Health Assessment exam 1.docx

NSG121 Health Assessment Exam 1 Updated Notes Unit 1 The nurse's role in health assessment - To promote health, to prevent illness, to treat human responses to what is the role of the nursing process in health assessment? - Utilizing the nursing process to systematically collect and analyze...

NSG121 Health Assessment Exam 1 Updated Notes Unit 1 The nurse's role in health assessment - To promote health, to prevent illness, to treat human responses to what is the role of the nursing process in health assessment? - Utilizing the nursing process to systematically collect and analyze data about a client is the most accurate description of the nurse's role when performing a health assessment. Types of assessments - Emergency -- Life-threatening/unstable - Airway, breathing, circulation - Comprehensive - Broad and complete, complete health history and physical assessment. - General survey - Begins immediately upon meeting the patient and continues throughout the assessment. No measurements are done - Focused -- Based on patient's health issues (what they are in for) - Knee injury - assess the knee, Abdominal pain assess the abdomen Levels of intervention to promote healthy change - Primary -- Preventing problems - Immunizations, health teaching, safety precautions - Secondary -- Screening to promote the early diagnosis of health problems - Vision screening, pap smears, BP screening, TB testing - Tertiary -- Focuses on preventing complications of an existing disease and promoting health to the highest level - Medication, surgical treatment, physical therapy Assessment frameworks - Functional -- Focuses on the functional patterns that all human share - Health perception, activity and exercise, nutrition and metabolism, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, stress tolerance, values and beliefs, sexuality and reproduction. - Head-to-Toe -- Most organized system for gathering comprehensive physical data. - Body Systems Approach -- Tool for organizing data when documenting and communicating findings Communication process - Verbal -- Exchange of information using spoken or written word - Nonverbal -- Transmission of information without the use of words - Electronic -- Electronic medical record, email Components of communication - Sender -- Person or group who initiates or begins the communication - Receiver -- Must translate and interpret the message sent - Understanding -- Was the message understood - Perception - Culture Therapeutic communication/ Nontherapeutic communication See Week 1 Lesson Plan Therapeutic communication - Caring -- Encompasses your empathy for and connection with patient - Listening, nodding, touch, following-up - Empathy -- Being able to see and feel the situation from the patient's perspective rather than your own - Self-concept -- Need to be aware of your own biases, values, personality, cultural background, and communication style. - Don't let these from developing a therapeutic relationship with patient Verbal and non-verbal communication skills - Active listening -- Ability to focus on patients and their perspectives - Restatement -- Relates to the content of the communication. Asking a question to get the patient to elaborate - Reflection -- Summarize the main themes of communication - Elaboration -- Encourages the patient to keep talking and completely describe difficulties - Focusing -- Use when patients are straying from a topic and need redirection - Clarification -- Important when the patient's word choice or idea isn't clear - Summarizing -- Review and condense most important information Nontherapeutic responses - False reassurance -- Giving false hope of a positive outcome when the chances are not good - Sympathy -- When being sympathetic, you are not being therapeutic because you are interpreting the situation as you perceive it - Unwanted advice - Biased questions - Change of subject - Distractions - Technical or - Overwhelming - Interrupting Unit 2 Phases of the interview process - Pre-interaction -- Before meeting with the patient, collect data from the medical record - Beginning -- Introduce yourself by name and state the purpose of the interview. Explain reason for asking questions. - Working -- Collect data by asking specific question of client or family member. Closed or open-ended questions - Closing -- Summarize and state what the two or three most important patterns or problems might be Data sources for the heath history - Primary -- Directly from the patient only - Secondary -- All other sources: Chart, other family members - Reliable historian -- Provides information consisted with record - Inaccurate historian -- Information differs from record Lifestyle factors - Hearing impairment - Decreased level of consciousness - Cognitive impairment Mental Illness - Anxiety Safety precautions to prevent infection - Handy Hygiene -- Most important - Gloves -- Contact with blood/body fluid - Standard precautions - Everyone - Latex allergy - Skin reactions The physical examination Non-abdomen - Inspect - Palpate - Percuss - Auscultate Abdomen - Inspect - Auscultate - Percussion - Palpation Hyperresonant - Emphysematous lungs Resonant - Healthy lungs Tympanic - The Stomach Dull - The Liver Flat - Bone Purpose of documentation - To keep record of all patient assessment data and interventions - "If it's not documented, it's not done" Principles of documentation - Accuracy & Completeness -- Descriptions should be as clear and precise as possible. Accuracy provides important details, like the size of a wound and exactly what a