216 Exam 1 Study Guide PDF

lOMoARcPSD|33372414 216 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 (ryannamae...

lOMoARcPSD|33372414 216 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 Study Guide:  Overview of health assessment  ADPIE (Basic Nursing: Thinking, Doing and Caring pg. 45, 51, 52, 62, 69-74, and 79)  Assessment: involves gathering data about the patient and their health status; info is related to the physiological, psychological, sociocultural, developmental, and spiritual status of the individual  Primary data: obtained directly from the patient; subjective – what the patient SAYS/TELLS you, objective – what you can SEE for yourself  Secondary data: obtained secondhand from the medical record or another care provider  Diagnosis: using critical-thinking skills, the nurse analyzes the Assessment to identify patterns in the data and draw conclusions about the client’s health status (strengths, problems, and factors contributing to the problem). The purpose of diagnosing is to identify the client’s health status; accuracy is essential because the diagnosis is the basis for planning patient-centered goals/interventions.  Nursing diagnosis: a statement of patient health status that nurses can identify, prevent, or treat independently  Medical diagnosis: describes a disease, illness, or injury; purpose is to identify a pathology so appropriate treatment can be given to cure the condition  Planning: encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plan  Initial Planning: begins with the first client contact; refers to the development of the initial comprehensive care plan  Ongoing Planning: changes made in the plan; allows you to prioritize the problem(s) the client has  Discharge Planning: process of planning a self-care and continuity of care after the client leaves the healthcare setting; promotes clients progress towards health/disease management outside of facility care and reduces chances of readmission to hospital care  Nursing Care Plan: the comprehensive central source of info needed to guide holistic, goal-oriented care to address each client’s unique needs; it specifies dependent, interdependent, and independent nursing actions necessary  Implementation Intervention: involves preforming or delegating planned interventions, and carries out the care plan  Evaluation: last step of the nursing process; involved making judgements about the client’s progress towards desired health outcomes, the effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Structure Evaluation: focuses on the setting in which care is provided  Process Evaluation: focuses on the activities preformed; it does not describe the results of the activities preformed, it focuses on WHAT was done and HOW WELL it was done  Outcomes Evaluation: focuses on the observable and measurable changes in the client’s health status resulting from the care given  Critical thinking and Clinical judgment in the nursing process (ATI – Fundamentals for Nursing 10.0 pg. 37)  Assessment/data collection – systematic collection of information about clients’ present health statuses to identify needs and additional data to collect based on findings  Analysis/data collection – nurses use critical thinking skills to identify clients’ health statuses or problems, interpret or monitor the collected database, reach an appropriate nursing judgment about health status, and coping mechanisms, and provide direction for nursing care  Planning – nurses must establish priorities and optimal outcomes of care they can readily measure and evaluate; these established priorities and outcomes of client care then direct nurses in selecting interventions to include in a plan of care to promote, maintain, or restore health  Implementation – nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps of the nursing process; they must use problem- solving, clinical judgment, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health.  Evaluation – nurses evaluate clients’ responses to nursing interventions and form a clinical judgment about the extent to which clients have met the goals and outcomes  Critical Thinking  Critical thinking requires lifelong learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgment  The components of critical thinking competencies, attitudes, and intellectual and professional standards  Critical thinking is facilitated by seeking truth in an open-minded manner and being inquisitive about why something is effective or ineffective.  Critical thinking follows a systematic process or pattern, not jumping to conclusions but using reason to guide decisions Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Nurses make inferences when making clinical decisions by pulling pieces of information together to determine a relationship between the data  Critical thinking incorporates reflection, language, and intuition, and it evolves through three distinct levels as a nurse gains knowledge and experience while maturing into a competent nursing professional  Reflection using purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event. A nurse should reflect on the following  “Why did I say that or do this?”  “Did the original plan of care achieve optimal client outcomes?”  