Health Assessment Study Guide PDF

Chapter One: 7 Questions Health Assessment: the systematic method of collecting and analyzing data to plan patient-centered care. What is it for? The systematic data collection and analysis, Baseline data for patient-centered care, and to develop a plan of care. Components of Health Assessment 1...

Chapter One: 7 Questions Health Assessment: the systematic method of collecting and analyzing data to plan patient-centered care. What is it for? The systematic data collection and analysis, Baseline data for patient-centered care, and to develop a plan of care. Components of Health Assessment 1.​ Health History: Current status, meds, HX, SX, family, personal, psychosocial, review of systems. This is Subjective Data! 2.​ Physical Exam: Ht, Wt, BP, T, HR, RR, O2. This is Objective Data! 3.​ Documentation of data: The point of care, and communicating with the team. The order of the components: Collect Health History>Perform Physical Examination>Document Data>Analyze and Interpret Data>Develop plan of care Types of Health Assessments 1.​ Comprehensive: Admission to the facility 2.​ Problem based/focused: ER/Urgent Care 3.​ Episodic/Follow Up: Primary Care 4.​ Shift: Hospital 5.​ Screening/Exam: Clinic/Health Fair Nursing Process: The order in how a nurse works. Assessment>Diagnosis>Outcomes Identification>Planning>Implenmentation>Evaluation Standards of Nursing Process -​ Assessment: Collect Data -​ Diagnosis: Identify need/problem -​ Outcome Identification: Individualized -​ Planning: SMART -​ Implementation: Coordination and education -​ Evaluation Clinical Judgement and Reasoning (pages 4 and 5) “The outcome of a health assessment is a portrait of the patient's physical status, strengths, weaknesses, abilities, support system, health beliefs, and activities to maintain health, as well as the patient's health problems and available resources to maintain health” How Nurses make judgments By using their Nurse’s knowledge, experience, ethical perspective, and knowing the patient, their expectations include Interpreting, Responding, Reflecting, and noticing.  Chapter One Cont’d Health Promotion and Protection -​ Based on Assessment: Risks, health status, practices -​ Health Promotion: Increase well-being and health potential -​ Health Protection: Avoid illness, detect early, and maintain function Levels of Health Promotion Primary ​ The focus is to protect to prevent. Examples include immunizations and exercise. Secondary ​ The focus is to detect diseases early. Examples include screenings like a mammogram Tertiary ​ The focus is to minimize severity and disability. Examples include cardiac rehab. Goals of Healthy People ATTAIN a high quality, longer, free-from-preventable disease life. ACHIEVE health equity, eliminate disparities, and improve the health of all groups CREATE social and physical environments that promote health for all PROMOTE quality of life, healthy development, and healthy behaviors across all life stages  Chapter Two: 9 questions The Interview: Meeting the patient 1.​ Appropriate Physical Setting: For Privacy and Comfort 2.​ Patient-Centered Approach: Age, Culture, Gender, Language, Physical/Emotional distress, Sensory Impairment, Cognitive Impairment 3.​ Positive rapport: Critical, Professional behavior, Effective communication Phases of Interview 1.​ Introduction. Greet the patient and introduce yourself, establish purpose of visit and describe purpose and process of interview. Example: “Hello Miss. Beyonce! My name is Bob Bobby and I’ll be your nurse today! What seems to be the problem?” 2.​ Discussion. Facilitate patient-centered discussion and use various communication skills and techniques. Example: Be clear and concise with your words, and be respectful. 3.