Health Assessment Final Exam Study Guide (1) PDF

INTRO TO HEALTH ASSESSMENT Introduction/Interview First point of contact with the patient – the beginning of collection of subjective data Physical environment should be set up appropriately ○ Privacy, no interruptions ○ Distance between you and patient should be 4-5...

INTRO TO HEALTH ASSESSMENT Introduction/Interview First point of contact with the patient – the beginning of collection of subjective data Physical environment should be set up appropriately ○ Privacy, no interruptions ○ Distance between you and patient should be 4-5 feet with equal-status seating Use open-ended and closed questions ○ Open – begins interview and asks for narrative/unbiased information; also allows for full expression Health Assessment The collection of comprehensive data about a person’s health state ○ Subjective – information that a person tells you about their health, including symptoms, past medical history, and lifestyle habits ○ Objective – observable or measurable signs collected through physical examination techniques Assessment Techniques Inspection – assessment of size, color, shape, position, and symmetry Palpation – assessment of temperature, turgor, texture, moisture, vibrations, shape (light then deep) Percussion – assessment of location, size, and dentistry of tissues/organs General Survey This is done before taking a history or performing a physical assessment – it is the first impression of your patient when you enter the room Survey of physical appearance ○ Age – do they look their stated age? ○ Sex – sexual development appropriate for gender and age? ○ Level of consciousness – alert, oriented, attentive, appropriate responses? ○ Skin color – even tone, no abnormalities? ○ Facial features – symmetric? Survey of body structure ○ Stature – height and posture normal for their genetics? ○ Nutritional status – obese or malnourished? ○ Symmetry – limbs symmetric? ○ Posture – can they stand and sit comfortably in an erect position? ○ Body build – are they proportionate? Survey of mobility ○ Gait – feet shoulder width apart? ○ Foot placement – accurate placement and smooth walking? ○ Range of motion – full ROM? Survey of behavior  ○ Facial expressions – maintain eye contact and appropriate expressions for the situation? ○ Mood and affect – are they comfortable? ○ Speech – fluent talking and clear ideas? ○ Dress – appropriate clothing for climate and culture? ○ Hygiene – clean and good hygiene? Nursing Process Assessment – gather objective and subjective data Diagnosis – identify patient’s health problems based on the data Planning – develop a plan to achieve the desired health outcomes Implementation – carry out the plan with interventions Evaluation – assess patient’s response to interventions and revise the plan if needed SOAP Note Subjective – patient’s own report of symptoms (ex: I have a headache) Objective – measurable data from physical exam (ex: BP 120/85) Assessment – nursing diagnosis or clinical judgment based on findings Plan – immediate interventions, diagnostic tests, or follow up Pain Assessment OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Time, Severity) Wong-Baker and Faces Scale assess severity on scale of 0-10 FLACC (Facial expression, Leg movement, Activity level, Cry, Consolability) and CRIES (crying, oxygenation requirements, vital signs, facial expression, and sleeplessness) measure neonatal and infant pain INTEGUMENTARY SYSTEM Lesion Assessment ABCDE ○ Asymmetry – one half of lesion does not match the other half ○ Border – edges are ragged or blurred ○ Color – multiple colors such as brown, red, black, blue ○ Diameter – greater than 6 mm ○ Evolving – any change in size, shape, color, elevation Status ○ Primary – develop on unaltered skin and skin has not been broken ○ Secondary – changes in lesions due to scratching and infection/open skin Types of Lesions Nodule – solid, elevated, firm or soft lesion that is LARGER THAN 1 CM (ex: fibroma, xanthoma) Bulla – vesicle that is LARGER THAN 1 CM in diameter (ex: blister, burn, contact dermatitis)  Papule – raised, solid lesion LESS THAN 1 CM in diameter, palpable, and can have various colors (ex: wart, mole) Wheal – superficial, raised, transient lesion that is red with irregular borders due to edema in skin (ex: insect bites, allergic reaction) Pustule – pus-filled, elevated lesion that is usually LESS THAN 1 CM (ex: pimple, impetigo) Vesicle – fluid-filled, elevated lesion that is LESS THAN 1 CM and fluid is usually clear (herpes, chickenpox, shingles) HEAD, FACE, NECK, EYES Facial Droop Signs – uneven smile, drooping eyelid, difficulty closing