Health Assessment Exam 1

Front 1

Health

Back 1

a state of complete physical, mental, and social well-being

Front 2

Health Assessment

Back 2

systematic method of collecting data about a client for the purpose of determining the client's current and ongoing health status, predicting risks to health, and identifying health-promoting activities

Front 3

Interview

Back 3

(subjective data is gathered) included is health history and focused interview - will come from primary and secondary sources

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Primary Source

Back 4

data is collected from the client/patient

Front 5

Subjective Data

Back 5

information that the client experiences and communicates to the nurse - ex: pain, nausea, dizziness, itching sensations, or feeling nervous

Front 6

Health History

Back 6

to obtain information about the client's health in his or her own words and based on the client's own perceptions

Front 7

Focused Interview

Back 7

enables the nurse to clarify points, to obtain missing information, and to follow up on verbal and nonverbal ques identified in the health history

Front 8

Physical Assessment

Back 8

hands-on examination of the client. components of the physical assessment are the survey and examination of systems

Front 9

Objective Data

Back 9

observed or measured by the professional nurse. AKA overt data or signs

Front 10

Constant Data

Back 10

information that does not change over time. EX: race, sex or blood type

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Variable Data

Back 11

may change within minutes, hours or days EX: blood pressure, pulse rate, blood counts, and age

Front 12

Client Record

Back 12

a legal document used to plan care, to communicate information between and among healthcare providers, and to monitor quality of care

Front 13

abd

Back 13

abdomen

Front 14

ADL

Back 14

Activities of Daily Living

Front 15

CBC

Back 15

Complete blood count

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CNS

Back 16

Central Nervous System

Front 17

CVA

Back 17

Costovertebral Angle

Front 18

Dx

Back 18

Diagnosis

Front 19

Hx

Back 19

History

Front 20

LMP

Back 20

Last Menstrual Period

Front 21

What is important when recording subjective data

Back 21

always use quotation marks and to quote the client exactly rather than interpret the statement

Front 22

Confidentiality

Back 22

information sharing is limited to those directly involved in client care

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Anterior (ventral)

Back 23

toward the front

Front 24

Cephalad

Back 24

toward the head

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Distal

Back 25

farthest from the center, or a medial line

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Deep

Back 26

below the surface

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medial

Back 27

closer to the midline

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superior

Back 28

upper

Front 29

supine

Back 29

face up

Front 30

posterior (dorsal)

Back 30

toward the back

Front 31

Caudad

Back 31

toward the feet

Front 32

proximal

Back 32

closest to the center or a medial line

Front 33

superficial

Back 33

on or above the surface

Front 34

internal

Back 34

inside of

Front 35

lateral

Back 35

farther from the midline

Front 36

inferior

Back 36

lower

Front 37

prone

Back 37

face down

Front 38

SOAP

Back 38

Subjective Data, Objective Data, Assessment, and Planning

Front 39

APIE

Back 39

Assessment, Problem, Intervention, and Evaluation

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Focus Documentation

Back 40

a method that does not limit documentation to problems but can include client strengths

Front 41

Interpretation of Findings

Back 41

can be defined as making determinations about all of the date collected in the health assessment process

Front 42

Communication

Back 42

refers to the exchange of information, feelings, thoughts, and ideas. can occur non-verbally and verbally

Front 43

Holism

Back 43

considering more than the physiologic health status of a client - includes all factors that impact the client's physical and emotional well-being

Front 44

Nursing Process

Back 44

systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client

Front 45

Nursing Process Steps

Back 45

Assessment, Diagnosis, Planning, Implementation, and Evaluation

Front 46

Assessment

Back 46

step 1 of nursing process

collection, organization, and validation of subjective and objective data

Front 47

Diagnosis

Back 47

using critical thinking, applies knowledge from the sciences and other disciplines to analyze and synthesize the data

Front 48

Nursing Diagnosis

Back 48

judgement after the analysis and the synthesis of collected data - basis for planning and implementing nursing care

Front 49

R/T

Back 49

Related To

Front 50

3 types of nursing diagnoses

Back 50

actual problem, risks for problems, wellness issues

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Planning

Back 51

Step 3 - involves setting priorities - stating client goals or outcomes and selecting nursing interventions, strategies, or orders to deal with the health status of the client

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Impeltmentation

Back 52

Step 4 - care plan is put into action

Front 53

Evaluation

Back 53

Step 5 - compares the present client status to achievement of the stated goals or outcomes

Front 54

Critical Thinking

Back 54

Process of purposeful and creative thinking about resolutions of problems or the development of ways to manage situations

Front 55

5 Essential Elements of Critical Thinking

Back 55

collection of information, analysis of situation, generation of alternatives, selection of alternatives & evaluation

Front 56

Informal Teaching

Back 56

generally occurs as a natural part of a client encounter - may be to provide instructions, to explain a question or procedure, or to reduce anxiety

Front 57

Formal Teaching

Back 57

Occurs in response to an identified learning need of an individual, group, or community

Front 58

Learning Need

Back 58

identified as discrete knowledge deficits for an individual or as common needs of individuals and groups

Front 59

Purpose of Assessment

Back 59

to make clinical judgement or Dx about the patients health state or response to actual or risk health problems

Front 60

Analysis of Situation

Back 60

Gather information, cluster data and cues, identify patterns, identify missing information & validate!

Front 61

Clinical Judgement

Back 61

identify problems and make decisions using the nursing process - ability to solve problems based on level of experience

Front 62

pt is in acute pain, has not been sleeping well, and is having difficulty breathing. How should the RN prioritize these problems?

