Exam 1 practice questions: HEALTH ASSESSMENT

Nurse’s Role in Health Assessment

• Health assessment aims to understand a patient's physical, mental, and emotional health, guided by the American Nurses Association.
• Utilizes the Nursing Process (ADPIE): Assessment, Diagnosis/Analysis, Planning, Implementation, and Evaluation.

Nursing Process (ADPIE)

• Assessment: Gather subjective (patient's feelings) and objective (measurable signs) data.
• Diagnosis/Analysis: Analyze collected data to prioritize clinical judgments.
• Planning: Develop solutions and determine outcome criteria.
• Implementation: Execute the personalized care plan.
• Evaluation: Assess if outcomes are met and revise if necessary.

Phases of the Nursing Interview

• Pre-introductory: Preparing for the interview.
• Introductory: Building rapport and establishing trust.
• Working: Engaging in detailed questioning and data collection.
• Closing: Summarizing findings and next steps.

Communication Techniques

• Employ open-ended questions to gather detailed responses.
• Avoid excessive or insufficient eye contact, distractions, and biased questions.
• Use verbal cues like rephrasing and well-placed phrases.
• Use nonverbal cues: facial expressions, listening, and appropriate demeanor.

Subjective Data Collection

• Chief Complaint (CC) and History of Present Illness (HPI) are crucial in assessing patient concerns.
• Utilize the COLDSPA acronym for pain assessment:
  • Character
  • Onset
  • Location
  • Duration
  • Severity
  • Pattern
  • Associated factors.

Major Steps in Health Assessment

• Collect subjective and objective data.
• Validate and document all findings.

Types of Assessments

• Initial Comprehensive Assessment: Thorough overview of all body systems, personal, family, and health history.
• Ongoing/Partial Assessment: Follow-up on body systems and health patterns.
• Focused/Problem-Oriented Assessment: In-depth examination of specific issues.
• Emergency Assessment: Immediate evaluation in life-threatening situations.

Framework for Assessments

• Focused: Collects subjective data relating to the chief complaint and personal health history.
• Comprehensive: Encompasses biographic data, past medical history, psychosocial factors, and a review of systems.

Social Determinants of Health

• Emphasizes the importance of understanding health disparities and advocating for health equity.
• Encourages nurses to recognize that individual needs vary and require tailored approaches.

Screening Tools

• SBIRT: Screening, Brief Intervention, and Referral to Treatment for substance use, incorporating tools like CAGE and AUDIT for alcohol use disorder.

Physical Exam Approach

• Establish a nurse-client relationship before starting the exam.
• Explain processes to ensure comfort and understanding.
• Start with non-invasive procedures.

Vital Signs Norms

• Temperature: 98.6°F (37°C)
• Pulse: 110 bpm
• Respiratory Rate: 16 breaths/min
• Oxygen Saturation: 88%
• Blood Pressure: 120/76 mmHg
• Pain Score: 6/10

Types of Pain

• Acute: Sudden onset, resolves with healing.
• Chronic: Lasts longer than 3-6 months, can be debilitating.
• Nociceptive: Arises from tissue damage.
• Neuropathic: Results from nerve damage.

Clinical Scenarios

• Focused assessments target specific clinical issues instead of comprehensive evaluations that consider all body systems.
• Pain severity is assessed by asking patients to rate their discomfort on a scale of 0 to 10.

Quiz Information

• A module quiz will be available, covering both module content and syllabus administration, allowing multiple attempts to achieve a passing grade.

Laboratory Participation

• Emphasizes consent and trauma-informed care in lab settings, ensuring student comfort and safety during peer assessments.

Skin Cancer Risk Factors

• Malignant melanoma is characterized by the ABCDE method for assessment:
  • Asymmetry: Uneven halves of moles
  • Border: Irregular or scalloped edges
  • Color: Varied pigmentation (multiple colors in one mole)
  • Diameter: Moles larger than 6mm
  • Evolving: Changes in size, shape, or color
• Common risk factors for skin cancer include:
  • Sun exposure: Significant risk factor
  • Moles: Presence of atypical moles increases risk
  • Fair skin and light hair: Higher susceptibility
  • Age: Increased risk with advancing age
  • Genetics: Family history of skin cancer plays a role
  • Actinic keratosis: Precursor lesions
  • Ultraviolet radiation: Key environmental contributor

