HESI Review- Health Assessment

Past Health questions

Childhood Illnesses, Accidents or Injuries, Serious or Chronic Illnesses, Hospitalizations, Operations, Obstetric History, Immunizations, Last examination date, Allergies, Current Medications

Complete database

Complete health history and physical examination. It describes current and past health state and forms a baseline against which all future changes can be measured. Yields first diagnoses

What is the yin/yang theory of health?

Health exists when all aspects of the person are in perfect balance.

Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage?

Heritage consistency

Phases of the Interview

Introduction, working phase, and conclusion

Purpose of the assessment

Is to make a judgement or diagnosis

Folk Healer

Lay healer in the person's culture apart from the biomedical/ scientific healthcare system.

Internal Factors of the interview

Liking others, empathy, and the ability to listen

Interpretation

Links events, makes associations, or implies cause

8 Critical characteristics of a symptom

Location, Quality, Severity, Timing, Setting, Relieving Factors, Associated Factors, Patients Perception

Biographic data

Name, address, phone number, age, birthdate, gender, marital status, race, ethic origin, occupation, primary language

Interview with infant

Nonverbal communication is the primary method of communicating with infants. They respond best to firm, gentle handling and a quiet, calm voice.

What would a lethargic pt look like?

Not fully alert, drifts off to sleep when not stimulated, looks drowsy, thinking seems slow and fuzzy, inattentive, loses train of thought

Sign

Objective abnormality that you as an examiiner could detect on physical examination or in laboratory reports

What symptom is greatly influenced by a person's cultural heritage?

Pain. Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain are all embedded in a cultural context.

Nonverbal skills

Physical appearance, Posture, Gestures, Facial Expressions, Eye Contact, Voice, Touch

Vocal cues

Pitch, tone, quality, loudness, intensity, rate & rhythm, sounds such as groans, laughs, coughs, "um", "uh"

Past Health for children (extra)

Prenatal status, Labor and delivery, Postnatal status, are to be asked of the mother

Diagnostic reasoning

Process of analyzing health data and drawing conclusions to identify diagnoses.

Cultural Care Nursing

Professional health care that is culturally sensitive, appropriate, and competent.

What is a person's mood?

Prolonged display of a pt's feelings

10 traps of interviewing

Providing false assurance or reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing, using professional jargon, using leading or biased questions, talking too much, interrupting, using "why" questions

(P)QRSTU

Provocative or palliative- what brings it on? what were you doing when you first noticed it? what makes it better or worse?

P(Q)RSTU

Quality or Quantity- How does it look, feel, sound? How intense/severe is it?

Emergency database

Rapid collection of the database, usually compiled concurrently with life-saving measures

Source of History

Record who furnishes the information, judge how reliable the informant seems and how willing, note any special circumstances

PQ(R)STU

Region or radiation- Where is it? Does it spread anywhere?

Reflection

Response echos patient's words, is repeating part of what the person says

Confrontation

Response in which examiner gives honest feedback about what he or she has seen or felt after observing a certain patient action, feeling, or statement

Facilitation

Response that encourages patient to say more, continue with story, shows person you are interested and will listen further

Functional Assessment

Self esteem, Self concept, Activity/exercise, Sleep/rest, Nutrition/elimination, Interpersonal relationships/resources, Spiritual resources, Coping and stress management, Personal Habits, Alcohol, Illicit or street drugs, Environment/hazards, Intimate partner violence, Occupational health

When interviewing a person currently under the influence of alcohol or illicit drugs ask what?

Simple and direct questions

Symptom

Subjective sensation that the person feels from the disorder

What is affect?

Temporary expression of feelings or state of mind

Ethnocentrism

Tendency to view your own way of life as the most desirable, acceptable, or best and to act superior to another culture's lifestyle.

What is the Mini-Cog?

Test pt's executive function, ability to plan, manage time, organize activities, manage working memory

Who has a developmental task of finding the meaning of life and the purpose of his or her own existence, and adjusting to the inevitability of death?

The aging adult

Health/Illness

The balance/imbalance of a person, both withing one's being (physical, mental, and or spiritual) and in the outside world, ( natural, communal, and/or metaphysical)

Religion

The belief in a divine or superhuman power or powers to be obeyed and worshiped as the creator(s) and ruler(s) of the universe; and a system of beliefs, practices, and ethnic values.

Working phase

The data-gathering phase, includes two question types: open and closed

Heritage Consistency

The degree to which a person's lifestyle reflects his or her traditional heritage, whether it is American Indian, European, Asian, African, or Hispanic.

While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following will most likely describe this patient's view of wellness?

The humors must be balanced.The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the balance of the humors.

Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand

The logic of the traditional belief systems

Socialization

The process of being raised within a culture and aquiring the characteristics of that group.

What is thought process?

The way a person thinks (logical train of thought)

First level priority problems

Those that are emergent, life threatening, and immediate(establishing and airway, breathing)

Third level priority problems

Those that are important to the patient's health but can be addressed after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low self esteem)

Second level priority problems

Those that are next in urgency requiring your prompt intervention to forestall further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results

PQRS(T)U

Timing- Onset, exactly when did it first occur? Duration, How long did it last? Frequency, How often does it occur?

PQRST(U)

Understanding Patient's Perception of the problem- What do you think it means?

