Health Assessment Overview

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Questions and Answers

What is a primary disadvantage of leading questions in data collection?

They ensure honest feedback from subjects.

They are effective in gathering unbiased information.

They may confirm the questioner's assumptions. (correct)

They provide clear and objective data.

Which component is NOT part of personal history in health history documentation?

Menstrual history (correct)

Smoking/Substance abuse

Hygienic habits

Dietary pattern

How is empathy differentiated from sympathy in nursing?

Empathy requires the nurse to feel pity for the patient.

Empathy involves understanding the patient's feelings; sympathy does not. (correct)

Empathy is about sharing emotions; sympathy is not.

Sympathy is a deeper connection than empathy.

What is the correct purpose of using the diaphragm of a stethoscope?

Check for breath sounds. Signup and view all the answers

What technique should be used when performing light palpation?

Place the hand lightly with little to no depression. Signup and view all the answers

Which of the following is considered subjective data?

Fatigue Signup and view all the answers

What is a critical aspect of developing empathy as a nurse?

Creating a space for patients to share uncommunicated needs. Signup and view all the answers

Which of the following is true about objective and subjective symptoms?

Subjective data cannot be measured, while objective data can. Signup and view all the answers

What is the primary site for pulse assessment?

Radial artery Signup and view all the answers

What does the pulse deficit indicate?

The difference between the apical and radial pulse rates Signup and view all the answers

What is a characteristic sign of jaundice?

Yellowing of the skin and eyes Signup and view all the answers

What is the primary purpose of performing an arthroscopy?

To visually inspect a joint Signup and view all the answers

What is the primary purpose of cardiac markers in patients with chest pain?

To diagnose and manage acute coronary syndrome Signup and view all the answers

What is a recommended nursing management step after an arthroscopy procedure?

Elevate the leg without flexing the knee Signup and view all the answers

Which of the following best describes a vesicle?

A small, fluid-filled blister Signup and view all the answers

Which cardiac marker is specifically known as an indicator of myocardial infarction?

Troponin T and Troponin I Signup and view all the answers

How is visual acuity typically tested?

Using an eye chart, such as the Snellen chart Signup and view all the answers

What does a DEXA scan primarily evaluate?

Bone mineral density Signup and view all the answers

What is the normal response of pupils to light?

Pupils constrict and are equal in diameter Signup and view all the answers

According to the Muscle Strength Scale, what does a score of 3 indicate?

Active movement against gravity Signup and view all the answers

Where is the apical pulse typically located?

5th intercostal space, left of midline Signup and view all the answers

Which test is performed to compare air and bone conduction of sound?

Rinne Test Signup and view all the answers

Which component of the Glasgow Coma Scale assesses a patient's ability to open their eyes?

Eye Opening Signup and view all the answers

What characterizes normal bowel sounds during auscultation?

Irregular, clicking, gurgling, and high-pitched Signup and view all the answers

A GCS score between 9 and 12 indicates what level of brain injury?

Moderate injury Signup and view all the answers

Ectropion refers to which condition regarding eyelids?

Outward turning of the eyelid margin Signup and view all the answers

What does a positive Murphy's sign indicate?

Potential cholecystitis or gallbladder inflammation Signup and view all the answers

What is an important post-procedure care step following a therapeutic intervention?

Maintain the dressing Signup and view all the answers

What should be done with the affected leg after arthroscopy for the first 48 hours?

Keep it non-weight bearing Signup and view all the answers

Which sign suggests abnormal turbulence in the aorta when auscultating?

Bruit over the aorta Signup and view all the answers

What is the significance of observing continuous bowel sounds over the ileocecal valve?

Possible sign of intestinal obstruction Signup and view all the answers

What does a positive Psoas sign indicate?

Appendicitis Signup and view all the answers

Which of the following symptoms may indicate vitamin A deficiency?

Dry skin with poor turgor Signup and view all the answers

Which symptom is NOT typically associated with protein deficiency?

Weight gain Signup and view all the answers

During abdominal palpation, what is the expected condition of a healthy abdomen?

Soft and smooth Signup and view all the answers

What does a magenta tongue indicate?