​ Summary: Allow Clarification, shared understanding and plan the next steps and conclude. Types of Interview Questions Open Ended Directive Techniques that enhance the interview -​ Active Listening -​ Faciliation -​ Clarification -​ Reflection -​ Confrontation -​ Interpretation -​ Summarization Behaviors that interfere with Interview -​ Medical Terminology -​ Expressing Value Judgments -​ Interrupting -​ Authoritarian or Paternalistic. -​ Why’s Some Examples of Awkward Moments/Challenging Situations -​ Personal Questions -​ Silence -​ Displays of Emotion -​ Others in the room/Disruptive Individuals Chapter Two Cont’d Types of Health Histories -​ Comprehensive: New PT any setting -​ Problem-based/Focused: SPecfic problem and relevant info -​ Episodic/Follow-Up: Change from previous visit. Components of Health History 1.​ Biographic Data 2.​ Reasons for seeking healthcare 3.​ OLDCARTS (History of Present Illness) 4.​ Present Health status (Current Health Issues, Medications, Allergies) 5.​ Past Medical History (Surgical History, Immunizations, OB history, etc) 6.​ Family History 7.​ Personal/Psychosocial history (Think about the questions we had to ask for our Psychosocial Assessment in Clinical) 8.​ Review of Systems (Body Systems) OLDCARTS -​ Onset -​ Location -​ Duration -​ Consistent -​ Aggravating Factors -​ Related Symptoms -​ Treatment -​ Severity -* There are also age-related variations when it comes to health history. For example, with infants and children, you want to ask about their school status and prenatal care for infants. -* Box 2.4 In the book explains how to recognize victims of Human Trafficking. Some examples include Physical injuries, Malnutrition, and STDs, accompanied by a person who won’t let them speak. -*Box 2.5 explains screening questions for the victims. “Where do you live, sleep, and eat?” “Are you allowed to leave the place you are living or working?” “Has anyone threatened to harm you or your family if you try to leave?” -*Box 2.7 discusses Domestic Violence. To recognize it, you can check for drug and alcohol abuse, and the patients partners acts. You can also ask screening questions such as “Are you afraid of an individual with whom you have previously had a relationship?”  Chapter Three: 10 questions Infection Control Practices -​ Standard Precautions in all settings. Hand Hygiene, PPE, Cough Etiquette -​ Transmission-BASED Precautions: Contact, Droplet, Airborne Techniques of Physical Assessment Inspection Visual Exam and Smell Preserve modesty Adequate lighting Critical Eye Concentration without distraction PRACTICE Equipment: Penlight. Otoscope, Ophthalmoscope, or vaginal speculum Palpation -​ Feeling: Texture, size, shape, consistency, pulsation, location -​ Have a gentle touch, warm hands, and short nails. -​ Cultural Considerations. “Can I touch you?” -​ State purpose, manner, and location of touching Palmar surface of fingers and finger pads are more sensitive than fingertips Ulnar Surface of hand to fifth finger is most sensitive to vibration Dorsal surface is better for assessing temperature *Also think about how deep you go. 1 cm or 4cm Percussion -​ It is performed to: Evaluate size, borders, and consistency of internal organs. It also detects tenderness, and determine extent of fluid in a body cavity Direct Percussion: When you strike a finger or hand directly against a patient’s body. Indirect percussion: Requires both hands. You place the distal aspect of the middle finger of the nondominant hand against the skin over the organ being percussed and strike the distal interphalangeal joint with the tip of the middle finger of the dominant hand Five Percussion Tones 1.​ Tympany: loud, high pitch sound over the abdomen 2.​ Resonance: heard over normal lung tissue 3.​ Hyperresonance: heard in overinflated lungs (emphysema) 4.​ Dullness: heard over liver 5.​ Flatness: heard over bone and muscle  Chapter Three Cont’d Auscultation -​ Listening for sound and characteristics: Intensity, pitch, duration, and quality -​ Concentrate: sounds may be transitory or subtle. -​ Optimize the best quality of auscultation of findings within a quiet room, or using a stethoscope -​ A stethoscope helps isolate sounds within the body Types of Equipment -​ Thermometer: checks temperature. There are electronic, tympanic, and temporal. -​ Blood pressure cuff: checks BP -​ Pulse Oximetry: measures oxygen saturation in blood -​ Snellen chart: helps check vision -​ Ophthalmoscope: checks eye up close with light -​ Otoscope: inspects ear -​ Penlight: provides light for