Hair and Nail Conditions

• Common hair issues include:
  • Folliculitis: Inflammation of hair follicles
  • Alopecia: Hair loss
  • Tinea capitis: Fungal infection of the scalp
  • Lice: Infestation affecting hair
• Nail conditions to recognize:
  • Koilonychia: Spoon-shaped nails indicating iron deficiency
  • Pitting: Small indentations in nails, often associated with psoriasis
  • Longitudinal ridging: Vertical lines on nails
  • Yellow nail syndrome: Associated with respiratory issues
  • Paronychia: Infection of nail folds

Methicillin Resistant Staphylococcus aureus (MRSA)

• Clinical manifestations include:
  • Infected area, erythema, edema, and pain
  • Warm to touch with possible pus drainage
  • Fever in patients can indicate systemic involvement
• Treatment involves antibiotics like Vancomycin
• Potential serious complications: sepsis, respiratory failure, amputation, or death

Assessing the Head and Neck

• Key history elements include family history of headaches, concussions, and strokes
• Inquire about lifestyle habits: medications, smoking, alcohol, and drug use
• Observe for new lumps, dizziness, or any swallowing difficulties
• Physical examination requires attention to head alignment, posture, and movement.

Eye Assessments

• Snellen chart is used for testing distant visual acuity; top number indicates distance, bottom number indicates the last line read.
• Jaeger test assesses near visual acuity held 14 inches away.
• Eye movement assessment includes checking pupil reaction:
  • Mydriasis: dilation of the pupil
  • Miosis: constriction of the pupil
• Cardinal fields of gaze: checks for smooth eye movements; nystagmus may indicate underlying issues.
• Confrontation test evaluates peripheral vision through finger counting.

Auditory Assessments

• The Weber test uses a tuning fork placed at the center of the head; sound lateralizes to the affected ear in conductive loss.
• The Rinne test compares air and bone conduction, with normal hearing showing air conduction greater than bone conduction.
• The Romberg test evaluates balance; a positive sign indicates potential vestibular disorders.
• Common auditory abnormalities:
  • Otalgia: Earache
  • Tinnitus: Ringing in ears
  • Presbycusis: Age-related hearing loss

Mouth, Throat, Nose, and Sinuses Assessment

• Subjective questions should cover pain, taste/smell changes, drainage, and any lesions.
• Key vocabulary includes:
  • Epistaxis: Nosebleed
  • Anosmia: Loss of smell
  • Dysphagia: Difficulty swallowing
• Objective data collection involves inspection of lips, teeth, and buccal mucosa; palpation of sinuses is also performed.

Throat and Nasal Assessments

• Inspect tonsils using a grading scale:
  • 0: removed
  • 1+: visible
  • 2+: midway between pillars and uvula
  • 3+: touching uvula
  • 4+: kissing tonsils
• Assessment of nasal condition includes symmetry, mucosa, tender areas, and any masses/polyps.

Assessment Questions

• Symptoms of dry, brittle hair and flaky skin may indicate poor nutritional status.
• In assessing moles, 'C' in ABCDE stands for Color.
• For a 66-year-old with fatigue and cold intolerance, further assessment should be prioritized, potentially looking into thyroid function or iron deficiency.

Common Breast Variations in Older Adults

• Decreased size and firmness of breasts due to reduced estrogen levels.
• Shift from glandular tissue to increased fatty tissue, leading to pendulousness and sagging.
• Nipples may appear smaller and flatter with reduced erectile ability; breasts feel more granular.

Breast Palpation Techniques

• Importance of knowing Last Menstrual Period (LMP) for identifying cyclical breast tenderness.
• Pads of three fingers recommended for effective palpation; techniques include circular, wedge, or vertical strip motions.
• Light, medium, or firm palpation, adjusting according to breast tissue characteristics.

Management of Breast Size Differences

• Inquiry about new breast size variations should be prioritized in patient assessments to rule out pathology.

Glandular Breast Tissue Functions

• Provides structural support and is crucial for milk production; also influences breast size and shape.

Breast Palpation Descriptions

• Vertical, circular, and radial refer to techniques used in breast palpation assessments.

Risk Factors for Breast Cancer

• Key risk factors include genetics, obesity, and the number of pregnancies; caffeine not considered a significant risk.

Variations in Older Adults' Breasts

• Older adults typically exhibit decreased glandular tissue and increased fatty tissue, alongside a decline in firmness.

Lung Assessment Subjective Data

• History of present illness should include symptom onset, type of symptoms, changes over time, triggers, and recent infections.
• Medical history includes chronic respiratory illnesses, smoking status, and family history of respiratory diseases.

Lung Anatomy

• Right lung features three lobes; pleural layers include parietal and visceral pleura, surrounding pleural space.
• In dehydrated patients, pleural rub may be detected during auscultation.

