain? What does that pain mean to you? Why do you think you’re having this pain? o Pain assessment tools One-dimensional pain scales Visual analog scale (VAS) Verbal descriptor scale (VDS) Numeric pain intensity scale (NPI) Combined thermometer scale combines VDS + NPI Multidimensional pain scales McGill pain questionnaire (MPQ) used for experimentally induced circumstances, following procedures, with several medical-surgical conditions Brief pain inventory (BPI) initially used for cancer pain, also valid for chronic nonmalignant pain Brief pain impact questionnaire (BPIQ) used for chronic pain o Nonverbal behaviors of pain Use behavioral cues when individual cannot verbally communicate pain Facial expression, grabbing area, rubbing area, bracing themselves Influenced by nature of pain, age, gender, and cultural expectations o Lifespan considerations
o Urban living impacts growing/processing own food
- USDHHS and USDA publish guidelines for healthy eating o Revised every 5 years o Consider age, gender, activity levels in dietary recommendations o MyPlate emphasizes need for consuming five food groups, encourages wiser food choices and portion size
- Lifespan Considerations o Pregnant/lactating women Increase calories by 300 to 500 a day emphasizing protein sources and maybe even take supplements Iron, folate, and zinc are vital if these are deficient can cause neural tube defects Vitamins A, C, and calcium too o Infants/children/adolescents Adolescents – growth spurts, need protein and extra calories Infants and small children – need fat for brain development o Older adults BMR declines so need less calories and vitamin D
- Cultural Considerations o Learned food preference influences tradition, geography, income, education o Food practices may be based on religious beliefs o Fasting, abstaining from specific foods
- Collecting nutritional data o Ongoing process delegation to nurses Assessing patients nutritional risk and reinforcing dietary counseling o Complete nutrition screening assessment parameters Risk assessment & physical assessment Focused history of common symptoms Comprehensive nutritional history Calculated measurements Serial lab values o Urgent assessment Nutritional deficits Trauma or stress increased caloric need Increased risk for nutritional deficit Surgery Trauma Infection Head injury Burns o Subjective data collection Areas for health promotion pertinent topics, interventions Assessment of risk factors Medical/surgical history Weight history
o Appetite and taste changes, gastro symptoms, food allergy or intolerance Family history o Crohn disease, CM II, cystic fibrosis, anemia, obesity, heart disease Food and fluid intake patterns eating patterns, fluid patterns Psychosocial profile habits, cooking ability, dietary lifestyle changes Medications and supplements medication schedule, barriers to accuracy, supplements, alcohol use
- Risk assessment and health related patient teaching o Patient teaching – high density vs. low density nutritional intake, reading and using food labels, restrictive diets o Focused health history related to common symptoms – common symptoms of altered nutrition o Symptom assessment – body weight changes, changes in eating habits, malnutrition symptoms o Cultural considerations
- Comprehensive nutritional history o Food records 24 hour recall, 3 day food diary, food frequency questionnaire o Direct observation intake and out put, calorie count o Older adults medications (malnutrition screening), risk for deficient fluid volume
- Objective data collection o Equipment scale, measuring tape, skin calipers, growth chart (for children) o Preparation o Physical assessment Body type: small, average, or large build General appearance Swallowing Elimination: urine, emesis, and stool BMI: under weight < 18 , normal 18 – 24 , overweight 25 – 29 , obesity 30 – 39 , extreme obesity 40 + Weight calculation: waist to hip ratio = waist circumference (largest point) Android obesity - men > 1 women > 0. Skin fold thickness Midarm muscle circumference, upper arm o Lifespan considerations Older adults simplest screening measures, measuring BMI, assessing for weight change, unintentional weight change (associated with risk of death) Cultural considerations
- Common lab diagnostic testing o Serum proteins liver synthesized Albumin – prealbumin, transferrin, creatinine o Hemoglobin and hematocrit poor iron intake/absorption o Lymphocyte count compromised inflammatory response?
