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1
Holistic Health
Assessment FALL
13 Exam 1 Study
Guide
This first Exam includes the 4 chapters involved in the basics of Assessment – Evidence-Based Assessment, The Interview, Health History and Assessment Techniques. Pay attention to charts and tables that help categorize and clarify information. I will point out whether certain elements are emphasized or whether there will not be a focus on them. Chapters 5 & 9 cover Mental Status & Vital Signs/General Survey/Measurement. Ch. 12 & 22 are the beginning of the “body system” chapters. For every body system chapter: know the specific Structure & function (pay attention to my slides and the info below for areas I emphasize), Subjective data, including abnormal findings. Objective data – Exam across the lifespan; age specific findings and exam techniques, normals and abnormals. ALWAYS pay attention to my slides. Unless I indicate that something below is excluded from the material, info on my slides could be covered on the exam. Know HOW to perform the physical assessment. Always know the abnormal findings in the right shaded column) – for each chapter. This outline will give specific details, as well as those abnormals at the end of each chapter – narrowed down a bit.
Ch. 1 – Evidence-Based Assessment:
A clinical body of evidence – validated the importance of using assessment techniques Assessment – first step of the Nursing Process, includes o Subjective and objective data o Database – gathering data Diagnostic reasoning o Forming hypotheses o Clustering data o Validation of data Critical Thinking and the Diagnostic Process (See Figure 1-2, p. 3) Nursing Process o Assessment (data collection) o Diagnosis (clustering and interpreting testing hypotheses, validating diagnoses & documenting diagnoses). o Outcome Identification (Goal): Identify expected outcomes, Individualize to the person, culturally appropriate, SMART Goal (Specific, Measurable, Attainable, Realistic & Timed) o Planning (Establish priorities, Develop outcomes, Set timelines, Identify interventions, integrate evidence-based trends and research, document) o Implementation (Put the plan in place); Collaborate with colleagues, provide teaching, document o Evaluation – (Progress toward outcomes, conduct systematic, ongoing criterion- based evaluation, include patient and significant others), The way we apply the nursing process depends on our level and time of experience o Novice nurse (uses rules to guide performance)
o Competent nurse (2-3 years in similar situations) o Proficient nurse ((Sees the patient as a whole v. list of tasks) o Expert nurse (Has intuitive grasp of a clinical situation) Critical thinking o The way of moving from novice to expert is through use of critical thinking o “Thinking about your thinking while thinking”
o Guide to Clinical Preventive Services: presents evidence-based, gold standard recommendations on screening, counseling, and preventive topics and includes screening factors to gather during the history, age-specific items, etc. Culture & Genetics o Assessment factors must include culture o Many terms: melting pot, mosaic, salad bowl o Newer term “emerging minority” o Health care professionals need to address cultural needs of patients
Ch. 3: The Interview
The interview: definition and purpose. A meeting between you and the patient. Purpose is to record the complete health history; collect subjective data. Communication Process – verbal and nonverbal; sending and receiving Internal and External factors o Liking others o Empathy o Ability to listen o Ensuring privacy o Physical environment
- • • • • • o Dress Comfortable temperature Sufficient lighting Remove distractions Twice arm’s length (about 4- feet) Equal seating status Face to face when possible o Note-taking (use caution so as not to take attention away from patient) o Electronic Health Recording
- Many^ facilities^ now^ using^ computerized^ record
- Don’t^ let^ it^ become^ a^ barrier^ to^ patient^ communication Phases of the Interview and description o Introduction o Working phase
- Open-ended^ questions^ –^ when^ used.^ Recognize^ examples^ of^ these.
