Health Assessment #1 (plus focused assessment)
What are the elements of a focused cardio assessment
-Color, cap refill, edema, hydration status (turgor) -radial and dorsalis pedal pulses -auscultate apical pulse (regularity) for a full minute -Assess heart sounds (S1, S2, extras?) -if abnormal sounds present or heart patient, listen to all valves with diaphragm and bell -note ECG rhythm if monitored -check cardiac blood work
What are the components of a focused neuro assessment?
-GCS (eye, motor & verbal responses) -PERRLA -ability to swallow -gait -grip strength -sensation in feet prior to OOB -mental status/behavioral assessment -more specialized test depending on problem (DTR, CN's, sensory)
What are the elements of a focused respiratory assessment?
-airway - clear/artificial/suction -Rate, rhythm & depth, work of breathing -tracheal deviation -drooling -audible sounds (wheezing, stridor, cough) -auscultate A&P breath sounds -adventitious sounds? ask patient to cough, then listen - grab an experienced nurse -ventilation (CPAP, BIPAP etc) -blood work / ABGs
What are the elements of a focused GI assessment?
-ask about flatus and stool -ask about meal completion / eating -inspect skin, abdominal contour and symmetry -presence of NGT, PEG or stoma -check tube/stoma site, placement and drainage -auscultate bowel sounds in all quadrants -lightly palpate to check soft/firm, masses and any tenderness/guarding -girth measurement as needed
What are the elements of a focused GU assessment?
-assess regularity and ease of voiding -examine urinary drainage devices for patency then check securement and insertion site - check urine for color, clarity and amount -check fluid balance, BP, daily weight -check BMP/CMP
What are the elements of a focused skin assessment?
-inspect color, integrity, lesions, rashes, bruising -presence of dressings -inspect bony prominences -palpate for temperature, moisture and turgor -complete any standardized scales used for risk of skin breakdown (braden etc)
What are the elements of a focused HEENT assessment?
-sclera -do they track you in conversation -visual acuity (glasses/aids etc) -hearing (can they hear conversation, do they wear hearing aids or need them?) -presence of tears -nasal membranes (v. important with O2 delivery) -check for oral care and dentures -check mouth and throat for airway clearance -check oral hydration (lips, tongue, buccal membranes
what are the elements of a focused MSK assessment?
-strength of outermost periphery: grip strength, push/pull of feet -ROM of affected joints as needed -assist with ADL's, sitting up, moving to chair -aids at bedside: canes, walkers, wheel chairs etc -activity: watch patient get out of bed, note assistance needed, patient activity tolerance -complete any standardized scales used to quantify the patient's fall risk
List and describe some therapeutic communication techniques
1) Active listening 2) guided questioning - moving from open ended to focused questions 3) nonverbal communication 4) empathic responses 5) validation 6) reassurance 7) summarizing 8) transitions 9) empowering patient
What are the types of nursing assessment and when is each appropriate?
1) Comprehensive / admission assessment ---Performed when patient is new to the unit/facility ---Subjective and objective. ---Establishes a baseline (complete history, general survey, VS, head-to-toe, all systems and regulatory assessment tools addressed) 2) Focused assessment ---Performed at the beginning of the shift or as a follow-up / re-evaluation ---Used when a comprehensive assessment has been completed previously in the unit/facility a) Shift assessments are subjective and objective ---Patient is known to unit/nurse ---Clinical judgment is used to decide the extent of the physical exam. All systems should be addressed but not all elements will need IPPA. All regulatory assessment tools should be updated/addressed, focus on assessment of affected and at-risk systems, update history as needed. b) Follow-up or re-evaluation is done if shift assessment has already been completed. Is subjective and objective. ---Focuses on symptom and asks pertinent questions, focuses on affected systems, evaluation of interventions 3) Emergency assessment ---ABCs, blood type, neurological status ---Pertinent info only (name, allergies, current medications)
What are the three levels of preventative care?
1) Primary prevention (ie: vaccinations, education, promoting healthy lifestyle/environment etc) - focuses on improving overall wellness and protection from disease or disability. 2) Secondary prevention (ie: screening etc) - focuses on early detection and treatment of disease when curable or has few complications or disabilities. 3) Tertiary prevention (rehabilitation, provision of hospital land community facilities, promotion of employing rehabilitated individuals in the workplace, sheltered communities, prevention of skin breakdown in immobile patients etc) - Focuses on decreasing effects of disease or disability by preventing complications or loss when defect is permanent.
