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Questions and Answers
What is the primary objective of collecting health history data?
Which of the following is a recommended step in initiating the nurse-patient relationship? (Select all that apply)
How can a nurse enhance communication during the health history interview?
In what manner should an interview for nursing health history be conducted?
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What should a nurse do at the beginning of the assessment regarding the patient's preferred name?
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Why is it important for patients to feel comfortable sharing their health information?
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What is the primary purpose of asking about the present illness during patient assessment?
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Which aspect is crucial when documenting a patient's health history?
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When conducting environmental history, what type of information is mainly sought?
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Which method is recommended for assessing the quality and quantity of a symptom?
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What is the purpose of obtaining family history during patient assessment?
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Which of the following is NOT a component of the review of systems (ROS)?
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During an assessment, what should a nurse do if the patient reports difficulty breathing?
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What should be included in the physical assessment toolkit?
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Why is it important to identify patient expectations about their care?
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Which classification correctly describes decreased bowel tones?
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What scale is utilized to assess a patient's risk for skin breakdown?
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What should a nurse do if they palpate a pulsating mass during abdominal examination?
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Which of the following conditions may lead to non-pitting edema?
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At what rate are normal bowel sounds produced per minute?
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What does the presence of a large, rounded 'barrel chest' indicate?
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What does the auscultation of crackles typically indicate?
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Which of the following describes sibilant wheezes in respiration?
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What does a high-pitched crowing sound during inspiration suggest?
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What is the purpose of having a patient cough before auscultating breath sounds again?
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Which segment of the heart is heaviest during the S1 sound?
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What might decreased skin turgor indicate?
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What does a capillary refill time of more than 3 seconds indicate?
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What is the normal expected shape of the abdomen upon inspection?
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What factors should be assessed when examining the peripheral vascular system?
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What is indicated by a Glasgow Coma Scale score of 8?
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Which condition is characterized by drowsiness or increased sleep time but can be aroused?
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How should the pupils respond when checked for reactivity to light?
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What is the normal range of breaths per minute for an adult?
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What assessment is performed to check the neurological status of the patient regarding their awareness of their environment?
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What should be used to check for patency during a nasal examination?
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What does AVPU stand for in the context of measuring levels of consciousness?
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What is characterized by a temporary loss of consciousness often due to low blood flow to the brain?
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Which of the following indicates an abnormal finding during a carotid artery assessment?
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Which condition describes confusion, disordered perception, and decreased attention span with motor and sensory excitement?
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Study Notes
Nursing Health History
- The initial step in the assessment process.
- Provides information about the patient's level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.
Objectives
- Identify patterns of health and illness.
- Determine risk factors for physical and behavioral health problems.
- Identify deviations from normal.
- Identify available resources for adaptation to life changes.
Initiating the Nurse-Patient Relationship
- Introduce yourself, including your name, position, and the purpose of the interview.
- Give an estimated time needed for the assessment.
- Communicate your trustworthiness and discretion to patients.
- Convey a professional manner, attitude, and appearance.
Conducting the Interview
- Conduct the interview in a relaxed, unhurried manner in a quiet, private, well-lit setting.
- Determine the patient's preferred name and use it throughout the interview.
- Maintain a pleasant and accepting facial expression, eye contact, and an appropriate posture.
Biographic Data
- Includes data such as date of birth, gender, address, family members' names and addresses, marital status, religious preference and practices, occupation, source of health care and insurance, Medicare and Medicaid benefits.
- Verify this information with the admitting department.
Reasons for Seeking Health Care
- The admission diagnosis may differ from the patient's subjective reason for seeking care.
- Ask, “What is the reason for the admission?” or “What brought you to the hospital / doctors appointment?”
- Helps establish goals for nursing interventions and determine whether patients' expectations are realistic.
Present Illness or Health Concerns
- Relates to the progression of the present illness from the onset to the current signs and symptoms.
- Use the OPQRST method:
- Onset of time and duration: When did it begin? Did it happen suddenly or gradually?
- Precipitating-provocative-palliative: What causes it? What makes it better?
- Quality-Quantity: How bad is it? How much of it is there?
- Radiation-Region: Where is it? Does it spread?
- Severity: How bad is the problem?
- Time/Treatments: How often do you experience the problem? What helps?
Health History
- Provides data on the patient's health care experiences.