patient said in quotations. Completeness coincides with accuracy in which labels are included and all the pertinent information needed to understand the findings. Ex: Patient's wound is round, beefy red, and measures 4cm x 2cm with no odor or drainage." Accuracy provides important details, like the size of a wound and exactly what a patient said in quotations. - Confidentiality -- Keeping private any information pertaining to health status or care received - Organization -- Entries are made chronologically - Timeliness -- Point of care documentation (in room) reduces errors that can occur with batch charting - Conciseness -- Be complete with documentation but avoid unnecessary words. Documentation formats - Narrative -- Unstructured paragraphs - SOAP(IE) - Subjective - Objective - Analysis - Plan - Intervention - Evaluation - PIE - Problem - Intervention - Evaluation - DAR - Data - Action - Response - Charing by Exception -- Abnormal assessments require a note - SBAR - Situation - Identify patient - Brief summary of primary problem - Background - Date of admission - Reason for admission - Recent set of vitals - Current medications - Lab work - Plan of care - Assessment -- - Current nursing assessment - Most recent set of vital signs - Relevant lab values - Recommendation - What do you need from this individual? - Suggestions to advance the plan of care - Any new/urgent needs that need follow-up - Any orders need to be changed or reviewed Unit 3 Assessment for violence & abuse - Put client's safety first - Do not question in front of friends and family (abuser could be there) private room - Establish rapport and ask questions simply and directly - "Do you feel safe at home?" - Do not assume who abuser is - Do not ask about police or pressing charges. This decision is up to a prosecutor Objective data for social assessment - Identifying the social factors influencing the patterns of health and illness for individual patients, communities, and societies Lifespan considerations - Pregnant women -- Require additional 300-500 cal/day - Infants/young toddlers -- Fat intake is crucial for brain development - Children and adolescents -- Extra protein during growth spurts - Older adults -- Diminished taste of sweet and salty, Lower metabolic rate, Reduced physical activity Nutritional assessment - Past medical history -- Medical conditions, food allergy or intolerance - Lifestyle and personal habits -- Eating patterns, fluid intake, cooking ability - Medications and supplements -- Medication schedule, alcohol and drug use - Family history -- GI or other diseases that influence nutrition Objective mental health assessment (ABCT Order of Assessment) - A -- Appearance - Posture, movement, activity, hygiene and grooming, dress - B -- Behavior - LOC, eye contact and facial expressions, speech - C -- Cognitive function - Orientation, attention span, memory, judgement - T -- Thought process - Logical, relevant, coherent, consistent Unit 4 General survey - Begins immediately upon meeting the patient and continues throughout the assessment - Overall appearance - Hygiene and dress - Skin color - Body structure and development - Behavior - Facial expressions - Posture - Range of motion - Gait - Speech - Level of consciousness Objective versus subjective data - Objective data is observable and measurable by nurse - Subjective data is gathered from what the client says and is based on the client's experience and perception Basic theories of pain (Gate control theory of pain) The gate control theory of pain describes the steps of pain transmission as that the body responds to a painful stimulus by either opening a neural gate to allow pain to be produced or creating a blocking effect at the synaptic junction to stop the pain. The transmission of a pain stimulus uses two separate but continuous systems: the peripheral nervous system and the central nervous system. Continued input from the peripheral nervous system can create a centrally mediated pain syndrome, in which pain occurs without a pain stimulus.  Transmission: The neuronal signal moves from the periphery to the spinal cord and up to the brain. Serotonin is a pain blocking substance - Transmission of the pain stimulus uses both the peripheral and central nervous system - Opening a neural gate to allow pain to be produced or - Creating a blocking effect at the synaptic junction to stop the pain Pain assessment (OPQRST) - O - Onset - P - Provocative/palliative - Q -- Quality - R - Region/radiation - Visceral -- Abdominal organs -- crampy - Somatic -- Muscles, bones, joints - Sharp - Cutaneous -- Skin -- Burning - Referred -- Originates from a specific site but the person experiencing it feels the pain at another site along the innervating spinal never - Phantom -- Pain in an extremity or body part that is no longer there - S- Severity - Numeric pain scale - Wong-Baker FACES pain scale - T- Timing Considerations and barriers to pain assessment Pain-facilitating substances - Substance pulse -- Quickens pain substance - Bradykinin -- Released at site of injury - Glutamate -- Neurotransmitter Pain-blocking substances - Serotonin -- Neurotransmitter - Opioids - Gamma-aminobutyric acid, gabapentin, pregabalin Documenting and reporting pain Vital signs - Normal versus abnormal Values & Findings - Temperature routes and Celsius-Fahrenheit - conversions - Pulse Sites - Proper Method - Temperature routes - Oral -- 97.7-98.6 - Axillary -- 96.7-98.5 - Rectal -- 98.7 -- 100.5 - Tympanic -- 98.2 -- 100.0 - Temporal -- 98.7 -- 100.5 Pulse sites - Temporal - Carotid - Apical - Brachial - Radial - Ulnar - Femoral - Popliteal - Posterior tibial - Dorsalis pedis https://brooksidepress.org/vitalsigns/wp-content/uploads/2015/04/MD0531\_img\_21.jpg 1. You are collecting subjective data from an adult patient you suspected of being a victim of domestic violence. How would ensure the patient's safety? - Taking the patient to a private room away from family/friends/caregiver will allow you to ask questions in a private safe place. Questions should never be asked in front of friends/family/caregiver, in case one of the person's present is the abuser. This could put the patient in more danger. 