Riboflavin deficiency Signup and view all the answers

Which laboratory study result would likely confirm iron deficiency anemia?

Low hemoglobin levels Signup and view all the answers

Which symptom is specifically associated with vitamin D or calcium deficiency?

Bone pain and bow legs Signup and view all the answers

What is the purpose of evaluating dietary habits in a patient history?

To detect nutritional deficiencies Signup and view all the answers

Which finding in the throat and mouth could indicate riboflavin deficiency?

Cracks at the corner of the mouth Signup and view all the answers

What is indicated by a positive Romberg sign during the test?

The patient may have difficulty maintaining balance. Signup and view all the answers

What does ascites typically suggest?

Protein deficiency Signup and view all the answers

Which spinal segments are associated with the Achilles reflex?

S1-S2 Signup and view all the answers

In the consensual pupillary reflex, observing constriction in the contralateral pupil indicates what?

Normal reaction to light stimulus. Signup and view all the answers

What does a graded reflex score of '1+' indicate?

Hypoactive reflex. Signup and view all the answers

Which technique is NOT utilized for eliciting major reflexes?

Chvostek sign Signup and view all the answers

What is the purpose of dimming the lights during a pupillary reflex test?

To facilitate better observation of reflex responses. Signup and view all the answers

Which of the following is a characteristic of tetany in hyper-parathyroid disorders?

Involuntary muscle contractions. Signup and view all the answers

Which response is NOT part of the deep tendon reflex grading scale?

Anomalous Signup and view all the answers

Study Notes

Health Assessment - BLUEPRINT SLIDES

Types of Assessment:
- Initial assessment: Performed within a set time after admission to a healthcare facility.
- Problem-focused assessment: Ongoing process integrated into nursing care.
- Emergency assessment: During any physiological or psychological crisis of a patient.
- Time-lapsed reassessment: Several months after the initial assessment.
Collecting Data:
- Subjective (Symptom): Verbal statements from the patient (e.g., nausea, pain, fatigue, itching).
- Objective (Signs): Observable data, measurable by an observer (e.g., what the patient says, what can be seen).

PURPOSE OF HEALTH ASSESSMENT

Purpose: To collect baseline physical and mental health data.
Purpose: To supplement, confirm, or question data already obtained in the nursing history.
Purpose: To obtain data that helps establish nursing diagnoses and develop a care plan.
Purpose: To evaluate the appropriateness of nursing actions and the physiological outcome of care.
Purpose: To identify deviations from normal health and potential health problems, providing a foundation for a patient-centered care plan.

Open Questions

Structure: Always start with open-ended questions like "what," "why," "when," "how," or "which."
Purpose: Encourage conversation, find details, and give the responder control during the conversation.
Examples: "What is your name?", "Do you smoke?", "What do you prefer, tea or coffee?"

Closed Questions

Structure: Closed questions have short, simple answers like "yes," "no," or "don't know."
Purpose: To gain clarification, but misplaced questions can stop or hinder conversation.
Examples: "What is your name?", "Do you smoke?"

Leading Questions

Structure: Questions based on assumptions that guide the patient to a specific answer.
Purpose: To get a confirmed answer; should not be used frequently.
Disadvantage: Can lead to unusable data.

Components of Health History

Menstrual and Obstetrics History: Length of cycle, duration of cycle, pain, number of children, type of childbirth.
Personal History: Hygiene habits, smoking/substance abuse, dietary preferences, and food intake, allergies.
Functional history Rest and sleep patterns, bowel and bladder habits.

Development of Empathy

Importance of Nurses being receptive to patients' feelings and perceptions.
Ability of Nurses to place themselves in the patient's position to understand patient needs that patient may not freely express.
For example, understanding a patient refusing food following a painful experience.
Distinction from sympathy, empathy is about understanding the patient's perspective.

Some examples of Subjective & Objective data

Examples of subjective data: Tachycardia, Dizziness, Fatigue, Nausea, Shortness of breath, Vomiting, Cough, Itching, Pain.
Examples of objective data: Unconsciousness, Hyperthermia, Wheezing, Tenderness

Auscultation

Diaphragm: Used for high-pitched sounds (breath sounds, normal heart sounds, bowel sounds).
Bell: Used for low-pitched sounds (abnormal heart sounds, murmurs).