- Includes:
- Previous hospitalizations or surgeries.
- Allergies and description of the reaction and treatment.
- Habits and health patterns: alcohol, tobacco, illegal drugs, caffeine, herbal products, over-the-counter drugs, and prescription medications.
Family History
- Obtain health data about the patient's immediate family members and blood relatives.
- Determine if the patient is at risk for illnesses of a genetic or familial nature.
- Identify areas of health promotion.
Environmental History
- Provides data about the patient's home and work environments.
- Identifies areas of concern such as exposure to pollutants, high crime rates, and available resources.
Psychosocial and Cultural History
- Cultures are complex systems that influence health behavior in individuals and families.
- Provides data about primary language, cultural group, educational background, attention span, and developmental stage.
- Be certain to identify major values, beliefs, and behaviors related to particular health concerns.
- Avoid making assumptions about cultural beliefs and behaviors without receiving validation from the patient.
Review of Systems
- A systematic method for collecting data on all body systems.
- Ask the patient about normal functioning of each system and any changes they have noted.
- Be alert to the patient's comfort and well-being.
- Assess painful areas last.
Physical Assessment
- Provides powerful tools to detect changes in a patient's health.
- The nurse is usually the first to detect changes in the patient's condition.
Performing the Nursing Head to Toe Assessment
- Ensure essential items are available: penlight, stethoscope, blood pressure cuff, thermometer, gloves, watch with a second hand, scissors, black pen, and tongue blade.
- Use all senses: touch, smell, sight, and hearing.
- Wash hands, identify your patient using 2-identifiers, confirm allergies, and provide the patient the opportunity to empty their bladder before the examination.
- Obtain vital signs and pain assessment.
- Start with neurologic assessment:
-
Level of consciousness : Determine if the patient is oriented to person, place, time, and situation.
- Confusion: Inappropriate response to stimuli.
- Lethargy: Drowsiness, easily aroused but falls asleep again immediately.
- Delirium: Confusion, disordered perception, and decreased attention span.
- Coma: Loss or lowering of consciousness.
- Brain death: No responses noted, reflexes absent.
- Syncope: Temporary loss of consciousness.
- Fugue state: Purposeless activity without memory of the event.
- Amnesia: Memory loss over time or for specific subjects.
- Pupillary response: Check pupils for size, equality, and shape. Use penlight to check constriction.
- Extraocular movement: Assess for voluntary movement of eyes together: up, down, laterally, and diagonally. Assess for nystagmus (involuntary eye movements).
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Glasgow Coma Scale: Standardized tool for measuring level of consciousness.
- Eye opening (4-1)
- Verbal responses (5-1)
- Motor responses (6-1)
- Normal GCS is 15; Lowest score is 3; 3-8 is considered coma.
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AVPU: Another tool to measure level of consciousness.
- A = Awake
- V = Verbal
- P = Pain
- U = Unconscious
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Level of consciousness : Determine if the patient is oriented to person, place, time, and situation.
-
Head and Neck:
- Inspect symmetry of the face, normal facial movements.
- Inspect eyes for sclera (should be white), conjunctiva (should be pink), assess for periorbital edema.
- Inspect ears for symmetry, assess for hearing aid use, ringing in the ears.
- Inspect nose for symmetry, assess for patency (ability to breathe through nostrils) and assess for bleeding or drainage.
- Inspect lips and mucous membranes, assess teeth and gums.
- Assess gross range of motion of neck.
- Palpate carotid pulse for regularity, assess for thrills (vibrating sensation).
- Inspect for jugular vein distention.
- Auscultate carotid artery for bruits (abnormal swishing sound).
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Chest, Lungs, and Heart:
- Inspect chest for bilateral chest expansion with equal rise and fall, assess for tachypnea (rapid breathing), bradypnea (slow breathing), and use of accessory muscles.
- Auscultate lungs for breath sounds:
- Crackles: Short, discrete, interrupted, crackling or bubbling sounds.
- Wheezes: Sounds produced by the movement of air through narrowed passages.
- Sibilant wheezes: High-pitched squeaking and musical quality.
- Sonorous wheezes: Lower-pitched, coarser, gurgling, snoring quality.
- Stridor: High-pitched, inspiratory, crowing sound.
- Pleural friction rubs: Rubbing, grating, or squeaking sound.
- Auscultate heart sounds:
- Determine regularity of rhythm.