If so: “Which interventions were successful?”  If not: “Which interventions were unsuccessful?”  ?? Solve interactively and drill questions???  Ethics, Safety, and Privacy  Ethical Principles for Client Care (ATI Fundamentals for Nursing 10.0 pg. 11)  Autonomy: the right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest  Beneficence: action that promotes good for others, without any self-interest  Fidelity: fulfillment of promises  Justice: fairness in care delivery and use of resources  Nonmaleficence: a commitment to do no harm  Veracity: a commitment to tell the truth  Basic Principles of Ethics:  Advocacy: support and defend clients’ health, wellness, safety, wishes, and personal rights, including privacy  Responsibility: willingness to respect obligations and follow through on promises  Accountability: ability to answer for one’s own actions  Confidentiality: protection of privacy without diminishing access to high-quality care  Standard of Care (Practice)  Nurses base practice on established standards of care or legal guidelines for care, including the following  The nurse practice act of each state  Published standards of nursing practice from professional organizations and specialty groups (ANA, AACN, and AAOHN pg. 18)  Health care facilities’ policies and procedures, which establish the standard of practice for employees of that facility. They provide detailed information about how the nurse should respond Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 to or provide care in specific situations and while preforming client care procedures  Standard of care define and direct the level of care nurses should give, and they implicate nurses who did not follow these standards in malpractice lawsuits  Nurses should refuse to practice beyond the legal scope of practice or outside of their areas of competence regardless of reason (staffing shortage, lack of appropriate personnel)  Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence  Communication Skills:  Active Listening: being attentive to what the client is saying (verbally and nonverbally); sit facing the patient, open posture, lean in, eye contact, relax  Sharing Observations: commenting on how the client looks, sounds, or acts  Sharing Empathy: the ability to understand and accept another person’s reality; to accurately perceive feelings and communicate understanding  Sharing Hope: communicating a “Sense of possibility” to others; encouragement when appropriate and positive feedback  Sharing Humor: contributes to feelings of togetherness, closeness, and friendliness; promotes positive communication in prevention, perception, and perspective  Sharing Feelings: help client’s express emotions by making observations, acknowledging feelings, encouraging communication, and giving permission to express “negative” feelings and modeling healthy anger  Using Touch: **most potent form of communication** comforting touches are especially important for vulnerable clients who are experiencing severe illness or stress  Silence: time for nurses and clients to observe one another, sort out feelings, think about how to say things, and reflect; nurse should allow client to break the silence  Providing Information: relevant information is vital to decision making, reducing anxiety, and feeling safe and secure  Clarifying: to check whether understanding is accurate or to better understand  Focusing: taking notice of a single idea or word expressed  Paraphrasing: restating another’s own message, briefly, in one’s own words; conveys the essential idea  Asking Relevant Questions: to seek further information for decision making; asking only one question at a time and fully exploring one topic before moving on to another; open-ended questions allow for Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 taking the conversational lead and introducing pertinent information about a topic  Summarizing: pulls together information for documentations; a concise review of key aspects of an interaction; brings a sense of closure and full understanding  Self-Disclosure: subjectively true personal experiences about self are intentionally revealed to another for the purpose of emphasizing similarities or differences of experiences; offered as an expression of genuineness and honesty  Confrontation: helping the client become more aware of inconsistencies in his/her/their feelings, attitudes, beliefs, and behaviors; should be done with sensitivity and ONLY AFTER trust has been established  Assessment Techniques: (Nursing Health Assessment pg. 4-11)  Inspection  Types; direct (direct visualization), indirect (using a light source and/or magnifier for visualization, ie: otoscope)  Senses: sight, smell  Data: surface characteristics, symmetry, gross abnormalities, signs of distress, unusual odors  Palpation  Types: single handed or bimanual  Light: indenting the skin no more than ½ inch  Deep: indenting the skin more than ½ inch  Ballottement: assess partially free-floating objects  Different parts of the hand are best for assessment data  Dorsal aspect of hand: best to assess temperature changes  Balls and ulnar surface of hands (bones): best to assess vibrations  