Health Assessment Exam I

Front 1

Discuss the use of the nursing process in clinical judgment

Back 1

Nursing Process is the standards of practice in nursing. ADOPIE
Assessment, Diagnosis, Outcome Identification
Planning, implementation, Evaluation

Front 2

Organize based on nursing process: 1. Pt has fever. Why? 2.Post-op Patient says to you “I feel hot” Subjective/Objective Data : T 104 3. Temp was 104 when re-checked. Lungs sound junky, and clear after C&DB, WBC normal on labs, MD notified and said watch for now and continue C&DB 4. Need to find out what is source of fever and then speak with doctor to treat it. 5. Lower fever 6. Re-Check temp., listen to lungs, cough and deep breath, draw labs, look at the wound, notify physician.

Back 2

Assessment: 2. Post-op Patient says to you “I feel hot” What type of data? Subjective/Objective Data-T 104
Diagnosis: 1. He has a fever. Why?
Outcome Identification:5. Lower fever
Planning: 4. Need to find out what is source of fever and then speak with doctor to treat it.
Implementation: 6. Re-Check temp., listen to lungs, cough and deep breath, draw labs, look at the wound, notify physician.
Evaluation: 3. temp was 104 when re-checked. Lungs sound junky, and clear after C&DB, WBC normal on labs, MD notified and said watch for now and continue C&DB

Front 3

Objective data

Back 3

Objective data: the data medical professionals obtain through observations by seeing, hearing, smelling and touching. This can include patient behaviors, actions and information gathered from test measurements or the physical examination.
The signs refer to the objective data while the symptoms refer to the subjective data.Notice the words subjective and says both begin with the letter S, while objective and observes begin with the letter O.

Front 4

Subjective Data

Back 4

involves collecting information through communication. Patients are first asked the reason for visiting the doctor. Then whatever they say is classified as the subjective data. Patients often complain about physical symptoms pertaining to how they feel. This can be pain, discomfort, itching or any type of abnormal sensations. They state problems they are experiencing with their bodies, such as coughing, vomiting or muscle spasms. Patients may mention health concerns surrounding their beliefs, attitudes and perception. They may think they have a particular illness because they had it before or researched their symptoms on the internet. Other patients may feel they are healthy and just want a doctor's check-up.

Front 5

Describe the use of critical thinking skills in diagnostic reasoning and clinical judgement

Back 5

1. Identifying Assumptions
2. Identifying an organized and comprehensive approach
3. Validation
4. Distinguishing normal from abnormal
5. Making inferences
6. Clustering related cues
7. Distinguishing relevant from irrelevant
8. Recognizing inconsistencies
9. Identifying patterns
10. Identifying missing information
11. Promoting health (identifying risk factors)
12. Diagnosing actual and potential (risk) problems
13. Setting Priorities
14. Identifying patient-centered expected outcomes(specific time frame)
15. Determining specific interventions
16. Evaluating and correcting thinking
17. Determining a comprehensive plan

Front 6

Differentiate first-level, second-level, and third-level priority problems.

Back 6

First Level: Emergent, life threatening, and immediate. Airway, Breathing,Cardiac, Signs (vital signs concerns)
Second Level: Requiring prompt intervention to forestall further deterioration. Mental status change, abnormal lab values

Third-level: Important to health but can wait to be addressed

Front 7

Conceptual framework: Holistic Model

Back 7

The nursing model: Considering the whole person; Assessment factors must be expanded to include such things as culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, and failures and frustrations of life. All of these are significant to health.

Front 8

Conceptual framework: Biomedical Model

Back 8

Person is certified as healthy when these symptoms and signs have been eliminated.
Increasing interest in lifestyle, personal habits, exercise and nutrition, and the social and natural environment. Biomedical Model is the absence of disease, With this view, the focus of data collection is on biophysical signs and symptoms and on curing disease. For us in nursing we collect a lot of information during assessment, because we have a holistic view.

A nursing model

Front 9

Contrast medical diagnosis with nursing diagnosis

Back 9

Medical diagnoses: concerned with the cause of disease; stand alone but they're related.
Nursing diagnosis: concerned with the impact of the health problem on the person and the person’s response to the problem

Front 10

Relate the patient situation to the amount of data collected.

1. A complete health history and a full physical examination.

2. Episodic or problem-centered problem list

3.Emergency Database

Back 10

The amount of data collected depends upon the patient situation.
1. Would be done in the primary care physician’s office and with each admission to the hospital.