- Auscultate the 5 cardiac regions (APE TO MAN).
- Palpate radial or carotid pulse while auscultating if heart sounds faint or very rapid.
- Note if the patient is on telemetry and ensure proper placement of leads.
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Upper Peripheral Vascular System:
- Inspect skin for: symmetry, color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions. Assess hair distribution.
- Palpate distal pulses for rhythm and strength.
- Perform capillary refill test.
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Gastrointestinal System:
- Interview patient regarding: flatus (expelling of gas), bowel movements, nausea, vomiting, and changes in appetite.
- Inspect abdomen for: shape, contour, lesions, scars, lumps, or rashes.
Note
- The assessment process is ongoing.
- Data collected is used to form the nursing care plan.
Abdominal Assessment
- Assess the appearance of the abdomen, which may be flat, sunken, round, or distended.
- Auscultate bowel sounds in all four quadrants using the diaphragm of the stethoscope.
- Normal bowel sounds are 4-32 per minute, classified as active, hyperactive, hypoactive, or absent.
- When evaluating for a silent abdomen, listen for one minute in each quadrant before concluding no bowel sounds are present.
- Loud, rushing, gurgling sounds (borborygmi) often accompany increased bowel motility, such as diarrhea.
- Palpate the abdomen for distention, firmness, and tenderness. Note skin texture, temperature, and moisture.
- Light palpation helps detect superficial lesions.
- If you feel a pulsating mass, stop palpating immediately and notify the healthcare provider (HCP). This may indicate an aneurysm.
Genitourinary System Assessment
- The most convenient time to assess the urinary system is during perineal care.
- Interview the patient regarding any voiding problems like frequency, hesitancy, or pain. Note the use of urinals, bedside commodes, or incontinence products.
- Inspect for lesions and observe urine for color, clarity, odor, and sediment.
- Palpate the suprapubic area to assess for distention.
Lower Peripheral Vascular System Assessment
- Inspect the extremities for temperature, color, motion, and sensation.
- Changes in skin color may indicate systemic disease: pallor, cyanosis, jaundice, erythema, or ecchymosis.
- Assess motion by asking the patient to flex their knees and ankles. Observe their gait for the best assessment.
- Test sensation by having the patient close their eyes and feel their shins and toes. Inquire about any pain or decreased sensation.
- Palpate for edema, which is the excessive fluid accumulation in interstitial spaces.
- Pitting edema is graded on a 1-4 scale depending on the depth and duration of the pit after pressing on the shin.
- Palpate distal pulses to assess arterial circulation, starting with the most distal pulse.
- Measure the pulse strength using a scale: 0 = absent, 1+ = thready, 2+ = weak, 3+ = normal, and 4+ = bounding.
- Perform the capillary refill test by pressing on the fingernail and observing the time it takes for the blood to return. Less than 3 seconds is normal, more than 3 seconds indicates sluggish circulation, and 5 seconds is abnormal.
Patient Safety
- Ensure the bed is in the locked and lowest position.
- Place the bedside table within reach.
- Raise the side rails and make the call light accessible.
- Remove safety risks from the immediate area.
Documentation
- Use standardized forms for documentation of the patient history and physical assessment.
- Maintain objective, clear, complete, and concise information.
Skin Integrity
- The Braden Scale is used to assess risk for skin breakdown. A lower score indicates a higher risk.
- Mild Risk: 15-18
- Moderate Risk: 13-14
- High Risk: 10-12
- Very High Risk: 9 or less
Morse Falls Scale
- Used to predict the likelihood of a patient falling.
- Scores range from 0 to 125.
- 0: No risk for falls
- 45: High risk
- Assess for falls risk factors and tailor interventions accordingly.
Do Not Resuscitate (DNR) Orders
- This is a joint decision between the patient, family, and HCP.
- Ensure the patient and family understand the implications of DNR orders and all treatment options.
- DNR does not mean withholding other care like hygiene, nutrition, fluids, or medications.
- Check that the DNR order is written and not just oral.
- Follow the institution's policies and procedures regarding DNR orders.
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Description
Test your knowledge on the initial steps of the nursing assessment process, focusing on health history. This quiz covers how to identify health patterns, risk factors, and the fundamentals of initiating a nurse-patient relationship. Ensure you understand the communication techniques necessary for a successful interview.