eye, speech difficulties, drooling, facial weakness Causes – stroke, Bell’s Palsy, tumor, Lyme disease, shingles, trauma near or at the facial nerve Sinus Assessment Using thumbs, palpate frontal sinuses by pressing up and under the eyebrows and palpate the maxillary sinuses below the cheekbones Tenderness or feelings of pressure indicate chronic allergies or sinusitis Thyroid and Trachea Assessment Inspect anterior neck while patient swallows and watch for thyroid rise Palpate thyroid gland from posterior approach ○ Normal – thyroid will feel spongy and non-modular, no tenderness ○ Abnormal – thyroid will appear unilateral, donut shaped → could indicate cancer or hormone disorders; enlarged thyroid may cause a bruit (whooshing sound) Palpate the trachea in midline Corneal Light Reflex Test Test to assess extraocular function → use a penlight and shine into middle of the patient’s eyes Normally the light should reflect in the same place in both eyes Snellen Eye Chart Test Test to assess distance vision → have patient stand 20 feet away from chart and read the letters Normal – 20/20 vision, meaning the person can see at 20 feet what a person with normal visitation should see at that distance Abnormal – larger the denominator (over 20), worse vision Confrontation Test Test to assess peripheral vision by comparing the patient’s field of view with the examiner’s field of view PERRLA Test Test to assess pupil function and cranial nerve III → use a penlight to assess the pupillary light reflex ○ Normal – equal constriction of pupils when bright light shines on the retina ○ Abnormal – no response, pupil dilation, fixed pupils which could indicate drugs, death, or neurologic problems Pupils are Equal, Round, and Reactive to Light and Accommodation Cataracts Clouding of the lens; common age-related condition Causes blurred vision and is a major cause of vision impairment Ocular Deviation Strabismus – crossed eyes ○ Esotropia – inward ○ Exotropia – outward ○ Hypertropia – upward ○ Hypotropia – downward Nystagmus – repetitive, uncontrolled eye movements which may cause the eyes to drift off target and then rapidly correct EAR, NOSE, THROAT, RESPIRATORY Otoscopic Exam Otoscope is used to inspect the external auditory canal and tympanic membrane ○ For all patients over age 3, pull the pinna up and back to straight eustachian tubes and insert otoscope safely Normal – clear of debris and tympanic membrane should appear pearly gray with cone of light visible Abnormal – redness and swelling are suggestive of otitis externa, yellow or amber fluid suggestive of otitis media, perforation, and bulging/retraction suggestive of pressure changes Adventitious Lung Sounds High-pitched wheeze – musical squeaking sounds that sound polyphonic ○ Diffuse airway obstruction from acute asthma or chronic emphysema Low-pitched wheeze – monophonic, musical snoring/moaning ○ Bronchitis, single bronchus obstruction from airway tumor Stridor – high-pitched, monophonic crowing sound ○ Croup, acute epiglottitis, foreign body inhalation, obstructed airway ○ ***life threatening Fine crackles – discontinuous, high-pitched, short crackling, popping sounds heard during inspiration and not cleared by coughing ○ Late inspiratory crackles - restrictive diseases such as pneumonia, heart failure, interstitial fibrosis  ○ Early inspiratory crackles - obstructive diseases such as chronic bronchitis, asthma, and emphysema Coarse crackles – loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration ○ Pulmonary edema, pneumonia, pulmonary fibrosis, terminally ill patients with depressed cough reflex Atelectatic crackles – sound like fine crackles but do not last and are not pathologic ○ Seen in aging adults, bedridden people, or people who just woke from sleep Auscultation Breath Sounds Bronchial – high pitch and loud amplitude ○ Heard over trachea and larynx ○ Heard more often during expiration Bronchovesicular – moderate pitch and moderate amplitude ○ Heard over major bronchi ○ Heard equally during expiration and inspiration Vesicular – low pitch and low amplitude ○ Heard over peripheral lung fields ○ Heard more often during inspiration Tactile Fremitus Normal lungs transmit a palpable vibratory sensation to the chest wall, called fremitus 99 Test ○ Place ulnar side of both hands firmly against either side of chest and have patient say “99” Normal finding - equal vibration Abnormal findings ○ Increased fremitus - presence of lung consolidation such as with pneumonia ○ Decreased fremitus - presence of pleural effusion, emphysema, pneumothorax Anteroposterior Diameter Should be LESS THAN transverse diameter - 1:2 ratio