What are the two steps of health assessment?
1) collect data 2) analyze data
describe the introduction phase of a patient interview
1) greet patient and establish rapport (used preferred patient name, introduce self and role) **always ask permission to interview in front of visitors 2) address visitors - in turn- introduce yourself and obtain their relation to the patient **prevent patient confidentiality 3) establish your agenda begin with open ended questions regarding chief complaint. Use open ended follow up questions to elicit more info
Describe the working phase of the patient interview
1) invite the patient's story with openers like "tell me more about...". Do not interrupt, add to or otherwise bias your patient's story. 2) once patient is finished, use FOCUSED QUESTIONING to explore more in depth "what happened next?" "how would you describe the pain?" etc. 3) identify and respond to emotional cues NURS -Naming (that sounds scary) -Understanding (I can understand why you feel that way) -ReSpecting (you've done better than most people with this) 4) expand and clarify the patient's story OLDCART Generating & testing hypothesis 5) arrive at a shared understanding of the problem by exploring the patient's perspective and synthesizing the patient's experience with your own explanation (FIFE) 6) negotiate a plan
What are the phases of a patient interview?
1) pre-interview 2) introduction 3) working 4) termination
Describe the pre-interview phase of a patient interview
1) self-reflection review pt record, set goals for both provider and patient, review your own clinical behavior, appearance and biases 2) make the environment comfortable always ask permission and ensure privacy 3) take notes 4) be prepared to be attuned to the patient's feelings, help the patient express them and respond to their content and validate significance
Describe the termination phase of the patient interview
1) summarize important points 2) discuss plans 3) review plans and follow up patient should have a chance to ask any final questions "is there anything else you wanted to talk about today?"
The right sized BP cuff can be assessed by assuring that the width of the bladder should fit _____% of arm and the length of the bladder should cover ____% of the circumference of the upper arm
40% / 80%
What is used to indicate level of consciousness
A = awake, alert, responsive -Alert - awake or easily arousable O = orientation to person, place and time A&O x 3 (some facilities use a 4th orientation measurement) If a person's orientation declines during the time you are taking care of them, that's a run event, as it is a solid indicator that some kind of neurological deterioration is taking place.
Define a focused assessment
A detailed assessment of specific body systems relating to the current and potential problems.
WHO definition of health
A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (WHO, 1947)
Nonverbal communication is a very important aspect in the nurse-client relationship. What can the nurse do to help gain the client's trust? SELECT ALL THAT APPLY a) use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally b) make sure that dress and appearance are professional c) do not use facial expressions such as rolling eyes or looking bored or disgusted d) do not look the client in the eye e) laugh a lot, which puts the client at ease
A, B, C
You are attending a seminar on transcultural nursing at a nursing conference. What aspects of culture relevant to health assessment would you expect to be discussed? (SELECT ALL THAT APPLY) a) health care practitioners b) educational goals c) wound care d) high-risk behaviors e) nutrition
A, D & E aspects of culture relevant to health assessment include communication and language; kinship and social networks; educational background and learning style; nutrition; child-bearing and rearing practices; high risk behaviors; health care beliefs and practices; health care practitioners
What is orthostatic hypotension?
Abrupt peripheral vasodilation due to a change in position without cardiac
What factors can influence BP readings?
Age, race, weight, emotions, gender, diurnal rhythm, exercise, stress, white coat HTN and poor technique.
To adhere to standard precautions, the nurse should remember to (SELECT ALL THAT APPLY) a) put on cover gown when entering a patient's room b) change white coat frequently c) wear gloves with each patient contact d) wash hands before each patient contact
B&D
You have finished the physical examination. What do you do immediately after finishing (SELECT ALL THAT APPLY) a) share findings with physician b) give your general impressions c) identify needed lab tests d) perform interventions e) tell patient what to expect next
B&D
The nurse is having difficulty auscultating Korotkoff sounds. The nurse should: (select all that apply) a) keep cuff inflated for 30 seconds before auscultating b) be certain there is full skin contact with the bell c) consider shock d) reposition stethoscope e) request ECG
B, C & D
Define and describe the beginning of shift assessment
Beginning of shift assessment: -Provides a baseline -IT IS THE STANDARD OF CARE -Systematic method is necessary -In depth assessment with affected system and systems at-risk
Spirituality is a human experience that (SELECT ALL THAT APPLY) a) does not involve religious traditions b) involves nursing presence c) includes a supreme being d) seeks to transcend self
C & D
What are some signs of cardiac or pulmonary distress?