2. In describing the gate control theory of pain to your patient. You should explain that the body responds to painful stimulus in the following ways. - The gate control theory of pain describes the steps of pain transmission as that the body responds to a painful stimulus by either opening a neural gate to allow pain to be produced or creating a blocking effect at the synaptic junction to stop the pain. In that: - The transmission of the pain stimulus uses both the peripheral and central nervous system - Creating a blocking effect at the synaptic junction to stop the pain - Opening a neural gate to allow pain to be produced 3. In a head-to-toe assessment on someone who was admitted with shortness of breath and found that the client has high blood pressure, headache, and irregular heartbeat. What models to document would you use to chart the findings? - The body systems assessment is an approach that allows the nurse to identify issues by reorganizing and clustering similar data when documenting and communicating findings. 4. You are assessing a 6-year-old patient, for post-operative pain. What pain tools would be appropriate to use? The Wong-Baker FACES scale is typically used for children and confused patient.  5. In using a balance beam scale to obtain accurate weight on your patient. You must - Balance the scale before weighing the patient. 6. In assessing a client\'s respirations. What method should you take? - The inspirations and expirations should be counted once each, as a pair, for 30 seconds and multiplied by 2. You should not make the client known that the respirations are being counted because it can cause the client to unconsciously breath differently than the client would without knowing. 7. In assessing a patient using the ABCT method to organize the data collection. ABCT is an organized method of collecting objective data during a comprehensive mental health assessment. Place in correct order 1. Ask questions about orientation, memory, judgement and note the client's ability to follow the conversation. 2. Observe the client's movements, appearance and notice any physical deformities. 3. Assess if the client is awake, alert and reacts to stimuli and the environment appropriately with facial expressions and eye contact. 4. Note if the client's words and sentences are easy to follow, coherent and goal directed. 8. During a general survey you are observing the physical appearance of a 69-year-old patient. What would you document as abnormal findings? - The patient arms swing freely at the sides. - The patient has slowed, sometimes slurred speech. - The patient appears stated age and appears well hydrated. - The patient has a wide gait and takes short steps when ambulating. 9. Your newly admitted patient discloses several previous unpleasant hospitalizations. What components of the communication process should you identify as a priority with this patient? Patient who has had negative experiences with the health care system would be perception. 10. What is the purpose of documentation in the medical record? \- Communication with other health care workers. \- The medical record is used for education and research. \- Financial reimbursement by insurance companies. \- Serves as legal document. 11\. What is NOT a purpose of documentation in the medical record? - The medical record is a legal document and not intended to provide real- time diagnostic results for patients, especially those which are not interpreted by a health care provider. 11. What type of therapeutic communication is uses to encourage the patient to say more, such as "Go on"? - Elaboration is demonstrated when you are using a response that encourages the client to keep talking. 13.You are obtaining the radial pulse of a patient and notes the rate to be 57 beats per minute. What should you document? \- Bradycardia is a heart rate less than 60 beats/min. 14\. What happen during the working phase of nurse patient relationship? The working phase includes asking closed or open-ended questions like, do you take medications or what brought you into the hospital. 15\. The nurse is completing an admission with a patient newly diagnosed with breast cancer. What will the nurse do to best demonstrate therapeutic communication with this patient? \- Encourage the patient to express concerns and listen attentively. Therapeutic communication is a basic tool you use in a caring relationship with patients. In therapeutic communication, the interaction focuses on the patient and the patient's concerns. Active listening is the ability to focus on patients and their perspectives. It requires that you constantly decode messages, including thoughts, words, opinions, and emotions. 16\. During the pre-interaction phase of the interview process? \- Demographic data is collecting during the pre-interaction phase from the patient's medical record. 