Health Assessment - Lecture 2

Front 1

What is the purpose of health history? This helps identify what? (7)

Back 1

-Provide baseline subjective database of what pt says -strengths, actual / potential health problems, support systems, learning needs, discharge/teaching, referral needs

Front 2

Name the two types of health history(5), describe, and give examples of each.

Back 2

Complete (head-to-toe, comprehensive, screens actual/potential problem, id strengths, health promotion patterns, 30mins to 1 hr) -I.e-Admission to hospital
-Focused (hh for acute problem) i.e-ER

Front 3

How does health history for medicine differ from health history for nurses? Examples of questions a nurse would ask themselves? (3)

Back 3

Medicine is geared toward diagnosis and treatment of illness (HTN) -Nursing geared toward diagnosis & treatment of human responses to health problems -what symptoms? what can we teach them? physiological effects?

Front 4

In the first part of the patient interview, what 4 things do you want to include upon introduction? Give example of what you'd say.

Back 4

-Introduce yourself, put patient at ease, explain purpose of interview, explain time frame - Hi my name is Mark, i'm a nursing student at SMU, i'm going to go through your health history which should take about an hour.

Front 5

What are the 2nd and 3rd phase of the interview? (explain each)

Back 5

Working phase (structured data collection(requires longest time)) Termination phase (end of interview, summarize & restate findings)

Front 6

For Biographical data, a health history component, which questions must always be asked? What other data is included?

Back 6

-Do you have advanced directives? -General demographics (name,age, education, etc)

Front 7

What is the Chief Complaint? What is usually stated? Give an example

Back 7

-Reason for seeking care in pt's own words. -one or two signs/symptoms - chest pain x2hrs

Front 8

What is included in the HPI for for a healthy patient? for example? How about an ill patient?

Back 8

(history present illness) short statement about the general state of health "how healthy they perceive to be, how do they take care of themselves" -PQRSTU

Front 9

For past health history questions, what data are we trying to obtain for the following: Hospitalizations, Surgeries, Serious injuries, transfusions, chronic conditions, childhood illnesses, immunizations, allergies, medications, recent travel, military service

Back 9

-name & dates; physical/psych - R/O or explain problems - trauma -blood -DM, HTN -Rheumatic fever -prevention of diseases -meds, food, enviro -prescription (name,dose, freq), otc, herbal, vitamins/supps everything! -exposure -exposure to toxins

Front 10

What does Functional assessment measure?

Back 10

Person's self care ability in general physical health or absence of illness (Activities of daily living) What can they do on their own?

Front 11

Nutrition, activity & exercise, sleep, family roles, sexuality are examples of what?

Back 11

Psychosocial/functional hisotry

Front 12

Why is family history important?

Back 12

To detect risk factors for genetic diseases.

Front 13

ROS: What information is obtained in general health status?

Back 13

unusual symptoms/probs, weight gain/loss(how?), fatigue, weakness, malaise, fever, chills, night sweats

Front 14

ROS: What information is obtained in Integumentary system? What are some health promotion questions?

Back 14

(skin, hair, nails)skin disease, rashes, pruritis, sores, lesions, warts, moles, changes, dryness, moisture; hair loss, change in texture, pattern of care; change in texture, color, care - sunscreen, skin examination

Front 15

ROS: What info is obtained in HEENT?

Back 15

H: unusual headache, head trauma, dizziness -E- vision difficultly, eye pain, redness, swelling, discharge, glaucoma, cateracts -E-Earaches, infx, discharge, tinnitus/vertigo -N-discharge, unusual colds, sinus pain, nasal obstruct, nosebleeds, allergies, hay fever, smell sense -T- Mouth pain, freq sore throt, bleed gums, toothache, lesion in mouth, voice change, altered taste, hoarse voice; Neck-pain, limitation, lumps, swelling, enlarged nodes, goiter

Front 16

ROS: What health promotion info is obtained in HEENT?