Finger pads/tips: best to assess fine sensations  Sense: touch  Data  Light palpation: surface characteristics (ie: temperature, texture)  Deep palpation: organs masses, tenderness  Ballottement: size, shape of partially free-floating objects (ie: fetal position)  Percussion  Types: direct, indirect  Direct (immediate): directly tapping over body surface to elicit a sound or area of tenderness  Indirect (mediate): placing nondominant hand over body surface, striking to elicit a sound or area of tenderness  Fist or blunt: directly or indirectly striking a body surface to note area of tenderness  Senses: touch and hearing  Data: direct or indirect: Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Density (air, fluid, solid)  Size and shape  Tenderness  Deep tendon relaxes  Percussion Sounds:  Resonance: low, loud, long (ie. Lung)  Hyperresonance: very low, very loud, very long (ie: emphysema)  Dull: high, soft, short (ie. Liver)  Flat, very high, very soft, very short (ie. Soft tissue)  Tympany: medium, medium, medium, musical, drum like (ie. Stomach)  Fist/Blunt:  Tenderness  Auscultation  Type: direct, indirect  Direct: directly listening for sounds  Indirectly: using a stethoscope to hear sounds  Stethoscope types:  Single hand: pressure-sensitive to direct high and low pitch sounds; apply heavy pressure for high-pitch sounds and light pressure for low-pitch sounds  Combination head with bell and diaphragm: diaphragm (flat side) best for high-pitch sounds; use heavy pressure. Bell (cone shaped) best for low-pitch sounds; use light pressure.  Senses: hearing  Data:  Heart sounds (high, medium, and low pitch)  Lung sounds (high)  Bowel sounds (high)  Vascular sounds (low)  ****Always go in this order except for abdomen, Auscultation will go before Palpation ****  Equipment used for assessments  Nasoscope: nostrils, nasal mucosa, turbinate, septum  Transilluminator: sinuses, scrotum, fontanels  Tape measure/ruler: lengths, circumferences, liver size, jugular venous pressure, lesions  Goniometer: range of motion of joints  Triceps skinfold calipers: body fat  Marking pen: marking measurements such as liver, diaphragmatic excursion, pulse sites  Scales: weight  Tongue depressor: mouth gag reflex and strength of masseter muscle  Cotton balls: neurological examination; sensory  Test tubes: neurological examination; temperature  Sent: sugar, salt, lemon; neurological examination; sensory Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Cup of water: thyroid, swallowing  Paper clip, coins: neurological examination, stereognosis  Documentation of findings: (Module 1 – Intro to Health Assessment Student PowerPoint pg. 36, Nursing Health Assessment pg. 4)  SOAPIE  S = subjective data  O = objective data  A = assessment  P = plan  I = intervention  E = evaluation  DAR  D = data  A = action  R = response  PIE  P = problem  I = interventions  E = evaluation  Documentation  Physical or electronic record is a legal document  Accurately  Concisely  Objectively  Record by systems  Chart pertinent negatives  If it is not documented, it is not done  General Survey: (Module 2 General Survey and Vital Signs PowerPoint)  The general survey is a study of the whole person the minute you come into contact with them  Physical appearance  Age – do they appear their stated age  Sex – sexual development appropriate for gender/age  Color of skin – skin tone even, pigmentation will vary w/ethnic, background, skin intact with no lesions, texture  Facial features – symmetric with movement, emotional expressions, eye contact, LOC  Indications of distress – labored breathing, extremely anxious  Indications of physical abuse – bruises, cuts  Indications of substance abuse – track marks, teeth  Level of consciousness  Is the patient alert and oriented X 4  Oriented to person? Can they state their name/DOB?  Oriented to time? Can they tell you the date, who the president? is, what time it is? Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Oriented to place? Can they tell you where they are right now and their address?  Oriented to situation? Do they know why they are there?  Behavior  Mood and affect  Eye contact (may be different depending on culture)  Speech – clear and understandable, conveys ideas clearly, word choice appropriate  Dress  Hygiene  Grooming  Odors  Body structure  Body build – stature, height, weight, expected vs unexpected mobility and ROM  Nutritional status  Symmetry of body – body parts are in proportion and equal on each side  Posture and usual position – Kyphosis or Lordosis?  Gross abnormalities – congenital defects, amputations, ect.  Mobility  Gait  Any mobility aids?  Limping  Shuffling  Movements  Purposeful, tremors?  