AP = transverse diameter indicates barrel chest (abnormal) Pleurisy Condition that causes inflammation of the pleura which can lead to sharp chest pain when breathing or a constant dull ache Caused by pneumonia, TB, viral infections, chest trauma, cancer, blood clots CARDIOVASCULAR, PERIPHERAL VASCULAR, LYMPHATIC Cardiac Sites Aortic Valve  ○ Right side of heart at 2nd ICS ○ S2 loudest Pulmonic Valve ○ Left side of heart at 2nd ICS ○ S2 loudest Tricuspid Valve ○ Left side of sternum at 4th-5th ICS ○ S1 loudest Mitral Valve ○ Over MCL at 5th-6th ICS ○ S1 loudest Heart Sounds S1 - “LUB”; occurs with closure of the tricuspid and mitral valves and is the beginning of systole ○ Normal heart sound S2 - “DUB”; occurs with closure of the aortic and pulmonic valves and is the end of systole S3 - ventricular gallop; occurs immediately after S2 ○ Pathologic S3 occurs with heart failure and volume overload S4 - atrial gallop; occurs just before S1 ○ Pathologic S4 occurs with CAD Thrills Palpable vibration felt on the skin overlying the heart or blood vessel, caused by turbulent blood flow, typically resulting from a murmur Assessed by feeling chest with fingers or palms Bruits Abnormal, whooshing sound heard during auscultation of an artery, caused by turbulent blood flow through a narrowed or partially blocked blood vessel Assessed by auscultation with bell of stethoscope PMI Point of maximal impulse, also called the apical pulse Located at 5th ICS and MCL Note if a thrill is present (abnormal) Pulses Palpate radial pulses, brachial pulses, femoral pulse, popliteal pulse, posterior tibial pulse, dorsalis pedis pulse 3-point scale ○ 3+ full, bounding (indicative of state of exercise, anxiety, fever, anemia, hyperthyroidism) ○ 2+ normal ○ 1+ weak (indicative of shock and PAD) ○ 0 absent Jugular Vein Distention To assess, have patient lie in fowler’s position (45 degrees) and turn head to side while you measure height of jugular vein from surface of neck with a ruler Normal finding – no distention Presence of JVD indicates hypovolemia – due to congestive heart failure Signs and symptoms – bulging of the jugular veins, dyspnea, peripheral edema Deep Vein Thrombosis Presents with unilateral leg swelling, tenderness to severe pain, possible warmth and redness, and possible superficial venous dilation Assessed using Wells Score ○ Score of 1 to 2 - moderate probability ○ Score of 3 or more - high probability Calf swelling of 2 cm or more Venous Stasis The slowing or pooling of blood flow in the veins, most commonly in legs Causes – venous insufficiency, prolonged immobility, DVT, obesity, pregnancy Peripheral Artery Disease Circulatory condition where narrowed arteries reduce blood flow to the limbs, typically the legs Occurs due to atherosclerosis Symptoms – pain or leg cramping, weak or absent pulses, coldness in lower legs, pale or blue skin discoloration, slow healing sores Lymph Node Assessment When palpating, they should feel movable, soft, separate and distinct, and non-tender Use a circular motion with finger pads to palpate Begin with preauricular lymph nodes then posterior auricular, occipital, submental, submandibular, superficial cervical, deep cervical, and supraclavicular Lymphadenopathy Enlargement of lymph nodes May be present in infection, cancer, HIV, lymphomas ABDOMEN Quadrants Right upper ○ Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon Right lower ○ Cecum, appendix, right ovary and tube, right ureter, right spermatic cord Left upper  ○ Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal, splenic flexure of colon, part of transverse and ascending colon Left lower ○ Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord Percussion Sounds Tympany – should predominate because air rises to the surface when client is supine; normal Dullness – occurs over fluid and underlying organs such as liver or spleen Vascular Sounds These are called bruits and are auscultated with bell of stethoscope Normal finding - nothing heard Abnormal finding - whooshing sound that is reflective of turbulent blood flow Bowel Sounds Normal – high pitched, gurgling, cascading and occur anywhere from 5 to 30 times per minute Hyperactive – loud, high pitched, rushing, tinkling sounds that signal increased motility Hypoactive – low or absent, usually follow abdominal surgery or may be due to inflammation of peritoneum ○ These are uncommon - must listen for five minutes before documenting as absent Order of Assessment 1. Inspect 2. Auscultation 3. Percussion 4. Palpation *** Auscultation comes before percussion and palpation so peristalsis is not increased Auscultation Use diaphragm of