Clutching chest, pallor, diaphoresis, labored breathing, shortness of breath, tripod position
What is a shift assessment?
Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
What factors can result in a false low BP?
Cuff too large Repeating BP too quickly Inaccurate level of inflation or released to quickly Pressing stethoscope too tightly
What factors can result in a false high BP?
Cuff too small Cuff too loose are uneven Arm below heart level Inflating or deflating too slowly (high DBP) Deflating cuff to quickly (high DBP, low SBP)
What factors can influence pulse and HR readings?
Drugs, disease, exercise, age, gender, temperature, BP, electrolyte balance, caffeine, stress
The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds (T/F)
FALSE
Define FIFE
FIFE is a mneumonic for the patient's perspective on illness F-feelings I-ideas effect on F-function E-expectations
What is the difference between fatigue, lethargy and malaise?
Fatigue - non-specific symptom with many causes that refers to a sense of weariness or loss of energy. Can be a normal response to hard work. Malaise - a generalized feeling of illness "I don't feel well enough to get off the couch" Lethargy - physically cannot get off the couch or keep eyes open
List the order of deteriorating orientation
First to go: time second to go: place third to go: familiar persons/situation Last to go: SELF
What are some factors that you should be assessing during the general survey?
General appearance, apparent state of health, demeanor, facial affect or expression, grooming, posture & gait
What are some of the main components of the physical exam
Goal is also to collect data Structured head-to-toe examination Identify changes in patient's body systems, unusual or abnormal findings may support history data or trigger new questions, document all findings in a clear, concise manner (this is a legal and professional responsibility), pull together all the information with medical records...does your exam agree with the history/record?
What are some of the main components of a health history?
Goal is to collect data. Assess validity, ask pertinent questions to gather data, gain past medical history, past physical issues, past psychological issues, social history, cultural history and spiritual beliefs
What are the cardinal techniques of examination?
IPPA Inspection, Palpation, Percussion, Auscultation
What is OLDCART?
It is an acronym to help direct your gathering of subjective data from the patient / describe the seven attributes of a symptom. i. O - onset ii. L - location iii. D - duration iv. C - characteristic symptoms v. A - associated manifestations vi. R - relieving factors vii. T - treatment
What is pulse pressure?
It is the difference between systolic and diastolic readings. 30-40 mmHg is normal for pulse pressure. (PP = SBP - DBP) High pulse pressure (high SBP with low DBP) indicates poor elastic rebound. SBP increases due to increased peripheral resistance and DBP decreases due to lost arterial wall elasticity
Differentiate between lethargic obtunded, stupor and coma.
Lethargic - not fully alert, drifts off when not stimulated Obtunded - sleeps most times, difficult to arouse (loud noise, vigorous shaking or pain), speech affected (mumbling) - when you stop stimulating they continue to mumble / groan Stupor - need persistent loud noise or pain for arousal, may respond to stimuli with groan but stop once stimuli stops- only respond to painful or loud stimuli Coma - unresponsive
You are doing an orthostatic assessment on a patient. After they have been standing for three minutes, you note that their systolic BP has dropped by 23 mmHg. Is this a normal value?
No, a decrease of 20mm Hg or more for systolic and/or a decrease of 10mm Hg or more in diastolic value is an abnormal finding indicating orthostatic hypotension.
What is considered a normal fluctuation in blood pressure and what is an abnormal change?
Normal ---SBP: unchanged or less than 10mmHg ---DBP: unchanged or slight rise Abnormal ---SBP: decrease of 20mmHg+ ---DBP: decrease of 10 mmHg+
What are the various routes for taking temperature? Which one most accurately reflects core temperature?
Oral, temporal, axillary, rectal and tympanic Rectal most accurately reflects core temperature Axillary is least reliable
What is often referred to as the fifth vital sign?
Pain
What measurements indicate pre-hypertension
Pre-hypertension: SBP (120-139) or DBP (80-89)
Differentiate between reliability and validity.
Reliability is how well repeated measurements of the same stable phenomenon produce the same result. Validity describes how closely a given observation agrees with the true state of affairs.
Differentiate between sensitivity and specificity.
