NUR216 Exam 1 Study Guide PDF

lOMoARcPSD|33372414 NUR216 Exam 1 Study Guide Health Assessment (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ryanna Mae Claveria (ryannamaecl...

lOMoARcPSD|33372414 NUR216 Exam 1 Study Guide Health Assessment (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 NUR216 Modules 1-3 Study Guide/Summary Module 1: Nursing Health Assessment (F.A. Davis-Bookshelf) Chapters: 1 ATI Modules: HealthAssess – Intro to Health Assessment Module 2: ATI Chapters (ATI-Learn-RN eBook Library – Fundamentals 10.0): 26, 27 Nursing Health Assessment (F.A. Davis-Bookshelf) Chapters: 18 ATI Modules: - HealthAssess – General Survey - ATI Skills Module 3.0 Comprehensive Physical Assessment of an Adult (only the portions below)  Accepted Practice- Equipment, Level of Consciousness, general patient survey, and vital signs  Step-by-Step Viewing-Level of consciousness, general patient survey, and vital signs Module 3: Nursing Health Assessment (F.A. Davis-Bookshelf) Chapters: 1 ATI Modules: HealthAssess – Health History Major Concepts to Review: Module 1: Overview of health assessment o Recognize the steps of performing health assessments. o Identify the major characteristics of critical thinking and clinical judgment in the Nursing process.  Clinical Judgment: Involves observing, comparing, contrasting, and evaluating the patient’s condition to determine whether change has occurred.  It also involves careful consideration of the patient’s health status in light of what is expected based on the patient’s condition, medications, and treatment.  Critical Thinking: A reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the info, and carefully considering options for action.  Some of the components of critical thinking include:  Contextual awareness  Analyzing assumptions  Exploring alternatives  Using credible sources  Reflecting and deciding o Solve interactively and drill questions. Ethics, safety, and privacy o Describe ethical principles related to health assessment. Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Nonmaleficence: Means to do no harm. It is first and foremost in health care.  Beneficence: To act to promote the good of a patient.  Autonomy: The clients right to make decisions. The client can refuse treatment if they desire.  Justice: To treat everyone fairly regardless of their ability to pay for treatment, their social status, or cultural or religious background.  Confidentiality: Respecting the rights of the client to maintain privacy. o Identify steps to ensure client privacy and safety.  Physical privacy is needed to make the patient feel secure.  Drawn the curtains  Draping the patients maintains their privacy. Make sure to only expose parts that need to be examined at that moment.  Beware of religious, cultural, and personal preferences of the patient.  Maintain personal privacy by identifying the patient and maintaining confidentiality. o Recognize the situations for mandated reporting.  Physical neglect or abuse  Physiological or emotional abuse  Sexual abuse  Communication skills o Recognize factors influencing the use of therapeutic communication.  Active listening  Silence  Leads  Focus questions  Open-ended questions  Clarifying, restating  Presence  Simple touch o Translate the use of therapeutic communication in collection of client data  Assessment techniques o Identify the use of assessment techniques to include inspection, auscultation, and palpation.  Inspection: A visual examination of the patient  Auscultation: This is an important physical examination technique used by your healthcare provider, where he or she will listen to your heart, lungs, neck or abdomen, to identify if any problems are present. Auscultation is often performed by using a stethoscope.  Palpation: palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. Palpation can include light and deep palpation. o Determine the tools to perform a health assessment.  Penlight  Tape measure  Pulse oximeter Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Stethoscope  Doppler o Documentation of findings  Be precise, factual, and complete. It is preferable that documentation be made as soon as possible to prevent forgetting information. o Recognize the components of documentation for a health assessment  All documentation should include:  Medications administered and patient’s response  Interventions and treatments provided  Objective and subjective data written to reflect the patient’s condition Module 2:  General Survey Module 3: o The client interview o Taking the health history o Content Outlines:  Introduction to Health Assessment o Preparing for the Client Interview o Tying the nursing process into assessment o Assessment o Analysis o Planning o Implementation o Evaluation  Using critical thinking and clinical judgment in assessment o Basic skills of health assessment o Ethical principles, safety, and privacy o Communication skills o Assessment techniques o Document findings  Initial survey and assessment o Identify the approach of the initial survey and assessment  During the initial survey and assessment, observe the patient’s appearance, behavior, body structure, and mobility. Note indications that the client may be experiencing abuse, neglect, or human trafficking. Obtain measurements of height, weight, BMI, and vital signs, and assess pain. o Recall and recognize the steps to performing general survey  Appearance:  Deviation from stated age  Race  Gender  Hygiene  Facial symmetry  Mental Status:  Easily awakened Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Aware of person, place, time, situation  response  Behavior/Mood:  Calm, agitated, anxious, compliant, etc..  