Back 62

Breathing, Pain, Sleep

Front 63

Physical Appearance

Back 63

age, gender, skin, color, facial features, symmetry, body structure, stature, odor

Front 64

Mental Status

Back 64

Orientation (LOC) x3 or x4, speech (Dysphonia, Dysarthria), recent and remote memory assessment

Front 65

Dysphonia

Back 65

difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords

Front 66

Dysarthria

Back 66

difficult or unclear articulation of speech that is otherwise linguistically normal.

Front 67

Mobility

Back 67

gait, posture, and range of motion

Front 68

Behavior

Back 68

Mood, affect, cleanliness, personal hygiene

Front 69

Inspection

Back 69

(to creep) focus eyes on the patient, use lighting appropriately, remember other senses (scents and odors)

Front 70

Palpation

Back 70

(to touch) fingertip vs dorsal vs fingertips

Front 71

Percussion

Back 71

(to tap) assessment of tissue density, fluid, or pain

Front 72

Auscultation

Back 72

(to listen) evaluation of sounds

Front 73

Vital Signs

Back 73

Temperature (influences)

Pulse (rate/rhythm, force)

Respirations (rise and fall of chest)

Blood Pressure (causes of B/P changes)

Pulse Oximetry (concentration of oxygen in the blood)

Front 74

How long do you count irregular respirations and pulses

Back 74

one full minute

Front 75

A significant elevation in blood pressure measurements from one day to the next could attribute to:

Back 75

a decrease in cuff size / new onset of pain or anxiety

Front 76

The nurse is taking a 75 y.o. female's BP. Her BP laying down is 140/88 on left. Sitting is 120/70 on left. Standing is 100/50. The nurse knows this is:

Back 76

The change in BP is called Orthostatic Hypotension

Front 77

The nurse is assessing the mental status of a 70 y.o. hospitalized male, named Sam. Which response would the nurse document that the patient is oriented X2?

Back 77

"My name is Sam, I am in the hospital and I am not sure what the date is"

Front 78

4 factors considered when assessing the pulse

Back 78

rate, rhythm, force, elasticity

Front 79

Oxygen Saturation

Back 79

Saturation of hemoglobin is measured using a pulse oximeter. uses a sensor and a photodetector to determine the light sent and absorbed by the hemoglobin

Front 80

Interactional Skills

Back 80

listening, attending, paraphrasing, leading, questioning, reflecting, summarizing

Front 81

Barriers of effective interaction

Back 81

providing false assurance, interrupting/changing the subject, passing judgement, cross-examination, using technical terms, sensitive issues use silence to promote interaction

Front 82

3 phases of interviewing

Back 82

pre-interaction, initial interview, focused interview

Front 83

Pre-Interaction Phase

Back 83

the period before first meeting with the client. nurse collects data from medical record, previous health risk appraisals, health screenings, therapists, dietitians and other healthcare professionals who have cared for, taught, or counseled the client. And family members or friends

Front 84

Initial Interview Phase

Back 84

a planned meeting in which the nurse interviewer gathers information from the client. In most cases, nurse uses a health history form to collect the data to avoid overlooking any area of information.

Front 85

Focused Interview Phase

Back 85

throughout the physical assessment, during treatment, and while caring for the client. the purpose of the focused interview is to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur

Front 86

Biographical Data

Back 86

name, address/phone#, age/DOB, birthplace, sex, relationship status, race, ethnic origin, occupation

Front 87

symptom

Back 87

subjective sensation person feels from disorder

Front 88

sign

Back 88

objective abnormality that can be detected on physical examination or in laboratory reports

Front 89

OLD CART ICE

Back 89

onset, location, duration, characteristic, aggravating factors, relieving factors, treatment, impact on ADL's, coping strategies, emotional response

Front 90

Information included with Past Health

Back 90

childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, OB history, immunizations, last examination date, allergies, current medications (Rx & OTC)

Front 91

Genogram

Back 91

family tree - shows information clearly and concisely

Front 92

Functional Assessment

Back 92

self-esteem, self-concept, activity, sleep, nutrition, I&O's, relationships, spiritual resources, coping/stress management, personal habits, alcohol/drug use, environmental/work hazards

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NKA

Back 93

No Known Allergies

Front 94

Types of pain

Back 94

Visceral, Neuropathic, Deep, Cutaneous, Radiating, Referred, Phantom, Intractable

Front 95

Visceral Pain

Back 95

results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax - deep somatic pain, burning, aching, or feeling of pressure

Front 96

Neuopathic Pain

Back 96

result of current or past damage to the peripheral or CNS and may not have a stimulus - pain is long lasting, unpleasant, burning, dull, aching

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Deep Somatic Pain

Back 97

Arises from ligaments, tendons, bones, blood vessels and nerves - is diffuse and tends to last longer than cutaneous pain

Front 98

Cutaneous Pain

Back 98

Originates in skin or subcutaneous tissue - paper cut

Front 99

Radiating Pain

Back 99

perceived at the source of the pain and extends to nearby tissues - heart pain felt in chest and along left shoulder & down the arm

Front 100

Referred Pain

Back 100

felt in a part of the body that is considerably removed from the tissues causing the pain

Front 101

Phantom Pain

Back 101

perceived in a body part that is missing or paralyzed by a spinal cord injury, in an example of neuropathic pain

Front 102

Intractable Pain

Back 102

Highly resistant to relief - pain from advanced malignancy

Front 103

Acute Pain

Back 103

short term, self-limiting, follows predictable trajectory, dissipates after injury heals

Front 104

Chronic Pain

Back 104

continues for 6 mo or longer, types are malignant (cancer related) and nonmalignant, does not stop when injury heals

Front 105

Pain Assessment Tools

Back 105

initial pain assessment, brief pain inventory, short-form McGill pain questionaire, pain rating scales, numeric rating scales, Wong-Baker FACES