2. is for a limited or short-term problem. May be collected in any health care setting but focuses on one problem or one body system. If a person presents with a rash in an outpatient clinic, the history and exam follow the direction of the presenting concern. Was the rash associated with a fever, was it localized or generalized. The status of any identified problems should be evaluated at regular and appropriate intervals. Is the problem getting better or worse?

3. Calls for a rapid collection of the data of done at the same time as life saving measures. Diagnosis must be swift and sure.

Front 11

Understand what comprises a database

Back 11

Complete (total health) database
Focused or problem-centered database
Follow-up database
Emergency database

Front 12

The frequency of health assessment depends on?

Always consider what two factors when performing a health assessment?

Back 12

the patient age and health status

Consider life cycle and cross-cultural factors

Front 13

Diagnostic Reasoning

Back 13

A way of collecting and analyzing information based on the scientific method.
COLLECT DATA i.e. ASSESSMENT
Create a list of abnormals
Cluster the abnormals that are related
Validate the data (IT MUST BE ACCURATE!)
Looks for Gaps and fill them!

Front 14

components of the health history.

Back 14

Biographical data
Reason for seeking care
Current health or history of current illness
Past health
Family history
Review of systems
Functional assessment or ADLs

Front 15

A health history of the older adult should have a particular attention to...

Back 15

Medication use and functional Assessment

Front 16

Reason for Seeking Care or the Chief Complaint

Back 16

Reason for Seeking Care: Note that this has commonly been called the “chief complaint.”
This term, according to the textbook, has been changed because of its negative connotations and lack of wellness reference. Also, it is incorrect to use a medical diagnosis in this location; specify the symptoms that the patient experienced that brought him or her in for care.

Front 17

Identify the difference between a symptom and a sign.

Back 17

Symptom: Subjective sensation
Sign: Objective abnormality; Detectable on physical exam or in laboratory reports

Front 18

Identify the 8 Critical characteristics of a symptom

Back 18

Location; Character or quality; Quantity or severity; Timing; Setting; Aggravating or relieving factors; Associated factors; Patient’s perception

Front 19

Demonstrate the correct way to document allergies

Back 19

List the allergy and the reaction

Front 20

The correct order of physical assessment is..

Back 20

inspection, palpation, percussion, auscultation

Front 21

Describe the use of inspection

Back 21

Inspection: critical observation of the patient in a systematic, deliberate manner.
Concentrated watching
General survey
Comparison

Front 22

Palpation

Back 22

use of touch to determine: size, texture, consistency , and location of body parts. Temperature, moisture, change in size, vibrations, pulsations, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain.
Use different parts of the hands
Light v. deep palpation

Front 23

Percussion

Back 23

striking a part of the body with short, sharp taps of the finger. Location, size, position, and density of the underlying organs. Thorax and abdomen

Front 24

Auscultation

Back 24

Listening to sounds produced by the body
Unassisted ear: Speech, percussion tones, difficult breathing, coughing, and loud abdominal sounds.
Stethoscope (or doppler): Heart, lungs, abdomen

Front 25

Relate the parts of the hands to palpation techniques used in assessment

Back 25

Fingertips: fine tactile discrimination
Opposition of finger and thumb: position, shape and consistency of an organ or mass
Dorsa (back) of hand: temperature
Base of the fingers or ulnar surface: vibrations

Front 26

Differentiate between light, deep, and bimanual palpation

Back 26

Light: surface characteristics and areas of tenderness

Deep: palpate an organ or mass

Bimanual: envelop or capture certain body parts

Front 27

Describe direct and indirect percussion

What are the percussion sounds?

Back 27

Direct Percussion: Adult sinuses
Indirect Percussion: Strike interphalangeal joint (short fingernails are a must!!!)

Resonant, Hyperresonant (louder, lower pitched), Tympany, Dull, Flat

Front 28

Discuss appropriate infection control measures used to prevent spread of infection

Back 28

Wash hands, Wear gloves, Clean Equipment

Airborne: Special Mask, Gown, Gloves, Special ventilation room

Droplet: Mask/Eye Protection, gloves, gown

Contact: Gloves, Gown

Front 29

List the information considered in each of the four areas of a general survey: physical appearance, body structure, mobility, and behavior.

Back 29

Physical Appearance: Age, gender, skin color, facial features
Body Structure: Stature, nutrition, symmetry, posture, body build
Mobility: Gait, range of motion
Behavior: Facial expression, speech, dress, personal hygiene

Front 30

Discuss measurement of weight

Back 30

Balance scale, bed scale; The person should remove his or her heavy outer clothing and shoes before standing on the scale.

