Health Assessment Final Exam Review PDF

FINAL EXAM REVIEW NEW CONTENT Mental Health Violence , and Substance Abuse Disorder : 5 Questions ,...

FINAL EXAM REVIEW NEW CONTENT Mental Health Violence , and Substance Abuse Disorder : 5 Questions , (CAGE Assessment) Tools assessing for substance use disorder usedfor anefferals) utilled When Tool key aspect asking about personal experiences of violence of bones , muscles , and joints · Roles of the body , protects vital organs , and are storage site to regulate accumulated materials (1) ) + Bones : Framework Universal rule : conduct patient interviews in private , with no one else Muscles : generate forced movement , give shape , and produce heat during movement shape a bulky Assess violent experiences as a normal and natural part of nursing assessment Joints : the area where two bones join together, provide mobility Priority Urgent assessment for alcohol use and drug use Documentation & Interprofessional collaboration : - Questions Includes questions about violence and harm to self or others purpose of the medical record Risk for Injury with psychotic states depression , dementia , delirium A document that is used in civil or criminal courts for evidence , legal suspected violence and risk for harm require urgent attention insurance , education , research , and financial reimbursement , communication , care planning , quality Homicidal or suicidal thoughts require urgent attention Principles the medical record HIPAA governing Question safety first and written medical records ; and any information pertaining to health status or ; presenting situation last protection of patient's privacy , computerized prevents forgetting to ask critical questions about safety care recieved. Allows more time to focus on presenting the situation Methods of conducting interprofessional communication forms of violence across SBAR age groups violenceand Belder Yu se Adren buse Situation - Introduce yourself spatient , then tell what patient is complaing about maltreatment Background-now the patient got to this point a · abusa ne Assessment No pain/tenderness Sibling · - Abandonment punking bullying Recommendation/request-ask for something /meds · and family violence = mportance of respecting cultural views family · · violence Patten to will not comply with a plan of care that is inconsistent with cultural beliefs and values (Do not convince them Definitions of Substance use disorder and addiction Hospitalized Client Assessment : 2 Questions otherwise) not prescribedo is misuseTakingamedicationmannorordosotherthanprescribedachyleftovermeds comprehensive , shift , focus Assessments comprehensive + family history medication , , surgeries Dependence and /or Withdrawal (cancer , chronic pain suddenly stop withdrawal symptoms : Indicate increased tolerance , taking opiods (first time a patient is admitted to a floor) Neurological Assessment : 6 Questions Shift or Organized Assessment > performed at beginning of shift and is a quicker version of the compre- Neurological findings in the older adults hensive assessment structural brain changes (brain hardens- > dementiaI focused midshift , focuses the issue indempt is - on main assessment , making sure nothing acutely Reduction in brain volume changing Reduction in cognitive abilities Safety in hospital setting Risk for poor balance , postural hypotension , falls , Injury Improve accuracy of client identification (Name &DOB) Light touch , pain sensation reduced Improve effectiveness of communication Slower thought processing Improve safety using meds (not poking yourselfw syringes (needles) Reduced response to stimuli Reduce harm associated with clinical alarm systems Delayed reflex Reduce risk of healthcare associated Infections - Populations at risk for stroke ↓ dentify clients at risk for suicide African Americans are two times more likely to die from stroke prevent mistakes in surgery Hispanics and Native Americans are also ata risk structure and function of the neurological system CNs - > brain spinal cord > - drowsiness & confusion PNS - consists of 12 paired cranial nerves and 31 paired spinal cords ↳ outside of brain Espinal cord + fingling , numbing weakness , Identifying lobes of the brain its Bigger portion indicates the front part of the head Priority Urgent findings for the neurological system Acute change in Mental Status (A204-Ado2 + contact provider) unless it is , sundowning Unexplained changes in conciousness - Jawake to super drowsy - notify provider) selzure activity ; posturing - (if they were not admitted for secures Pupil Size changes ; decreased reactivity to light in one or both pupils progressing weakness or paralysis : Extremity unilateral , changes in ability to identify sensation significant changes in vital sighs and health promotion to identify concerning findings with the neurological system Teaching Stroke prevention (FAST) Injury prevention = - Face (drooping) At Arm s - Speech Te Time Musculoskeletal Assessment : 7 Questions Basic way to assess the musculoskeletal system Inspect for alignment of limbs , joints , and spine Observe for symmetry of size , shape , position , and movement of extremites Safety and education for older adults focusing on the musculoskeletal system If older patient has a wall In shower make sure there are shower stools/chair As well as stapling rug to floor to prevent falls Aged gender differences for the musculoskeletal systems Men have lower chances of Osteoporosis because have their high levels of testosterone leading to stronger bones (white) women are likely to get Osteoporosis because of the ↓testosterone causing bones to be frail quicker than men Older Adults lower bone density · cartlidge degeneration postural changes and decreased height, especially after 6 0 Joint stiffness Increased bony prominences At the age su muscle atrophy and mass ↓ Priority Urgent assessment for the musculoskeletal system pain Deformity or discomfort (myolgia arthralgia , Lack of balance docordination (ataxia) weakness stifness or limited movement (contractures)