o Assessment of risk factors and health promotion General health, personal history, medications, risk factors Skin self-assessment, educate on the importance of limiting UV radiation and characteristics of normal/problematic moles ABCDE – asymmetry, borders, color, diameter, evolution
- Common integumentary symptoms o Pruritus – itching o Rash macular, ecchymosis, papular, vesicular, plaque o Single lesion/wound cancer
- Comprehensive skin assessment o Inspection reposition patient, bony prominences o Note changes in pigmentation Vitiligo – loss of skin color patchers Erythema – redness Cyanosis – blue Pallor – pale Jaundice – yellow Brawny – dark, leathery
- Categorize lesions o Primary – arise from normal skin Macules, papules, nodules, polyp, blisters, wheal, cysts, pustules, and abscesses o Secondary – follow primary Scar tissue, crusts
- Patterned/configuration of lesions o Annular – ringlike, circular o Linear – line shape o Polymorphous – several different shapes o Puncate – small, marked with points or dots o Serpiginous – curving, snakelike, scabies o Nummular/discoid – coin shaped o Umbilicated – central depression o Filiform – papilla-like or fingerlike projections o Verruciform – circumscribed, papular with rough surface
- Distribution patterns o Asymmetrical – distributed solely on one side of the body ex. contact dermatitis, herpes zoster o Diffuse – distributed widely across affected area without any pattern ex. drug reaction, rubella, rubeola o Discrete – single, separated well-defined border ex. melanoma, wart o Genralized – distributed over large body area ex. psoriasis, acne vulgaris, exfoliative dermatitis o Grouped – clustered ex. herpes simplex o Localized – located at distinct area ex. giant nevus, contact dermatitis, vitiligo
o Satellite – single lesion in close proximity to larger lesion, as if orbiting ex. cutaneous candidiasis o Zosteriform – distributed along dermatome ex. herpes zoster
- Psoriasis – chronic skin disorder commonly characterized by reddih pink lesions cover with silvery scales , commonly on extensor surfaces but CAN appear anywhere
- Malignant skin lesions o Basal cell carcinoma o Squamous cell carcinoma o Malignant melanoma o Metastatic malignant melanoma
- AIDS Kaposis lesions vascular tumor most common in persons infected with HIV, considered an AIDS-defining illness
- Abnormal hair conditions o Scabies, paronychia, pitting, clubbing, beaus line
- Pressure ulcers o 1. Non-blanchable redness, skin intact o 2. Partial thickness skin loss, skin not intact o 3. Full thickness skin loss, ulcer into dermis and subcutaneous tissue o 4. Full thickness tissue loss and bone exposed o 5. Unstageable unknown depth, dead obscures ulcer
- Skin conditions to know o Raynaud phenomenon – pallor of fingers and toes in response to cold o Macule – flat, freckled discoloration o Papule – raised, defined, any color, less than 1 cm diameter ex. wart, insect bite, molluscum contagiosum o Purpura – purplish macules or papules result from bleeding under skin secondary to inadequate clotting mechanisms o Petechiae – these small reddish to purple macules or papule can develop anywhere on the body in response to physical trauma o Hirsutism – women show male-pattern hair distribution, usually on face, neck, chest, abdomen, or genital area... dark patches of skin on the neck o Venous lake – this popular bluish purple lesion blanchers on pressure and is generally found on the face, especially on the lips or ears... it is benign and often associated with sun exposure o Tinea corporis – commonly called ringworm, this dermatophyte skin infection results in erythematous, commonly pruritic, annular lesion with a raised border and central clearing o Tinea versicolor – this dermatophyte infection caused by normal skin flora results in hypopigmented patchy lesions generally distributed on the upper chest, upper back, and proximal extremities, it rarely occurs on the face and legs o Vesicle’s fluid-filled less than 1 cm diameter ex. herpes simplex. Chicken pox o Nodule – large nodule ex. large nevus, basal cell carcinoma, lipoma
Health Assessment Exam 1 Study Guide
Course: Health Assessment (NSG 3309)
University: Troy University
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