stethoscope because bowel sounds are high-pitched Begin in the RLQ at the ileocecal valve because bowel sounds are normally always present here Blumberg’s Sign Positive sign in the rebound tenderness test May indicate peritoneal inflammation (appendicitis) Murphy’s Sign Positive sign in the inspiratory arrest test May indicate cholecystitis ANUS, RECTUM, FEMALE/MALE GU SYSTEMS Melena Black or tarry stools May indicate bleeding in upper GI tract Steatorrhea Pale and oily stools Condition where there is too much fat in stool (caused by fat malabsorption) Costovertebral Angle Tenderness Assessed by placing one hand over 12th rib at costovertebral angle on the back then thump hand with ulnar edge of your other first Normal – patient feels the thud but has no pain Abnormal – sharp pain indicative of kidney inflammation Breast Lumps Normal for texture of breast tissue to change with changes in hormone levels during the menstrual cycle Abnormal signs to look for – area, size, soft or firm, tender, fixed, color of skin over it, discharge MUSCULOSKELETAL Range of Motion Passive – movement of joints with assistance from provider ○ May present with pain, tenderness, or crepitation Active – movement of joints on your own ○ During assessment, stabilize body area proximal to that being moved ROM Movements ○ Flexion – bending limb at joint ○ Extension – straightening limb at joint ○ Circumduction – moving arm in circle around shoulder ○ Eversion – moving sole of foot outward at ankle ○ Inversion – moving sole of foot inward at ankle ○ Abduction – moving limb away from midline ○ Adduction – moving limb toward midline ○ Protraction – moving body part forward ○ Pronation – turning forearm so palm is down ○ Supination – turning forearm so palm is up ○ Retraction – moving body part backward Muscle Strength Assessment Repeat movements for active ROM and ask patient to flex and hold as you apply opposing force ○ Strength should be equal bilaterally and should fully resist opposing force Grading Scale ○ 5 – normal power, 4 – active movement against gravity with resistance, 3 – active movement against gravity without resistance, 2 – active movement with gravity eliminated, 1 – only a trace or flicker of movement, 0 – no movement Deep Tendon Reflexes Involuntary muscle contractions when a tendon is stretched (myotatic) Common – biceps reflex, brachioradialis reflex, triceps reflex, patellar reflex, achilles reflex Abnormal Spine Conditions Scoliosis – abnormal curvature of the spine → appears as S shape ○ Can be functional (flexible and disappears when bends) or structural Lordosis – excessive inward curve of the spine, affecting lumbar spine → swayback ○ Common causes – obesity, pregnancy, spondylolisthesis Kyphosis – excessive outward curvature of spine, affecting thoracic spine → hunchback ○ Common causes – osteoporosis, arthritis Carpal Tunnel Tests Phalen Test – have patient place the backs of their hands together and press ○ Pain or tingling may indicate carpal tunnel Tinel’s Sign – apply direct percussion to median nerve ○ Pain or tingling may indicate carpal tunnel NEUROLOGICAL SYSTEM & CRANIAL NERVES Neuro Assessment A complete neurologic exam consists of assessment of (1) mental status, (2) cranial nerves, (3) motor system, (4) sensory system, and (5) reflexes Glasgow Coma Scale The GCS assesses patient’s mental status or level of consciousness – assesses functional state of brain as a whole by looking at eye movement, motor function, and speech Scoring ○ Best score = 15 ○ 7 or less = coma state Cerebellar Coordination Function Tests Rapid Alternating Movements (RAM) Test – pat knees with palms, then back of hands as fast as possible Finger to Finger Test – have patient touch their nose then the examiner’s finger several times; constant deviation to one side is called past pointing  Finger to Nose Test – have patient touch their nose with their finger then alternate arms Heel to Shin Test – have the patient lie supine and slide one heel over the other leg’s shin Cerebellar Balance Function Tests Gait Test – observe as they walk 10-20 feet then return Romberg Test – patient stands up with feet together and arms at side with eyes closed for 20 seconds ○ Positive Romberg – swaying, falling, widened base ○ Alternatives – ask patient to perform shallow knee bend or hop in place OR ask them to rise from chair without using arm rest Paresthesia Abnormal feeling in the skin that can feel like tingling, burning, pricking, numbness, or itching Most common in arms and legs Syncope Fainting or passing out – sudden drop in blood flow to the brain Deep Tendon Reflex (DTR) Test To assess, stimulate