Recommended range for height
Men: 106 lb for first 5 ft, then add 6lb/in
Women: 100lb for first 5 ft, then add 5lb/in
Add 10% for client with larger frame
Subtract 10% for client with small frame

Front 31

Discuss measurement of Height

Back 31

Wall Mounted Device
Shoeless, standing straight and looking straight ahead. Feet, shoulders and buttocks should be in contact with the hard surface.

Front 32

Describe various routes of temperature measurement and normal value

Back 32

Route of temperature measurement
Oral (Normal 98.6)
Axillary (Normal 97.6)
Rectal (Normal 99.6)
Tympanic membrane thermometer (TMT) (99.5)

Front 33

Influences on Temperature

Back 33

Diurnal cycle (4pm), Menstrual cycle, Exercise
Age, elderly client(tend to have lower temps), faulty thermometer, dehydration, environment, infections

Front 34

Calculation for BMI and Healthy Range

Back 34

BMI: marker of optimal healthy weight for height
Healthy = level of 19 - 25.
BMI= weight (in pounds) X 703
height (in inches)2

Front 35

What is Pulse?

Back 35

Stroke Volume: amount of blood pumped into the aorta with each heart beat (70mL) and felt in the periphery as the PULSE

Front 36

Describe the four qualities considered when one assesses the pulse.

Back 36

Rhythm: Regular/Irregular

Rate: Varies with age, Normal 50-90 beats per minute (bpm), Bradycardia <50,Tachycardia >90

Force: 4 point scale,3+ Full, bounding, 2+ Normal, 1+Weak, thready, 0 Absent

Elasticity: Springy, straight, and resilient

Front 37

Describe the appropriate procedure for assessing normal respirations

Back 37

Measure: Rate, Pattern and Depth
Normal rate: 1 year old 20-40 respirations/min. Adult 10-20 rep./min

Procedure: Because breathing is normally relaxed, regular, automatic, and silent, respirations are counted while the hand is still in position for taking the pulse and the patient is unaware that respirations are being counted. Respirations are counted for 30 seconds unless an abnormality is suspected; the rate is then counted for a full minute. A ratio of 4:1 for pulse rate to respiratory rate is common.

Front 38

Describe the relationships among the terms blood pressure, systolic pressure, diastolic pressure, pulse pressure, and mean arterial pressure (MAP)

Back 38

Blood pressure: the pressure of the blood against the wall of the blood vessels; the pressure of the blood within the arteries.

Systolic pressure: the max pressure felt on the artery during left ventricular contraction.

Diastolic pressure: The elastic recoil, or resting pressure the blood exerts constantly between contractions.

Pulse pressure: the difference between the systolic and diastolic pressures and reflects the stroke volume.

MAP: the pressure forcing blood into the tissue, averaged over the cardiac output. It is the diastolic pressure plus 1/3rd the pulse pressure.

Front 39

List the factors that affect blood pressure.

Back 39

Disease, drugs, anxiety, Cardiac output, peripheral resistance, arterial elasticity, blood volume, blood viscosity, Age, weight, exercise

Blood volume: how tightly the blood is packed into the arteries.
Viscosity: the thickness of blood and is determined by its formed elements, the blood cells.
Elasticity: the distensibility of the arteries. As the arteries stiffen or clog, there is more pressure needed to push the blood through.

Front 40

BP=CO x SVR

Back 40

Cardiac Output: the amount of blood pumped out of the heart in one minute and it is recorded in L/min.
Systemic vascular resistance (Peripheral Vascular Resistance): the opposition to blood flow through the arteries.

Front 41

Relate the use of a blood pressure cuff of improper size to the possible findings that may be obtained

Back 41

1. Check both arms and compare results (difference 5-10mmHg normal)
2. Pulse pressure is difference between systolic and diastolic readings: normal 30-40 mm Hg
3. Cover 50% of limb from shoulder to olecranon with cuff
Too narrow – abnormally high reading
Too wide – abnormally low reading

Front 42

Discuss developmental care of the aging adult in relation to a general survey.

1. Physical Appearance
2. Measurement

Back 42

1 Kyphosis: A flexion of the spine, angulation of features, a redistribution of body proportions.
Gait: may be wider base compensates for change in balance. More prominent bony landmarks

2. Weight:Body weight decreases during the 80s and 90s. The distribution of fat changes. SQ fat is lost from the face and periphery; additional fat on the abdomen and hips.
Height: decreases by 80s and 90s. Shortening in the spinal colum from thining of the vertebral disks and kyphosis, slight flexion in the knees and hips.