- Closed^ or^ direct^ questions^ –^ when^ used.^ Recognize^ examples. o Table 3-1 Comparison of Closed and Open-Ended Questions o Closing the Interview- Give a final opportunity to express information. Responses to assist the narrative. Know these; how they are used, examples. o Facilitation o Silence o Reflection o Empathy o Clarification o Confrontation o Interpretation o Explanation o Summary 10 Traps of Interviewing: Know the description and an example, why they should not be used: o False reassurance, Unwanted advice, Using authority, Engaging in distancing, Using professional jargon, Leading or Biased questions, Talking too much, Interrupting, Why questions Nonverbal skills o Appearance, posture, gestures, facial expression, eye contact, voice, touch
Developmental care: Know specifics for each age group o Interviewing the parent
o Culture & genetics
o Culture & genetics o Review of Systems
- Ask^ questions^ about^ common^ symptoms^ in^ each^ of^ the^ body^ systems.
- Know^ purpose Evaluate past and present health of each body system Double check to avoid missing significant data Evaluate health promotion practices o Functional Assessment – Including ADLs
- Measures^ a^ person’s^ self-care^ ability^ in^ the^ areas^ of^ general^ physical health (^) or absence of illness; ADLS, IADLs, as well as nutrition, social relationships and resources, self-concept, personal habits, spiritual resources, coping, environment/hazards and home environment. Compare ADLs v. IADLs. Especially important in looking at how a person can function independently (injury) or an elderly person (how they manage independently). o Perception of health
- How^ do^ you^ define^ health
- What^ are^ your^ concerns
- What^ are^ your^ goals
- What^ do^ you^ expect^ from^ health^ providers o Developmental care
- Know^ the^ types^ of^ history^ to^ include^ specific^ to^ each^ age^ group in (^) additional to general areas of history. Children: includes developmental history and milestones, L&D history, nutritional history. Adolescent – HEEADSSS – Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression and Safety from injury and violence. The Older Adult: Includes additional questions on ways in which ADLs may have been affected by normal aging processes or by the effects of chronic illness or disability. General health is usually addressed for the past 5 years. Include positive health measures – what they do to stay healthy.
Ch. 5 Mental Status:
Structure & Function: Defining Mental Status: emotional (feeling) and cognitive (knowing) function Mental Disorder: apparent when the person’s response is much greater than expected in reaction to a traumatic life event. (Organic v. psychiatric) Terms (all of these on p. 72- consciousness, mood & affect, etc.) Developmental care – Infants & Children, Aging adult - distinctions Components of the Mental Status Exam: o Appearance, Behavior, Cognition, and Thought Processes (A,B,C,T) o When to do a complete exam vs. screening exam o Integrating the mental status exam into the health history is sufficient for most people o It is necessary to perform a full mental status exam when you discover abnormalities in affect or behavior or with family member concerns, brain lesions, aphasia or symptoms of psychiatric mental illness o Always include factors form the health history that could affect interpretation of findings
- Any^ known^ illnesses^ or^ health^ problems
- Current^ medications
- Educational^ and^ behavioral^ level
- Responses^ to^ personal^ history^ questions o If consciousness is clouded or language is impaired, the person cannot fully
o (^) Behavior o (^) Cognition: including orientation, attention span, recent & remote memory, and testing for New Learning (The 4 Unrelated Words tests). Tests for ability to lay down memories. It is a highly sensitive and valid memory test – includes recall and avoids the danger of unverifiable material. o (^) (Pay attention to the shaded area of Abnormal Findings on the right column) o (^) Additional Testing for Persons with Aphasia
- Word^ Comprehension
- Reading
- Writing o (^) Higher Intellectual Function – some tests have little evidence to support use (Omit tests of Higher Intellectual Function since not found to be valid). o (^) Judgment – Ask about a real situation to see if patient can compare and evaluate alternatives, problem-solve o (^) Thought Processes & Perceptions
- The^ WAY^ a^ person^ thinks^ –^ should^ be^ logical,^ goal^ directed,^ coherent,^ and relevant
- WHAT^ the^ person^ says^ -^ should^ be^ consistent^ and^ logical - Perceptions^ –^ Should^ be^ consistently^ aware^ of^ reality; perceptions (^) congruent with yours o (^) Screen for Anxiety Disorders - Be^ familiar^ with^ the^ GAD- o (^) Screen for Depression o (^) Screen for suicidal thoughts o (^) Supplemental Mental Status exam (Folstein Mini-Mental State Exam) to assess cognitive functions of the mental status exam. Will not test on this – copyrighted exam that we are not using. ( o (^) DO KNOW the Mini-Cog. o (^) Developmental competence exam-specific:
- Infants^ &^ Children:^ ABCT,^ developmental^ milestones,^ parent’s^ history. Also the Denver screening for problems with behavior, language, cognitive and psychosocial areas.