Legal and Ethical Aspects of Health Assessment

Confidentiality and Patient Privacy (HIPAA).
Informed Consent: Explanation of procedures and obtaining consent.
Professional Boundaries and Ethical Conduct: Respecting patient rights and cultural differences.

Assessment Sequencing

Head-to-toe examination: Systematic approach, starting from the head and moving to toes.
System-wise examination: Assessments of one body system at a time.
Emergency assessment: Rapid assessment of life-threatening conditions (ABCs).

Pulse

Tachycardia: Pulse rate exceeding 100 beats/minute.
Bradycardia: Pulse rate below 60 beats/minute.

Pulse Assessment Techniques

Radial artery pulse (inner wrist).
Apical pulse (at the apex of the heart).
Pulse deficit: Difference between apical and radial pulse rates.

Abnormal Conditions

Jaundice: Yellowing of skin and eyes due to excess bilirubin.
Paronychia: Inflammation of the tissue around the nail.
Rash: Noticeable change in skin texture or color.
Lesion: Abnormal area of tissue.
Vesicle: Small, fluid-filled blister.

Visual Acuity

Snellen Chart: Progressively smaller letters to determine distance vision.
Standard: 20/20 vision.
Procedure: Patient positioned at a specified distance (usually 20 feet) from the chart.
Testing order: Right eye tested first.

Pupillary Reaction to light

Pupil response is observed concerning penlight.
Normal pupil: Black, circular, and equal in size (2-6mm).

Cranial Nerve Testing

Examiner observes eye movements in all directions.
Place an object 12-14 inches from the patient's nose.
Ask the patient to follow your finger with their eyes, making an "H" shape.

Techniques & Tools for Ear Assessment

Weber Test: Assesses lateralization of sound.
Rinne Test: Compares air and bone conduction.
Whisper Voice Test: Assesses hearing acuity.

Normal Breath Sounds

Bronchial: High pitch, loud, inspiration shorter than expiration (over trachea).
- Bronchovesicular: Medium pitch, moderate volume, inspiration equal or slightly longer than expiration (over 1st and 2nd ICS and lateral to sternum).
- Vesicular: Low pitch, soft, inspiration longer than expiration (over the peripheral lung fields).

Adventitious Breath Sounds/Abnormal Sounds

Crackles (rales): Interrupted sounds (such as cellophane or Velcro ripping), often due to fluid in the airways.
Wheezes: Continuous musical sounds, often due to airway narrowing.
Rhonchi: Continuous snoring sounds typically related to secretions in larger airways.
Pleural friction rub: Discontinuous creaking sound from inflamed pleura, the linings of the lungs.

Laboratory Studies

Plasma Glucose: Normal range 60-110 mg/dL.
Hemoglobin: Normal levels depend on sex.
Hematocrit: Measures packed red blood cells. Low value suggests insufficient hemoglobin formation
Cholesterol: Measures blood fat levels. Normal range (120-200 mg/dL, moderate risk 200-239 mg/dL, High risk 240 mg/dL or above)..
Triglycerides: Measure blood fat levels, used to assess risk of CAD.
Serum proteins: (Albumin). Used to assess nutritional status.
Cardiac Markers: Indicators of heart damage.

Locating And Palpating Apical Pulse

Apical pulse is typically located in the 5th intercostal space.
Approx. 7-9cm left of the mid-line..

Murphy's Sign

Positive Murphy's sign indicates possible cholecystitis (inflammation of the gallbladder).
Performed by palpating the right upper quadrant (RUQ) subcostal area, asking the patient to take a deep breath when palpating.
Pain during palpation is the positive sign.

Findings on Auscultation

Absence of bowel sounds over a 4-minute period indicates paralytic ileus.
Borborygmi: Loud gurgling sounds during diarrheal episodes.
Specific findings like a bruit over the aorta should be reported.

Patient History Review

Chief complaint: Obtain details about the patient's symptoms.
GI system complaints: Nausea, vomiting, abdominal pain, alterations to bowel habits.
Medical history: Medical conditions and interventions.
Family and social history: Can reveal predispositions or risks.
Dietary habits: Daily diet; food intolerances; fluid intake.
Bowel habits: Frequency, consistency, and colour of stools.
Use of laxatives/medications.