the reflex by directing a short, snappy blow of reflex hammer onto the muscle’s insertion tendon → responses should be equal Grading Scale ○ 4 = very brisk, hyperactive with clonus, indicative of disease ○ 3 = brisker than average, may indicate disease ○ 2 = average, normal ○ 1 = diminished, low normal, or occurs with reinforcement ○ 0 = no response Hyperreflexia – occurs with upper motor lesions (stroke) Hyporeflexia – occurs with lower motor neuron lesions (spinal cord injury) Clonus Hyperreflexia that causes rapid rhythmic contractions of same muscle Clonus Test – support lower leg in one hand and with other hand, move foot up and down to relax muscle then stretch muscle by briskly dorsiflexing foot and holding the stretch ○ Normal response – feel no further movement ○ Clonus present – rapid rhythmic contractions of the calf and movement of foot Babinski Reflex Abnormal reflex response To assess – stroke bottom of the foot with an upside down J motion ○ Children 2 or younger should respond by fanning toes ○ Adults should respond with their toes curling and foot curving inward Positive Babinski Sign – fanning response after age 2 and can be indicative of upper motor neuron disease of the corticospinal cord Muscle Abnormalities Tics – involuntary twitch that can be physical or psychological Myoclonus – sudden jerk (ex: hiccups) Tremor – contraction of opposing muscle groups Fasciculations – rapid, continuous twitch of eye Abnormal Postures Decorticate rigidity – indicates hemispheric lesion of cerebral cortex ○ Upper extremities – flexion of arm, wrist, fingers; adduction of arms tight against thorax ○ Lower extremities – extension, internal rotation, and plantar flexion Decerebrate rigidity – indicates lesions in brain stem at midbrain or pons; more ominous ○ Upper extremities – stiffly extended, adducted, and internally rotated arms with palms pronated ○ Lower extremities – stiffly extended legs and plantar flexion; clenched teeth and neck/back hyperextended Opisthotonos – indicates meningeal irritation ○ Looks like prolonged arching of back with head and heels bent backward Flaccid Quadriplegia – neurological condition that causes paralysis or weakness in muscles of arms and legs, with reduced muscle tone Cranial Nerve Tests Olfactory – have patient close eyes and occlude one nostril while smelling a familiar aromatic substance Optic – test visual acuity with confrontation test and Snellen chart then use ophthalmoscope to examine ocular fundus Oculomotor, Trochlear, Abducens – check pupils for accommodation, equality, light reaction then assess extraocular movements by cardinal positions of gaze Trigeminal – test motor function by palpating temporal and masseter muscles while patient clenches teeth; test sensory function by touching cotton wisp on forehead, cheeks, chin while patient’s eyes are closed Facial – test motor function and facial symmetry as patient responds to requests to smile, frown, close eyes, life eyebrows, and show teeth Acoustic – assess patient’s ability to hear normal conversation then do a whispered-voice test Glossopharyngeal and Vagus – depress tongue down with tongue blade and note pharyngeal movement as patient says “ahhh”; touch posterior pharyngeal wall with tongue blade and note gag reflex then listen to their speech Spinal Accessory – examine sternomastoid and trapezius muscles for equal size and strength while they rotate head and shrug shoulders against resistance Hypoglossal – inspect tongue and have patient say “light, tight, dynamite” MENTAL HEALTH AND FAMILY VIOLENCE Mental Status Exam Systematic check of emotional and cognitive functioning which can be done during the health history review ABCT ○ Appearance – look at posture body movements, dress, grooming, hygiene, level of consciousness ○ Behavior – facial expressions, speech, mood, affect, orientation, attention span, recent and remote memories ○ Cognition/Thought Process – use Four Unrelated Words Test and Judgement Test Important to perform mental status exam when a patient’s initial screening includes indications of anxiety, depression, memory loss, inappropriate social interaction, brain lesions, symptoms of psychiatric mental illness Intimate Partner Violence Screening HITS – Hurt, Insult, Threaten, Scream Client answers following questions from never to frequently ○ How often does your partner physically hurt you? ○ How often does your partner insult or talk down to you? ○ How often does your partner threaten you with harm? ○ How often does your partner scream or curse at you? Anxiety Screening GAD-2 and GAD-7 – measures severity of anxiety ○ Scores of 0 suggest no