Common Respiratory Terms

• Familiarize with terms such as dyspnea, cough, orthopnea, and sleep apnea for comprehensive lung assessment.

Lung Assessment Techniques

• Objective assessment follows a stepwise order: inspection, palpation, percussion, and auscultation.
• Chest observations include color, shape, respiratory effort, and use of accessory muscles.

Thoracic Abnormalities

• Conditions such as pectus excavatum and barrel chest affect thoracic shape and indicate underlying respiratory issues.

Palpation and Percussion in Lung Assessment

• Assess tactile fremitus with "99" for fluid presence; unequal fremitus may indicate underlying conditions.
• Percussion tones vary: hyperresonance indicates air trapping (e.g., emphysema), dullness could suggest fluid or mass.

Auscultation Techniques

• Adventitious sounds include wheezing (indicating bronchospasm) and crackles; stridor may indicate upper airway obstruction.
• Documenting abnormal sounds (e.g., bronchophony, egophony) helps rule out serious conditions like pneumonia.

Patient Education on Respiratory Health

• Educate on smoking dangers, environmental factors, vaccination importance, and managing chronic conditions through physical activity.

Variations in Older Adults' Lung Function

• Common changes include increased chest diameter, diminished thoracic expansion, reliance on accessory muscles, and decreased cough reflex.
• Aging lungs experience reduced elasticity, lowered lung capacity, and increased risk for respiratory ailments.

Differences between Kyphosis and Scoliosis

• Kyphosis involves a rounded thoracic spine, while scoliosis presents as lateral spine curvature; both can affect respiratory function.

Chest Pain Assessment

• Chest pain can arise from a variety of sources: cardiac, vascular, gastrointestinal, musculoskeletal, or skin-related, emphasizing the need for thorough evaluation.

Cardiovascular and Peripheral Vascular Systems Assessment

• Objectives encompass identifying coronary artery disease (CAD) risk factors and effective reduction strategies.
• Emphasis on accurate patient interviews specific to heart and neck vessels.
• Importance of performing thorough physical assessments involving inspection, auscultation, palpation, and percussion techniques.
• Recognition of age-related findings in heart and neck vessel assessments.

Heart Disease Causes and Symptoms

• Subjective symptoms: chest pain, fatigue, shortness of breath, palpitations.
• Objective indicators: abnormal vital signs (VS), abnormal electrocardiograms (EKG), signs of edema.
• Key pathophysiological processes: myocardial ischemia, heart failure, atrial fibrillation.
• Potential diagnoses include coronary artery disease, myocardial infarctions (STEMI, NSTEMI), cardiomyopathy.

Coronary Artery Disease

• Risk factors include lifestyle choices (diet, exercise, tobacco use), family history, obesity, and diabetes.
• Myocardial ischemia occurs due to cellular injury from obstructed blood flow.

Case Studies Overview

• Mrs. Lim presents with swollen feet, orthopnea, and fatigue indicating potential heart failure.
• Focus on gathering vital signs, fluid status, and heart sounds during physical examinations.
• Mr. Pars presents with leg discoloration, non-healing wounds, and erectile dysfunction, linking peripheral vascular disease and diabetes.

Physical Examination Techniques

• Inspection and palpation of carotid and jugular veins, avoiding pre-palpation auscultation for bruits.
• Assess jugular venous pressure, heart sounds, lung sounds, and ensure careful examination of older adults to avoid complications.

Normal vs Abnormal Findings

• Normal findings for vascular assessments: warm skin, hair presence, appropriate skin color, and intact pulses.
• Abnormal findings suggest vascular issues: cool skin, hair loss, discoloration, delayed capillary refill, and the presence of bruits.

Diagnoses and Plan of Care

• Mr. Pars diagnosed with Peripheral Artery Disease (PAD) and erectile dysfunction; recommended diagnostic procedures and lifestyle changes.
• Patient education includes smoking cessation, diabetes management, regular exercise, healthy diet maintenance, and monitoring treatment interactions.

Key Takeaways for Clinical Practice

• Conduct thorough history taking to identify risk factors and symptoms.
• Utilize objective data from physical exams to inform potential diagnoses.
• Educate patients on the importance of lifestyle modifications to manage cardiovascular and peripheral vascular health effectively.

This quiz explores the essential role of nurses in health assessment, focusing on the ADPIE nursing process. It emphasizes data collection methods and the importance of both subjective and objective data in clinical judgments. Test your understanding of holistic nursing practices and the assessment process.