Evaluating Nutritional Disorders

Signs and Symptoms: Evaluate patient symptoms relating to general health, skin, hair, nails, eyes, throat/mouth, cardiovascular, GI system, musculoskeletal, and neurological systems.
Implications: Assess implications of potential nutrient deficiencies based on signs and symptoms

Diagnostic Investigations

Urinalysis: Evaluate for kidney diseases or infections.
Culture and Sensitivity: Identify infectious agents and appropriate antibiotics for treatment.
Imaging Studies: Noninvasive tests used to visualize kidneys or for structural or tumor assessment.
Post-Void Residual Measurement: Assessment of bladder emptying efficiency.
Cystoscopy: Direct visualization of the bladder and urethra to diagnose or treat conditions.

Percussion

Assessing for dullness in the suprapubic region to detect distended bladder.
Assessment for tenderness or presence of infection in a particular area of the kidney using Costovertebral Angle (CVA) percussion, assessing for costovertebral tenderness

How to Assess a Patient's Pain History (PQRST)

P (Provokes and Palliates): What triggers the pain? What makes it better or worse?
Q (Quality): Describe the pain (sharp, dull, stabbing).
R (Region and Radiation): Where is the pain located? Does it spread?
S (Severity): Rate the pain on a scale (1-10).
T (Time): When did the pain start? How long does it last?

Types of ROM Evaluation

Passive ROM: Movement produced by an external force.
Active-Assistive ROM: Movement assisted by another source.
Active ROM: Movement completed by patient.
Goniometer: Measures joint angles.
Inclinometer: Measures spine angles.

Diagnostic Tests (Arthrocentesis, Arthroscopy, DEXA, Imaging)

Arthrocentesis: Aspiration of joint fluid (synovial fluid) for diagnostic or therapeutic purposes.
Arthroscopy: Internal visual inspection of a joint using a fiber-optic endoscope. (Requires small incision).
DEXA Scan: Bone mineral density test, used in the diagnosis of osteoporosis; noninvasive procedure.
Imaging studies: Ultrasound, CT, and MRI scans help diagnose structural issues or conditions.

Muscle Strength Scale

Score of muscle contraction.
0 - No contraction.
1 - Trace contraction (twitch).
2 - Movement only against gravity removed.
3 - Movement against gravity, but not external resistance.
4 - Movement against gravity and some resistance.
5 - Movement against gravity and examiner's resistance.

Glasgow Coma Scale (GCS)

Neurological assessment for the severity of brain injury.
Uses eye opening, verbal response, and motor response.
The GCS score ranges from 3 (deep coma) to 15 (fully awake).

Pupillary Assessment

Direct pupillary reflex: Light shone into one eye, observes the pupil's reaction in that same eye.
Consensual pupillary reflex: Light shone into one eye, observes the pupil's reaction in the opposite eye.

Romberg Test

Patient instructed to stand with feet close together and eyes closed.
Positive sign: Inability to maintain balance; patient loses balance when eyes are closed.

Hyper-Parathyroid Disorders

Tetany: Muscle spasms due to low calcium levels.
Chvostek sign: Facial muscle twitching when tapping over the facial nerve.

Hypoglycemia

Blood glucose below 70 mg/dL (3.9 mmol/L).
Symptoms: Cold, clammy skin, rapid heartbeat, headache, nervousness, hunger, faintness.

Hypersecretion of Adrenal Glands

Cushing's Syndrome: Excessive cortisol secretion.
Symptoms: "Moon face," "buffalo hump," edema, thin extremities, high risk of fractures.

Diabetes Mellitus

Symptoms: Polyuria, polydipsia, polyphagia, weight loss, blurring of vision, acetone breath odor, Kussmaul's respiration.

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Description

This quiz covers the various types of health assessments and data collection methods used in nursing. It highlights initial, problem-focused, emergency, and time-lapsed assessments as well as the importance of subjective and objective data. Test your understanding of these essential concepts in health assessment.