inspection -​ Ruler and Tape measure: provides accurate measurements for various findings -​ Nasal Speculum: inspects internal surfaces of nose -​ Tuning fork: auditory screening and assessment of vibratory sensation -​ Reflex Hammer: tests deep tendon reflexes -​ Dopler: helps listen to difficult to hear vascular sounds. -​ Audioscope: the tone test -​ Goniometer: determines the degree of flexion or extension of joint -​ Monofilament: tests lower extremity sensation -​ Vaginal Speculum: spreads walls of vaginal canal to inspect vaginal tissue -​ Transilluminator: differentiates characteristics of tissue, fluid, and air in a specific body cavity -​ Woods Lamp: detects fungal infection of skin -​ Magnification Device: used to assist identification of skin lesions  Chapter 4: 16 questions (MOST) General Inspection 1.​ Appearance: overall health, age, LOC, s/s distress, skin, hygiene 2.​ Body structure: stature, nutritional status, symmetry, posture/position 3.​ Body movement: ambulation, repositioning, symmetry, assistive devices, ROM, tic, pains 4.​ Emotional status: alertness, facial expressions, tone, affect, eye contact, body language, appropriate conversations Height and Weight -​ Nutritional Status -​ Fluid Status -​ Growth and development -​ Beds have a scale on it! Vital Signs -​ Temp: 96.4-99.1 Average is 98.6. There is oral, tympanic, axillary, rectal -​ HR/Pulse: radial, brachial, or carotid. 1 min, 30x2, 15x4 -​ RR: breaths per minute, pt should be unaware -​ BP: systolic, diastolic. Think about the cuff, how to check it, just think about what we've done in lab -​ O2 Sat: >92% -​ Pain: is standard practice. -* remember rates thats considered normal -* details about each vital signs -*age-related variations  Chapter Five: 2 questions Chapter five is about cultural competence. With Nursing, you have to be considerate of other cultures and diversity. We are not responsible for KNOWING a patient's beliefs, practices, and values, but you are responsible for ASKING. There is a difference in culture, ethnicity, and race. Culture: socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics. Ethnicity: within a cultural and social system. Language, history, lifestyle, or religion Race: skin color, bone structure, eye color, and hair color Think about religion and spirituality. Religion is an organized belief. Spirituality is like a practice, examples being prayer or meditation There are 5 interrelated attributes of cultural competence. 1.​ Cultural Desire 2.​ Cultural Awareness 3.​ Cultural Knowledge 4.​ Cultural Skill 5.​ Cultural encounters DO NOT STEREOTYPE YOUR PATIENTS. Remember to: Be sensitive, ask questions, gather specific information, do not stereotype, do not assume, and take the time to know your patients.  Chapter Six: 6 questions Pain -​ Always assess for pain every encounter. Reassess after intervention as well -​ One person cannot judge the perception of the meaning of pain experienced by another person. -​ Pain can be considered anything. Development, functional ability, mobility, tissue integrity, fatigue, sleep, mood and affect, spirituality, and culture. Types of Pain -​ Duration: Acute. Can be physiological, < 6-month onset, self-limiting, ends when tissue heals, generalized stress response -​ Persistent (Chronic): intermittent or continuous, >6 months, inability, depression, and insomnia can be caused by this -​ Nociceptive: stimulation of nerves in a bone, joint, muscle, skin, or connective tissue -​ Neuropathic: abnormal processing of sensory input ​ There are variations in how patients interpret and respond to pain. ​ Pain threshold: the point at which a stimulus is perceived as pain. ​ Pain tolerance: the duration or intensity of pain that a person endures ​ Cognitive factors ​ Cultural influences ​ Coping strategies Pain Assessment -​ Inaccurate assessment can lead to inaccurate treatment -​ A lack of trust in PTs report can influence pain assessment -​ Labeling as “seekers” “frequent flyers” or “clock watchers” -​ When asking interview questions, think about OLDCARTS and how they are responding to the pain -​ Examine Vital signs, inspect and palpate the site of pain