Engaging in distancing

Using impersonal speech to put space between a threat and the self by using "the" instead of "my" or "your"; blunt specific terms in preferable to defuse anxiety

Jargon

Using medical vocabulary with patient in an exclusionary and paternalistic way

Empathy

Viewing the world from the other person's inner frame of reference while remaining yourself; recognizing and accepting the other person's feelings without criticism

Holistic health

Views the mind, body, and spirit as interdependent and functioning as a whole within the enviroment

Five types of nonverbal behaviors that convey information about the person

Vocal cues (crying & moaning), action cues(posture facial expression), object cues (clothes), use of personal and territorial space, touch

What is thought content?

What the person thinks (specific ideas, beliefs, use of words)

Explanation

You inform the patient, you share factual and objective information

What should be avoid in speaking with elders?

Elder speak, inappropriate plural pronouns, tag questions, shortened sentences, slow speech rate

External Factors of the interview

Ensure privacy, refuse interruptions, physical environment, dress, note taking, tape and video recording

Clarification

Examiner's response used when the patient's word choice is ambiguous or confusing

How do we interview with hearing impaired individuals?

Face directly so mouth and face are visible, do not shout, speak slowly, use hand gestures

Respones-assisting the narrative

Facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary

Summary

Final review of what the person has said, condenses the facts and presents a type of survey of how you percieve the health problem or need

Conclusion

Final statement of what you and the patient agree his or her health state to be. a summary or recap of what you have learned during the interview

What is top priority during drug consumption?

Finding out the time of the person's last drink or drug and how much

Focused or problem-centered database

For limited or short term problem. Collect "mini" database, smaller in scope, concerns mainly one problem, one cue complex, or one body system

What are the four main headings of mental status assessment?

A-appearance B-behavior C-cognition T-thought process

What is delirium?

Acute confusional change or loss of consciousness and perceptual disturbance

Each culture has its own healers who usually

Cost less than traditional or biomedical providers.

PQR(S)TU

Severity scale- How bad is it (on a scale of 1 to 10)? Is it getting better, worse, or staying the same?

Follow up database

Used in all settings to monitor progress on short-term or chronic health problems

Review of Systems

General overall health state, Skin, Hair, Head, Eyes, Ears, Nose and Sinuses, Mouth and throat, Neck, Breast, Axilla, Respiratory system, Cardiovascular, Peripheral vascular, Gastrointestinal, Urinary System, Male genitals, Female genitals, Sexual Health, Musculoskeletal system, Neurologic system, Hematologic system, Endocrine system

What is dementia?

Gradual progressive process, causing decreased cognitive function

Pedigree or genogram

Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations, also highlights health issues and diseases of family members

Developmental History for children

Growth, Milestones, Current development (children 1-preschool)

Assessment

*Collect data -review of the clinical record -health history -physical examination -functional assessment -risk assessment -review of the literature *Use evidence-based assessment techniques *Document relevant data

Culture is

*Learned from birth through the process of language acquisition and socialization *shared by all members of the same cultural group *adapted to specific conditions related to environmental and technical factors and to the availability of natural resources * dynamic and ever changing

Interview with Preschooler

2-6 yr old is egocentric. Sees the world mostly from his or her own point of view. can have animistic thinking about unfamiliar objects. May imagine unfamiliar inanimate objects can come alive and have human characteristics

Interview with School-age child

A child 7-12 years can tolerate and understand others viewpoints. Is more objective and realistic. He or she wants to know functional aspects--how things work and why things are done.

Values

A desirable or undesirable state of affairs and a universal feature of all cultures.

Spirituality is defined as

A personal effort to find meaning and purpose in life

Leading question

A question that implies that one answer would be better than another

Ad hoc

A relative or friend used as an interpreter

Cultural and Linguistic Competence

A set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations.

Ethnicity

A social group within the social system that claims to possess variable traits such as common geographical origin, migratory status, and religion.

When considering cultural competence, there are discrete areas that the nurse must develop knowledge of to understand the health care needs of others. These discrete areas include understanding of

A) the heritage of the health care system. B) the heritage of the nursing profession. C) the heritage of the patient. D) his or her own heritage. E) cultural and ethnic values.

What is a normal finding in the Mini-Cog?

Ability to recall all three words and draw a complete, round, closed clock circle with all face numbers present

Introduction

Address the patient using his or her surname. Introduce yourself and state your role in the agency. Give reason for the interview

Interview with adolescent

Adolescence begins with puberty which is a time of dramatic physiological change. Adolescents want to be adults but lack cognitive ability. Must consider attitude...needs to be one of respect. Adolescent needs to feel validated as a human being. Communication must be honest.

Silence

After open ended questions, communicates that the patient has time to think and organize what he or she wishes to say

ABC's

Airway, breathing, cardiac

Nursing process

Assessment, diagnosis, planning, implementation, evaluation

What would an alert pt look like?

Awake, oriented, fully aware of external and internal stimuli with appropriate response

What is perceptions?

Awareness of objects through any of the five senses

What is orientation?

Awareness of the objective world in relation to the self

What is consciousness?

Being aware of one's own existence, feelings, and thoughts and being aware of the environment

Components of Health History

Biographic data, reason for seeking care, present health or history of present illness, past history, family history, review of systems, functional assessment or activities of daily living

Equal-status seating

Both you and the patient should be comfortably seated at eye level, about 4-5 feet apart. Avoid standing which communicates haste and superiority

Reason for seeking care

Brief, spontaneous statement in the person's own words that describes the reason for the visit

Action cues

body movements automatic reflexes posture, facial expression, gestures, mannerisms