Pain:  Pain rating  Quality  Palliative factors  Location  Precipitating factors  When did it start?  Speech:  Clear, delayed, stuttered, slurred, mumbled  Mobility:  Ticks or tremors  Use of assistive devices  Range of motion  Body type:  Thin, overweight, weight appropriate for height  Room observations:  Safety  IV fluids  Bedside table assessment  Call light, rails, bed lowered o Discussion: Nurse meeting client for first time. What do you notice in someone initially? What should you be looking for?  Deviation from stated age  Race  Gender  Hygiene  Facial symmetry o Appearance  Describe facial features such as emotional expressions, eye contact, LOC  Inspect Skin color and texture o Behavior  Identify behavioral changes through the clients speech, mood, affect and personal hygiene o Body structure and mobility  Describe overall posture, build and mobility  Identify expected vs unexpected mobility findings and ROM o Measurement  Demonstrate understanding of measuring technique for height and weight and interpreting client changes  Translate and compare data in pounds to kilograms  Demonstrate the use of the BMI table. o Overview of vital signs Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Temperature  Recall physiology of thermoregulation, factors affecting temperature  Demonstrate the technique of using a variety of thermometers o Oral o Rectal o Axillary o Tympanic o Temporal  Pulse  Demonstrate the technique to palpate pulse quality, strength, rate and rhythm o Temporal artery o Facial artery o Carotid artery o Brachial artery o Radial artery o Femoral artery o Popliteal artery o Posterior tibial artery o Dorsal pedis artery  Pulse oximetry  Identify tools for measure oxygen saturations  Recognize factors that affect readings o Poor circulation o Skin pigmentation o Skin thickness o Skin temperature o Tobacco use o Nail polish  Respirations  Demonstrate technique of obtaining respirations  Demonstrate an assessment of respiratory rate  Recognize factors influencing respirations  Blood pressure  Identify a variety of tools to perform the assessment  Recognize factors that affect BP o Cardiac output o Peripheral vascular resistance o Volume of circulating blood o Viscosity of blood o Elasticity of vessel walls  General pain assessment  Identify sources of pain and variations of pain responses  Validate subjective data with objective data Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 o Complete documentation Module 3: o Overview of health and interviewing  Remember the key elements of the health interview by using the acronym PLEASE:  P- Past medical history to include previous illnesses, and state of health  L- Last oral intake of liquids and food  E- Events leading to illness or injury  A- Allergies and type of reactions  S- Symptoms or chief complaint  E- Each prescribed medication, OTC medications, and herbal supplements o Recall relevant prior learning related to therapeutic communication o Identify the purpose of a health history, the stages of the interview process and types of interview questions  Current health  Identify components of a current health history  Interpret client responses to interview and identify areas requiring further focus  Stages of the interview process:  Opening stage- introduce yourself and the reason for your health history interview  Information gathering stage- occurs when you use therapeutic communication techniques to collect and document client data  Closing stage- thank the patient for their participation, answer any questions, and summarize the collected information o History  Recognize components of a past health history and family history Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 o Review of systems  Understand the purpose of review of systems  The purpose of a review of systems is to evaluate the patient’s overall health and identify any unexpected manifestations.  Recognize the order in which the review of systems is conducted  Skin  Head and neck  Breast and lymphatics  Respiratory system  Cardiac and peripheral vascular system  Gastrointestinal system  Genitourinary system  Whole-body systems o Functional assessment  Understand the purpose of a functional assessment to include internal and external factors Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  A functional assessment determines the patient’s ability to care for themselves when they are not experiencing an acute illness.  Internal factors: o Self-concept o Health literacy o Stress o Activity and exercise o Sleep o Spirituality o Substance use  Alcohol use  Tobacco/nicotine use  Recreational use  External factors: o Occupational health o Living environment o Relationships o Abuse  Identify the questions addressing the functional assessment o Client Interview o Communication Techniques  Open ended communication versus direct questions.  How to ask a difficult or embarrassing question o Health History  Subjective Data  Objective Data o Review of Systems o Psychosocial o Cultural Influences o Physical Assessment Techniques  Inspection  A visual examination of the patient  Palpation  palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. Palpation can include light and deep palpation.  Percussion  Percussion is a method of tapping on a surface to determine the underlying structures, and is used in clinical examinations to assess the condition of the thorax or abdomen  Auscultation  This is an important physical examination technique used by your healthcare provider, where he or she will listen to your heart, lungs, neck or abdomen, to identify if any problems are present. Auscultation is often performed by using a stethoscope. Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Downloaded by Ryanna Mae Claveria ([email protected])