Back 16

-H-E- glasses/contact? last vision check? vision loss? E-hearing loss, hearing aid use?how to clean ears? N-T-last dental visit?daily dental care?

Front 17

ROS: What info is obtained for respiratory system? What health promotion questions?

Back 17

-Lung disease (asthma, emphysema, bronchitis, pnemonia, tb) chest pain, wheezing, SOB(& activity related), cough, sputum, pollution exposure - last chest xray?

Front 18

ROS: What information should be obtained for Cardiovascular? health promotion questions?

Back 18

-Chest pain, palpitations, cyanosis, DOE, Orthopnea, paroxysmal nocturnal disease, heart murmur, HTN, anemiea, CAD - last EKG, heart tests? cross legs/sit stand long term?

Front 19

ROS: What info should be obtained for Breasts?

Back 19

-BSE? Lumps, swelling? mammogram?

Front 20

ROS: What info should be obtained for GI? Health promotion q's?

Back 20

-Appetite, heartburn, abd pain, N&V, bowel movements, - use of antacids/lax, diet history here

Front 21

ROS: What info should be obtained for Urinary system? Health promotion q's?

Back 21

-Frequency, urgency, incontinence, pain in flank/growing/suprapubic/lower back, - prevent /treat UTI, kegels after giving birth

Front 22

ROS: What info should be obtained for Male system? Female system? Health promotion q's?

Back 22

-penis/testicle pain, sores, lesions discharge, lumps, hernia -age of menarche, lmp, spotting, vaginal itching, dischrage, meanopause -TSE, GYN, pap

Front 23

ROS: What info is obtained for Musculoskeletal system? Health promotion?

Back 23

-arthritis, gout, pain, stiffness, swelling, cramps, weakness, coordination probs, motion limit -how much walking? ROM? mobility aids?

Front 24

ROS: What info is obtained for neurologic system? Health promotion?

Back 24

-seizure, stroke, blackout, memory, mood change, depression -relationships, coping patterns

Front 25

Summarize Freud's theory of Psychosexual development.(4 components)

Back 25

Levels of awareness(conscious, subconcious, unconscious), Agencies of the mind(id, ego, superego), Anxiety and defense mechs, Psychosexual stages of development(inborn stages from infancy to adulthood-or biological drives influence adulthood)

Front 26

Summarize Erickson's theory of psychosocial development?

Back 26

8 stages of ego development from birth to death. Each stage is a crisis to be resolved, (if not resolved, conflict)

Front 27

Summarize Piaget's theory of development?

Back 27

Knowledge comes from interaction between genetic potential & environmental experiences / mind adapts to environment

Front 28

Summarize Kohlberg's moral devleopment stages?

Back 28

Cognitive development & emotional growth affect individual’s ability to make autonomous decisions - acceptance of values and rules of society that shapes behavior

Front 29

Summarize Havighurst's activity during aging theory?

Back 29

Elderly stay active and maintain or substitute activities more satisfied with life. Diminished activities equated with social isolation & accelerated physical decline

Front 30

You have come into a patient’s room to conduct an admission interview. Because you are expecting a phone call, you stand near the door during the interview. A more appropriate approach would be to:
A)Arrange to have someone page you so you can sit down on the side of the bed.
B)Have someone else answer the phone so you can sit facing the patient.
C)Use this approach given the circumstances; it is correct
D)Arrange for a time free of interruptions until the initial physical examination is complete.

Back 30

D

Front 31

Select the best description of “review of systems” as part of the health history.
A)The evaluation of the past and present health state of each body system
B)A documentation of the problem as described by the patient
C)The recording of the objective findings of the practitioner
D)A statement that describes the overall health state of the patient

Back 31

A

Front 32

What is the purpose of health assessment? Identifies?

Back 32

-provides an objective data base -actual/potential health problems, patient strengths, validates history data

Front 33

For physical assessment, which type should be done, complete or focused assessment?

Back 33

It depends on the situation, and on the initial interview/assessment/ subjective information gathered.