- School^ age^ children:^ Assess^ mood,^ play,^ school,^ friends,^ family^ relations.
- Adolescent:^ ABCT^ guidelines
- The^ Aging^ Adult: (^) Check sensory status; assess for confusion. (^) ABCT guidelines. (^) Behavior o (^) We will save the Glasgow Coma Scale until Neuro. Not on this test. (^) Cognition o (^) Orientation – Consider aging persons oriented if they know generally where they are and the present period o (^) New Learning – There may be an age-related decline in performance of the Four Unrelated Words Test (^) Supplemental Mental Status Exam o (^) The Mini-Cog o (^) Includes a 3-item recall test plus a clock drawing test o (^) Tests executive function, ability to plan, manage time, organize activities and manage working memory. (^) Important to conduct a brief exam of all older people admitted to the hospital. Up to 25% of older adults are hospitalized with delirium and up to 56% develop during hospitalization. ABNORMAL FINDINGS: END OF CHAPTER MATERIAL TO KNOW: Table 5-3: Levels of consciousness Table 5-4: Speech Disorders
o Dysphonia
o (^) NEVER LISTEN THROUGH A GOWN
Setting o (^) Comfort, privacy, warmth; position for ease of nurse’s height (^) Equipment: Some equipment not tested on until later in the semester (otoscope, ophthalmoscope, etc.) Additional equipment – be familiar with Doppler – more info in Ch. 9 and 20 A clean field; safe environment, hand hygiene, and PPE, Standard precautions General approach o Putting the patient at ease; they may be anxious about being in the hospital and the unknown
- The^ examiner^ who^ is^ confident,^ self-assured,^ considerate^ and appears (^) unhurried will help reduce anxiety
- Even^ if^ don’t^ feel^ confident,^ project^ that^ confidence.^ Practice makes (^) perfect o Varying the sequence per patient needs o Hands-on – Begin with non-threatening (height, weight, vital signs) o Proceed one step at a time, offer teaching, summarize findings o Organize the exam so the person does not change positions too often, logical sequence Developmental competence o Specifics for assessing
- Infants^ –^ position,^ preparation^ and^ timing,^ sequence^ (VERY^ IMPORTANT to know this)
- Toddler^ –^ Position^ –^ parent’s^ lap^ usually,^ preparation,^ sequence
- Preschool^ child^ –^ participates^ in^ exam^ somewhat,^ position, preparation, (^) sequence
- School^ age^ child^ –^ Position^ and^ preparation
- Adolescent^ –^ awareness^ of^ body^ image,^ examine^ alone^ without^ parents
- Aging^ adult^ =^ Position,^ preparation,^ assess^ sensory^ function
- The^ Ill^ Person^ –^ consider^ comfort,^ may^ need^ mini-database
Ch. 9 General Survey, Measurements and Vital Signs
Purpose of general survey General Survey is SEPARATE from measurements and vital signs (they are in the same chapter, but not the same thing). Components – Physical appearance, Body Structure, Mobility, Behavior, (expected findings and abnormalities) o (^) Abnormal findings in the right shaded column Know how to obtain height and weight (for all groups) Measurement: BMI and Waist-to-hip ratio will be covered in Ch. 11). Not covered on this exam. DO know how unexplained weight loss may be a sign of illness, chronic disease, malignancy, depression, anorexia VITAL SIGNS: o Temperature –
- Know^ which^ device^ is^ safest^ and^ most^ reliable^ in^ all^ age^ groups
- Know^ normal^ ranges^ for^ infants^ and^ adult,^ factors^ influencing,^ routes and (^) equipment, difference between hypothermia and hyperthermia.