Range of motion – full ROM in each joint  Motor activity – each movement is deliberate and coordinated  BMI – KNOW THESE PEREMETERS:  Less than 18.5 - reflects underweight and has increased effect on cardiovascular health risk  18.5 to 24.9 – reflects healthy weight and has no effect on cardiovascular health risk  25 to 34.9 – reflects overweight and has a moderately increased effect on cardiovascular health risk  30 to 34.9 – reflects obese and a significantly increased effect on cardiovascular health risk  35 and greater – reflects severely obese and a severely increased with health problems related to body fat likely present effect on cardiovascular health risk  Overview of vital signs  Temperature – recall physiology of thermoregulation (conduction, convection, radiation, and evaporation), factors affecting temperature (designed to return the body to homeostasis or a state Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 of equilibrium, controls the loss or gain of heat). General temp – 96.8 – 100.4 degrees F (will differ depending on age)  Oral - mouth  Rectal – Sim’s position (right leg flexed), use lubrication, insert 1 to 1.5 inches  Axillary - armpit  Temporal – hold flat against forehead and scan across forehead and temporal artery, lift thermometer and touch probe to skin behind earlobe  Tympanic – pull ear up and back (adult) or down and back (< 3 yrs.) and place into outer ear canal  Pulse  Adult expected range is 60-100 beat per minute at rest  Bradycardia – slower than normal  Tachycardia – faster than normal  Assess for rate, rhythm, amplitude, and quality  Count for 30 seconds and multiply by 2, if irregular, count for the full minute and compare to apical rate  Rate – number of times per minute you feel or hear the pulse  Rhythm – regularity of impulses  Strength – reflects the volume of blood ejected against the arterial wall with each heartbeat  0 = absent  1+ = diminished  2+ = brisk, expected  3+ = increased, strong  4+ = bounding  Equality – pulses should be symmetrical (equal)  Pulse points  Carotid – neck  Brachial – elbow area – ulnar side  Radial – wrist – radial side  Apical – left center of your chest, just below the nipple between 5th and 6th rib or at the 5th intercostal space; midclavicular line (use for infant, prior to cardiac meds, or validating a rapid or irregular pulse)  Femoral – groin area  Popliteal – behind the knee  Posterior tibial – Achilles tendon  Dorsalis pedis – top of the foot  Pulse Oximetry  Expected range is 95-100% (clients with chronic lung disease may tolerate as low at 85%)  Choose an intact, non-edematous site  Place digit probe onto finger Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Use earlobe or bridge of nose for clients with peripheral vascular disease  Sole of foot or toe for infants  Wait until the number is stable  Avoid nails with paint or gel  Respirations  Adult expected range 12-20 breaths per minute (Eupnea)  Bradypnea vs Tachypnea  Rate: number of full inspirations and expirations in 1 minute  Depth: amount of chest wall expansion (deep, shallow, expected)  Rhythm: observation of breathing intervals – expect a regular rhythm with an occasional sigh  Try to count when they aren’t noticing (don’t tell them)  You may place your hand on the client’s chest or abdomen to help assess respirations  Count for 30 seconds and multiply by 2 (count for a full minute if the respirations are irregular, faster than 20 bpm or slower than 12 bpm)  Note depth – shallow, normal, or deep and rhythm – regular or irregular  Blood Pressure  Rest for 5 minutes before measurement; no smoking or caffeine within 30 minutes before  Sitting in a chair  Legs uncrossed  Do not take BP in arm with IV, side where a client had a mastectomy, or AV shunt or fistula  Pulse pressure; difference between the systolic and diastolic pressure readings  Orthostatic (postural) hypotension: BP that decreases when a client changes position from lying to sitting or standing  Width of cuff should be 40% of the arm circumference at the point where the cuff is wrapped (the length of the bladder of the cuff should encircle 80 to 100% of the circumference of the upper arm at the same position)  Too large = falsely low reading  Too small = falsely high reading  Blood pressure classifications  Normal – less than 120 (systolic) and less than 80 (diastolic)  Elevated – 120 to 129 and less than 80  Stage 1 hypertension – 130 to 139 or 80 to 89  Stage 2 hypertension – > or = to 140 or > or = to 90  Apply cuff 1 inch above AC with brachial artery in line with the marking on the cuff  Pain Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  A client’s self-report is the best way to assess pain  Causes: trauma, surgery, cancer, arthritis, diagnostic or treatment procedures  Identify sources of pain and variations of pain responses  Validate subjective data with objective data  On a scale of 0 to 10, with 0 being no pain and 10 being the worst imaginable pain, how would you rate your pain level?  Documentation example:  Document LOC and whether the client is oriented to person, place, and time  Example: client is A&O X3  Describe general appearance, including general skin color and manifestations of distress  Example: Pallor noted to skin and client is in tripod position  Describe affect, or mood, as well as verbal and nonverbal behavior  Document temperature, pulse and respiratory rates, blood pressure, and pain level  Example:  T = 37 degrees C  P = 95 bpm  RR = 12 bpm  BP = 124/80  Denies any pain at this time  PT verbalizes pain of 4 on scale of 0-10  The Client Interview  Purpose of the Health Interview:  Gather subjective data  Goal – have a structured conversation with the client  Stages of the interview process:  Opening stage: start of the assessment, first contact with the client  Information gathering stage: continuation of the assessment with client, taking vitals, going over medical history and family history  Closing stage: coming up with a plan of care  Types of questions:  Nondirective (client controls the pace): open-ended questions  Use to begin interview  Use to introduce a new section of questions  Use whenever the client introduces a new topic  Examples:  “What kind of outcome would you want to achieve from your plastic surgery operations?”  “Describe how you are feeling.”  “When you say it hurts, what do you mean by that?”  Directive (structured): closed-ended  Highly structured Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Used to elicit short one- or two-word answers or yes or no answers  Use them in the following situations:  After opening narrative to fill in details person may have left out  When you need many specific facts about past health problems or during review of systems  To move the interview along  Examples:  “Are you feeling better today?”  “Do you have any allergies?”  “When did you have your first knee surgery?”  Each type has a different place and function in the interview  Medical vs Nursing History  Medical – focuses on diagnosis and treatment of illness  Nursing – focuses on diagnosis and treatment of human responses to health problems  Current Health History  Chief concern: a brief statement in the client’s own words of the reason for seeking care  History of present illness (HPI): a detailed, chronological description of why the client seeks care; details about the manifestation  P = precipitating/palliative factors: what causes the pain and what relieves the pain (Palliative – what makes it better, Provocation – what makes it worse)  Q = quality/quantity of symptoms: what does the pain feel like, is it sharp, stabbing, dull, crushing  R = region/radiation/related symptoms: where did the pain start, where does the pain travel to  S = severity: how bad is the pain, using 0-10 pain scale, how much does it affect your life  T = timing: when did the pain start, how long does the pain last, does it come and go or all the time  Current health status: immunization status, allergies to medication, food, environment; current medications (prescription, OTC, vitamins, supplements, herbal remedies, time of last dose); substance use (alcohol, tobacco, caffeine, recreational drugs)  Past Health History  Childhood illnesses  Surgeries  Hospitalizations  Serious injuries  Medical problems  Immunizations  Recent travel or military service  Family history Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Client  Spouse  Children  Siblings  Parents  Aunts and uncles  Grandparents’ health status, or if deceased, age and cause of death  Psychosocial History  Health practices and beliefs  Typical day  Nutritional patterns  Activity/exercise patterns  Recreation  Pets/hobbies  Sleep/rest patterns  Personal habits  Occupational health patterns  SES  Environmental health patterns  Roles/relationships  Sexuality patterns  Stress/coping patterns  Review of systems: purpose is to evaluate the client’s overall health and identify any unexpected manifestations  “Have you recently lost or gained weight?” “Are you having any discomfort right now?”  Skin  Head and neck  Breast and lymphatics  Respiratory system  Cardiac and peripheral vascular system  Gastrointestinal (GI) system  Genitourinary (GU) system  Whole-body system; musculoskeletal, neurologic, hematologic, endocrine system  Functional Assessment  Determines the client’s ability to care for themselves when they are not experiencing an acute illness  Assesses the client’s lifestyle, living environment, and ability to perform ADLs (active daily living)  Covers emotionally sensitive areas  Internal Factors:  Self-concept  Health literacy (ex. Determine client’s ability to read prescriptions and understand health-related instructions)  Stress Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Activity and exercise  Sleep  Spirituality  Substance use  External Factors:  Occupational health  Living environment  Relationships  Abuse  These internal/external factors can affect the client’s overall health and wellbeing  Client interview: techniques/tips  Introduce yourself  Don’t rush  Establish eye contact  Explain what you are doing  Work at same level as client  Consider personal space  Begin with the client’s problem  Leave sensitive topics until the end  Consider client’s cultural background  Consider developmental level of the client  Be nonjudgmental  Avoid “why” questions  Nonverbal communication is more valid than verbal  Be honest  Present reality  Look for teachable moments  Provide reassurance  Be respectful  Avoid medical jargon  Avoid leading the client  Ask one question at a time  LISTEN  Health History: Cultural influences  Working with interpreters  Nonverbal cross-cultural communication  Touch  Touching client is a necessary component of comprehensive assessment  Physical contact with client conveys various meanings cross- culturally  Always ask if it is okay to use touch Downloaded by Ryanna Mae Claveria ([email protected])