Front 43

BP Values

Back 43

Normal……………………<120 <80
Prehyperstion…………….120-139 80-89
Stage 1 Hypertension…….140-159 90-99
Stage 2 Hypertension…….≥160 >100

Hypotension………………<95/60

Front 44

Discuss developmental care of the aging adult in relation to a general survey.

Vital Signs

Back 44

Temperature: less likely to have fever; greater risk for hypothermia. Temp is a less reliable index; Sweat gland activity diminished.

Pulse: normal range is 50-90. Slightly irregular; radial artery may feel stiff, rigid

Resp: shallow and increased rate

Blood Pressure: increase in systolic pressure; widened pulse pressure With many older adults, both the systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension

Front 45

Define pain.

Back 45

Pain is highly personal and subjective and is whatever the patient says it is; existing whenever he/she says it does; Self-report of pain is considered the most reliable indicator of pain.

Front 46

Discuss the function of nociception and the patient's sensation of pain.

Back 46

Nociceptive Pain: Nerve fibers in periphery in periphery and CNS are functioning and intact; described as sharp, aching, throbbing, dull and cramping.

Neuropathic pain: described as burning, numbing, shooting, stabbing, or electric shock-like, or an itchy sensation

Front 47

Differentiate the different types of pain.

Back 47

Acute: short-term and self-limiting, predictable trajectory, and ends after the injury heals. Acute pain warns of tissue damage.

Chronic (persistent): 6 months or longer and can last for years. It results from abnormal processing by pain fibers from peripheral or central sites and does not stop when the injury heals. The level of pain intensity does not reflect the physical findings.
Breakthrough Pain: Pain starts before the next alagesic dose

Incident Pain: pain that increases due to an event (i.e. a dressing change)

Front 48

Describe developmental care as well as cross-cultural and gender considerations regarding pain.

Back 48

Older Adults: Sensitivity is diminished, Pain is not an expected finding
Gender: Men are stoic; Women are more prone to migraines & fibromyalgia; More sensitive to pain during menstrual cycle
Cross-Cultural Care: Different cultures regard pain, emotion, and reaction differently

Front 49

Describe the initial pain assessment.

Back 49

1. Pattern: When did the pain start (Onset) & it’s duration

2.Location: Referred Pain/Radiating Pain

3.Intensity: Quantitative assessment of the severity; Pain Scales

4. Quality:description of the pain (i.e sharp)

5. Associated Symptoms: Anxiety, fatigue, depression may exacerbate or be exacerbated by pain (i.e. “What activities increase or alleviate pain?”)

6. Management Strategies: Ways to control or manage pain

7. Impact of Pain: effect of pain on the patient’s ability to sleep, enjoy life, interact with others, perform work and household duties.
8.Pt’s Beliefs, Expectations, and Goals: Any beliefs that may hinder effective treatment (i.e. the belief med use may result in addiction)

9. Documentation.
10. Reassessment: reassess pain at appropriate intervals.

Front 50

Pain Assessment mnemonic

Back 50

P = Provocative or palliative
Q = Quality or quantity
R = Region or radiation
S = Severity scale: 1 to 10
T = Timing or onset
U = Understand patient’s perception of problem/pain

Front 51

Compare available pain assessment tools.

Back 51

Numeric Scale: Normally used for pain assessment

Wong-Baker FACES Pain Rating Scale: Children pain assessment

FLACC PAIN SCALE: Pt unable to communicate

McGill Questionnaire: Detail/Pain Centers

Front 52

Compare acute and chronic pain behaviors (nonverbal behaviors of pain).

Back 52

Acute-guarding, grimacing, moaning, objective signs of pain
Chronic- May not show objective signs of pain, patient may appear calm.
The most important and reliable indicator of pain is the patient's self-report.

Front 53

Describe the physical changes that may occur because of poorly controlled pain.

Back 53

Look for nonverbal behaviors of pain, such as guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, or vital sign changes, (increased BP, HR) Keep in mind that individuals react to painful stimuli very differently.

Front 54

Demonstrate physical exam on painful area and identify normal/abnormal findings.

Back 54

Assess the patient's joints, muscles, skin, and abdomen to detect injuries or other signs of painful disorders.
look for nonverbal behaviors of pain,
assess for physiologic changes in various body systems. These changes can result from poorly controlled acute or chronic pain.