17\. You ask a patient how you are feeling today?" The patient responds, "I feel great." However, you noted that the patient's facial expression is tense, and he grimaces when he changes position. Which of the following interventions would be most appropriate? \- The nurse should investigate further due to the incongruence of the patient\'s verbal and nonverbal communication {When it comes to communication, congruence and incongruence are two terms that are often used to describe the consistency or inconsistency between a person's verbal and nonverbal communication. Congruence is the proper word to use when describing the consistency between a person's verbal and nonverbal communication. It means that a person's words, tone of voice, and body language are all in alignment and conveying the same message. Incongruence, on the other hand, means that there is a mismatch between a person's verbal and nonverbal communication. This can create confusion and mistrust in the listener.} 18\. Subjective data from a client during an assessment would be. What the client reports. 19\. Utilizing the nursing process to systematically collect and analyze data about a client is the most accurate description of the nurse\'s role when performing a health assessment. 20\. The nurse is assessing a new patient for pain. The patient responses that require immediate nursing intervention are: \- "The pain starts in my chest and moves toward my arm." \- "The last time I had pain like this it turned out to be a heart attack." \- "I have the worst headache of my life today; it will not go away." 21\. You are caring for a patient from specific culture who refuses to eat the protein meat (bacon) at breakfast, and the protein meat (ham) at lunch. How would you respond to the patient? \- Do you have any specific dietary needs?" 22\. Difficulty chewing can occur with patients who have poorly fitted dentures or have no teeth can cause them to eat less and lose weight. 23\. Primary source when collection date. The patient 24\. Secondary sources are any other source other than the patient like, medical records, family members, primary health care providers, other nurses who cared for the patient. 25\. Proteins are more important during adolescence because it is needed for tissue building. 26\. Subjective data from a client for nutritional risk factors of malnutrition. When obtaining subjective data for nutritional risk factors the nurse should obtain past medical and surgical histories, medication and supplement use, family history, food and fluid intake patterns, and the client\'s psychosocial profile, like lifestyle and personal habits related to food. 27\. Pain-facilitating substances include substance pulse, bradykinin, and glutamate. 28\. Pain-blocking substances include: Serotonin, opioids, and pregabalin. 29\. Hand hygiene is the most important thing a nurse can do to prevent and reduce the risk of infection among clients. 30\. Accuracy provides important details, like the size of a wound and exactly what a patient said in quotations. 31\. Tertiary health prevention involves providing information for a client who already has an illness or disease. For example, teaching a client with a leg cast to crutch walk will help prevent complications and using the crutches incorrectly and from the client putting weight on a casted leg. 32\. Types of pain. \- Somatic pain described as sharp and occurs in muscles, bones and joints. \- Visceral pain originates from abdominal organs and is described as crampy or gnawing. \- Referred pain comes from a specific site, but the client feels the pain at a different site that is along the innervating spinal nerve. \- Cutaneous pain originates from the dermis, epidermis, and subcutaneous tissues and is described as burning or sharp 33\. General survey of a patient during a comprehensive physical examination is where the nurse makes mental notes of the patient's appearance, behavior, and mobility. Example, the patient walks with a limp on the left foot. 34\. During comprehensive physical examination if you are not unable to collect subjective data, would indicate further communication was needed. 35\. It is important to understand food/herb-drug interactions when caring for patients. Grapefruit juice or fruit can interfere with the action of certain medications. Statins can cause greater side effects if mixed with grapefruit. 36\. In assessing an older patient's social history to look for cues possibly related to his diagnosis. What address the patient's social history? The Social history section on the patient Summary contains data elements including, tobacco use, alcohol use, financial resources, education, physical activity, stress, social isolation and connection, gender identity, sexual orientation, nutritional history, and exposure to violence. Examples see below: \- The patient identifies as transgender. \- The patient worked in a tobacco plant making cigarettes for years but do not smoke  37\. During the working phase includes asking closed or open-ended questions like, do you take medications/what brought you into the hospital. 38\. A core temperature means to obtain the client\'s temperature rectally. A normal range would be between 98.7 to 100.5o F (37.1 to 38.1o C). A core temperature means to obtain the client\'s temperature rectally. A normal range would be between 98.7 to 100.5o F (37.1 to 38.1o C), which is slightly higher than an oral temperature. The rectal route should not be used to obtain a newborn\'s temperature, it is an appropriate route to obtain an accurate temperature for an adult or older adult client. An electronic thermometer with a red tip should be used for the rectal route.