Front 34

For General Survey, what should are the four components to be observed?

Back 34

Physical Appearance, Body Structure, Mobility, and Behavior

Front 35

GS: What type of info is collected for Physical Appearance?

Back 35

- Age, Sex, LOC(A&O), Skin color (tone even), facial features (symmetric)

Front 36

GS: What type of info is collected for Body Structure?

Back 36

-Stature (ht appropriate to age) Nutrition (well nourished well developed), Symmetry (equal bilat), Posture (erect), Position (sits comfortably on bed), Body build, contour (note any congenital or acquired defects)

Front 37

GS: What type of info is collected for Mobility?

Back 37

Gait (smooth, even,well balanced), ROM (deliberate, accurate, smooth, coordinated, FROM)

Front 38

GS: What type of info is collected for Behavior? (5)

Back 38

Facial expression (appropriate to situation), Mood & affect (comfortable, cooperative), Speech (clear, articulate), Dress (appropriate to climate), Personal hygiene (clean & well groomed)

Front 39

Name the four Physical assessment techniques?

Back 39

-Inspection, Palpation, Percussion, Auscultation

Front 40

What are direct and indirect methods of Inspection? Which sense are used in Inspection? What can Inspection tell you (findings)?(5)

Back 40

Direct(looking at pt), Indirect (using equipment to enhance visual i.e-opthalmoscope) - Sight, smell -Surface characteristics, Symmetry, Gross abnormalities, signs of stress, unusual odors

Front 41

What are two types of Palpation? Which sense is used? How much pressure is used for light touch? deep touch? What is ballottement?

Back 41

-Single handed- and bimanual (both hands) - Touch -<1/2 inch for surface characteristics ->1/2 inch for organs, masses, tenderness - used to assess partially free floating objects (trap organs to see movement/enlargement)

Front 42

Which part of the hand is best for sense of temperature?

Back 42

Dorsal portion

Front 43

Which part of the hand is best for sensing vibrations?

Back 43

Balls and ulnar surface of hands.

Front 44

Which part of the hand is best for fine sensations?

Back 44

fingertips

Front 45

For percussion, what is direct vs indirect? What is percussion used for? (4) Fist or blunt percussion is used for?

Back 45

Direct is tapping with short, sharp strokes, indirect taps stationary hand -Density(air, fluid, solid), Size/shape, Tenderness, Deep tendon reflex - tenderness

Front 46

Percussing a normal lung should sound? a hyper-inflated lung? Liver/pregnant uterus? Muscle?

Back 46

-Hollow, long, low pitch, med-loud -booming, very long, very low pitch, very loud -thudlike, medium pitch, soft-med loud, high pitch -flat, short, high, soft loud

Front 47

What are the direct and indirect ways to Auscultate? What types of sounds are typically detected using Auscultation? (Freq of each?)

Back 47

direct-with ears, indirect -with stethescope - heart(high/low), lung(high), bowel(high/low), vascular-blood vessles/bp(low)

Front 48

Approaching assessment, some things to consider are:? (9)

Back 48

-System or region, be systematic, minimize position change, expose only area being assessed, explain as you go, share findings/teach, ensure privacy & confid, consider devel level, consider culture

Front 49

Name 10 systems that start from head to toe?

Back 49

Integumentary, HEENT, Respiratory, Cardiovascular, Breast, GI, MS, Neuro, Urinary, reproductive

Front 50

What are five keys to sufficient documentation?

Back 50

Accurately, Concisely, Objectively
Record by systems, Chart pertinent negatives

Front 51

Various parts of the hands are used during palpation. The part of the hand used for the assessment of vibration is (are) the:
A)Fingertips
B)Index finger and thumb in opposition
C)Dorsa of the hand
D)Ulnar surface of the hand

Back 51

D

Front 52

The bell of the stethoscope:
A)Is used for soft, low-pitched sounds
B)Is used for high-pitched sounds
C)Is held firmly against the skin
D)Magnifies sound

Back 52

A