Sensitivity = true positives / (true positives + false negatives) - Sensitivity is the probability that test will indicate disease in individuals with the disease - When sensitivity is high, a negative response rules out target disorder (SnNout) Specificity = true negatives / (true negatives + false positives) - Specificity is the fraction of those with out disease who will have a negative result. - When specificity is high, a positive result rules in target disorder (SpPin)
What are the systems examined during the physical exam?
Skin, HEENT (head, eyes, ears, nose, throat), neck, cardiac, respiratory, abdomen, peripheral vascular, lymphatics, MSK, neuro, GU/breast
What measurements indicate stage 1 HTN?
Stage 1 hypertension: SBP (140-159) or DBP (90-99)
What measurements indicate stage 2 HTN?
Stage II hypertension: SBP (greater than or equal to 160) or DBP (greater than or equal to 100)
What is the difference between subjective and objective data?
Subjective data is what the patient feels, reports and believes (pain is always subjective). Objective data is nurse - observed data, lab results, physical examination or other direct measurements and observations.
Distinguish between systolic and diastolic pressure.
Systolic = maximum pressure on arteries during left ventricular contraction (systole) Diastolic = resting pressure that blood exerts constantly between each contraction
What are the normal values for vital signs Temp: RR: HR: BP: Pulse Ox:
Temperature: 98.6F or 37C Respiration: 12-20 Heart Rate: 60-100 BP: <120/80 Pulse Ox: 98%-100% (above 96% is permissible)
What is the diurnal cycle and how does it affect vital signs?
The diurnal cycle is the patterns of activity or behavior that follow day-night cycles. Blood pressures and heart rate are lowest around 3 am and highest around 3 pm.
From which side do you examine the patient?
The right
Why are vital signs taken as part of the admission assessment?
To establish a baseline
When assisting a patient with health promotion, what must the nurse also nurture? a) a healthy environment b) school/work attendance c) knowledge of Healthy People 2020 indicators d) family communication
a) a healthy environment
Mrs. Williams is an 89-year old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? a) do you have family who visit regularly? b) what amount of cleaning have you been doing in the past? c) have you tried to schedule a cleaning service? d) are you friendly with your neighbors?
a) do you have family who visit regularly?
The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. the nurse is utilizing: a) tertiary prevention b) secondary prevention c) primary prevention
a) tertiary prevention tertiary prevention decrease the effects of a disease and prevents additional loss. Ear plugs will help decrease further hearing loss
If I am describing a pulse, what does 3+, 2+, 1+ and 0 mean?
a. 3+ = bounding b. 2+ = brisk (normal) c. 1+ = thready d. 0 = not palpable (get a doppler)
What are the components of the health assessment?
a. History taking / interview b. Physical exam c. Can also be thought of as collection of data & analysis of data
Define the nursing process
a. Hone's nurse's ability to extrapolate findings, prioritize them and formulate and implement plan of care. b. It is an approach to the identification, diagnosis and treatment of responses to illness c. ADPIE - Assess, Diagnose, Plan, Implement, Evaluate
What are the contraindications for taking a BP on an extremity?
a. Mastectomy b. Peripheral IV c. Central line d. disease or injury to the extremity e. Fistula
How are nursing diagnoses different from medical assessments?
a. Nursing diagnoses focus on diagnoses and treatment of the actual or potential human responses. They identify many contributing factors to an individual's health and wellness. They assess the full picture - why is this happening (holistic approach)? b. Medical diagnoses focus on treatments of the disease. They focus on disease and cure.
What are the 7 facets of health and why are they significant?
a. Physical health, emotional health, social well being, cultural influences, spiritual influences, environmental influences and developmental level b. These seven facets demonstrate that health is a relative state
What is the significance of healthy people 2020?