anxiety and scores above 3 suggest anxiety is present Depression Screening Patient Health Questionnaire 2 (PHQ-2) – asks two questions about depressed mood and anhedonia (little interesting or pleasure in doing things) that will detect a majority of depressed patients ○ PHQ-2 Score of 2 or more = PHQ-9 will be administered ○ PHQ-9 scores – 5-9 = minimal symptoms; 10-14 = minor depression; 15-19 = major depression, moderately severe; 20 or greater = major depression, severe Suicide Screening Ask Suicide-Screening Questions (ASQ) – can be administered in 20 seconds and consists of 4 screening questions ○ In the past few weeks, have you wished you were dead? ○ In the past few weeks, have you felt that you or your family would be better off if you were dead? ○ In the past week, have you been having thoughts about killing yourself? ○ Have you ever tried to kill yourself? If person answers yes to any of the questions, it is a positive screen Mini-Mental State Exam (MMSE) Test of cognitive functions of the mental status examination (memory, orientation to time and place, naming, reading copying or visuospatial orientation, writing, ability to follow a three-stage command) It requires paper and pencil and the person must be able to write and have no visual impairment ○ Quick and easy; set of 11 questions and takes 5-10 minutes Useful for initial and serial measurement, therefore you can demonstrate worsening or improvement of cognition over time and with treatment Documentation of DV/IPV Abuse Documentation must include the following: ○ Detailed, unbiased progress notes ○ Injury maps ○ Photographic documentation in the health record ○ Other aspects of abuse history, including reports of past abusive incidents ○ Information can be paraphrased with use of partial direct questions Written documentations of histories of DV or IPV need to be verbatim – it is critical to document exceptionally poignant statements made by victim that identify both perpetrator and severe threats of harm made by perpetrator Documentation of Child Abuse/Neglect Use words that child has used to describe how their injury occurred Remember the possibility that the abuser might be accompanying the child If child is nonverbal, use reports from caregiver Know your institutional protocol for obtaining history Documentation of Elder Abuse Take photographic evidence of suspected injuries and ask about past trauma that may affect the physical exam Be alert for: ○ STIs ○ Pelvic pain ○ Complaints of sexual dysfunction ○ Chronic IBS ○ Back pain ○ Depression ○ Symptoms of PTSD ○ Sleeping problems ○ Panic attacks ○ Nervousness Written documentation of history must be verbatim Mandatory Reporter Individual who is legally required to report certain types of information, often involving suspicions of abuse or neglect, to authorities ○ Child abuse, DV, IPV, elder abuse Examples include teachers, doctors, nurses, social workers, therapists COMPREHENSIVE REVIEW NANDA Nursing Diagnoses Actual nursing diagnosis – reflect a current problem or condition that is present at the time of assessment ○ Acute pain, chronic pain, impaired physical mobility, impaired gas exchange, ineffective airway clearance, deficient fluid volume, imbalanced nutrition, impaired skin integrity, impaired verbal communication, activity intolerance, ineffective coping, fatigue Risk nursing diagnosis – indicate a potential problem that may develop in future based on risk factors ○ Risk for infection, risk for falls, risk for aspiration, risk for impaired skin integrity, risk for impaired gas exchange, risk for deficient fluid volume, risk for electrolyte imbalance, risk for bleeding, risk for constipation, risk for disturbed sleep pattern, risk for suicide Health promotion diagnosis – focus on patient’s readiness to enhance health behaviors ○ Readiness for enhanced nutrition, readiness for enhanced knowledge, readiness for enhanced family processes, readiness for enhanced coping, readiness for enhanced fluid balance BEFAST Assessment Tool Used to help identify early signs and symptoms of a stroke Balance – is there a sudden loss of balance or coordination? Person may feel dizzy, unsteady, or have difficulty walking Eyes – is there sudden vision trouble, such as blurred or double vision, or sudden loss of vision in one or both eyes? Face – is there face drooping on one side? Ask person to smile or show their teeth Arms – is there weakness or numbness in one arm or leg? Ask person to raise both arms, one arm may drift downward or person may be unable to lift the arm Speech – is speech slurred, garbled, or strange? Time – time is critical, must act quickly