a. Provides a framework that identifies risk factors, health issues and diseases of concern in the US (what needs to be fixed) b. Aims to improve health of individuals and communities by setting goals for 10 year increments. (how do we fix it) c. Aims to improve quality of life through guidelines, education and awareness while eliminating health disparities. (how do we fix it)
List some nursing responsibilities
a. promote health and prevent disease b. decide which levels of prevention are necessary c. deliver care across the life span d. educate and counsel individuals, families, groups and communities e. focus on health and goals of the patient f. oversee the holistic care of each patient g. collect data and rely on assessment skills h. make judgments that will impact patient safety and quality of care i. indentify what is priorities on a daily basis for each patient j. carefully watch and listen to the patient to determine what additional questions to ask k. utilize information detected in assessment to work with the patient to enhance quality of life l. learn to detect a change in patient to enable providing best care m. take advantage of teaching opportunities that present with the patient and family n. continually reassessing the patient for changes in order to achieve best results o. utilize the 7 facets of health to assess the patient - which includes culture
What is the primary function of the health care team? a) to develop an individual focus for each member b) to decide best overall care c) to work together to obtain maximum coverage d) to guide the patient's care throughout times of crisis
b) to decide best overall care
During the interview process, the nurse uses both open-ended and close-ended questions. During what phase of the interview process does the nurse use these specific types of questions? a) beginning b) working c) closing d) pre-interaction
b) working
The nurse has just asked a client how he feels about his emphysema. He becomes silent, folds his arms across his chest, and leans back in his chair. Then he replies "It is what it is". How should the nurse respond? a) "Next, I would like to talk about your smoking habit" b) "you have adopted a practical attitude toward your problem" c) "you seem bothered by this question" d) "Okay, lets move on to your other problems"
c) "you seem bothered by this question"
While discussing family history with a patient who is healthy except for a current UTI requiring IV antibiotics, the patient tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner? a) 3 circles and 3 squares with two diagonal slashed lines through lines connecting the 2 deceased siblings b) 3 circles and 3 squares with broken lines connecting 2 of the circles c) 3 circles and 3 squares with lines through 2 circles d) 3 circles and 3 squares with lines though 2 squares.
c) 3 circles and 3 squares with lines through 2 circles
When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the patient about alcohol use. The question most appropriate to ask next would be: a) do you take illegal drugs b) tell me why you drink so much c) do you ever drink then drive? d) is there a family history of alcohol abuse
c) do you ever drink then drive?
While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process? a) social b) mental c) emotional d) spiritual
c) emotional a subdued affect would be part of the emotional assessment
A patient is trying to explain how he feels about is eye problem. He pauses often during the conversation and often repeats himself when expressing his concern about his problem. After listening, the best response by the nurse would be: a) wow, I don't know how you do it! b) it sounds like you've been dealt a bad hand in life c) i can understand why you feel the way you do d) tell me more about how you feel
c) i can understand why you feel the way you do
The nurse documents periods of deep breathing followed by periods of apnea. The appropriate term for this type of breathing is: a) hypopnea b) ataxic c) obstructive d) Cheyne-Stokes
d) Cheyne-Stokes
The "evil eye" is an example of what? a) an ethnic belief b) a psychosocial condition c) a spiritually defined illness d) a cultural-bound syndrome
d) a cultural-bound syndrome cultural-bound syndromes are "illnesses" defined by a particular culture but that have no corresponding illness in western medicine.
How does a nurse best facilitate the nursing health assessment? a) formulating a nursing diagnosis b) maintaining privacy c) creating a nursing care plan d) asking appropriate questions
d) asking appropriate questions
The principle of confidentiality is of paramount importance in the nurse-patient relationship. When should you inform the patient of with whom his or her information will be shared? a) when the patient asks b) at the end of the interview c) whenever it seems appropriate d) at the beginning of the interview
d) at the beginning of the interview
A client comes to the emergency department wanting to be examined for the symptom of chest pain. While listening to the client describe his symptom in more detail, the nurse says "Go on," then later "Mm-hmm". This is an example of which of the following skilled interviewing techniques? a) nonverbal communication b) empathetic response c) echoing d) continuers
d) continuers
When planning a community program related to Healthy People 2020, the critical first step involves: a) formulating questions to ask the community leaders b) assessing the community c) planning an introductory program for the community d) defining the community
d) defining the community to determine what is needed in the a program, the community must be first defined to narrow the focus and plan specific interventions
A patient asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6F. The nurse would expect the new temperature reading to be: a) within an afebrile range b) within a subnormal range c) higher than previous d) lower than previous
d) lower than previous
A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process? a) sitting back with arms crossed b) wearing casual, neat and comfortable clothes c) ensuring there are no periods of silence d) portraying neutral and friendly expression
d) portraying neutral and friendly expression
The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of: a) the growing elderly population with chronic illness b) an increase in the number of baccalaureate programs in nursing c) an increase in the number of nurse practitioners d) rapid advances in biomedical knowledge and technology
d) rapid advances in biomedical knowledge and technology
What is the disease/illness distinction?
disease is the explanation the NURSE gives illness is how the patient experiences it an interview should synthesize both of these views
A nurse should interpret findings or lab values. T/F
false