- Factors^ that^ influence^ temperature Diurnal cycle trough in early morning hours; peak in late afternoon to early evening Menstrual cycle causes a rise in temperature Exercise increases body temperature Age – wider normal variations occur in the infant and young child due to less effective heat control mechanisms Older adults have lower temp than other age groups
Oral: when child is old enough to keep mouth closed, usually age 5-6 years; electronic is unbreakable and quicker (^) Tympanic: Useful with toddlers and preschoolers o (^) Data on use in infants is inconclusive o (^) Typically not as accurate in febrile patients (^) Axillary: Safer and more accessible than the rectal route, but accuracy and reliability have been questioned due to brown fat which artificially raises skin temperature (^) Rectal: Use when other routes are not feasible; Insert no farther than 1 inch because of risk of perforation of rectum;
- Wider^ normal^ variations^ occur^ in^ infants^ and^ young^ children^ due^ to less (^) effective heat control mechanisms o Aging adults:
- Temperature^ is^ usually^ lower^ than^ in^ other^ age^ groups
- Variations^ in^ weight^ and^ height;^ weight^ redistribution.
- VS^ -^ less^ likely^ to^ have^ fever.
- SBP^ increases^ as^ vessels^ are^ stiffer.
- Pulse^ may^ be^ slightly^ irregular Pulse oximeter is a noninvasive method to assess arterial O2 sat Doppler – is used to locate the peripheral pulse sites. This technique is used: o When sounds are hard to hear with a stethoscope o In critically ill individuals with low BP o In Infants with small arms o In obese persons where sound is muffled o Technique:
- Apply^ gel^ to^ probe
- Touch^ probe^ to^ skin
- A pulsatile^ whooshing^ sound^ indicates^ the^ artery
- Maintain^ skin^ contact Infants with small arms Obese persons; sound muffled Electronic Vital Signs Monitor – SHOULD NOT be used for patients with irregular heart rate Promoting Health and Self-Care Culture & Genetics KNOW FROM END OF CHAPTER: o (^) Table 9-5: Acromegaly, Anorexia and Endogenous obesity o (^) Table 9-6 Hypotension and Hypertension. Know Normal SBP and DBP.
Ch. 12 Skin, Hair & Nails
In class I may not have emphasized some points that I want to make here. We talked about very specific assessments of the skin and looked at lesions, moles, freckles, etc. That type of assessment would be seen more commonly in a clinic setting, if someone presented with a new or changed lesion. In the hospital we will focus on skin color, temperature, turgor (for hydration status), capillary refill, profile sign, and intactness of skin. You may talk some in Foundations about skin integrity and risk of developing a pressure ulcer. For a patient who is not ambulatory, you want to be sure to address areas of pressure: This would include the sacral area and the shoulders; it might include the elbows and wrists. In a person wearing a nasal cannula for oxygen or an oxygen mask, be sure and look at the area behind the ears for any breakdown. Be sure to always look under heels for areas of non- intact skin or skin shearing away. Review your scenario that goes with the Braden scale. If you haven’t talked about it in lab, you will probably do so soon. The Braden Scale is an evidence-based tool that looks at various factors that put patients at risk for developing a pressure ulcer (including sensory
various factors that put patients at risk for developing a pressure ulcer (including sensory perception, moisture, activity, mobility, nutrition, friction and shear). I am not going to test you on that specific tool or score, but you should be familiar with it as it is widely used. Structure & Function Dermis Epidermis Subcutaneous Layer Epidermal appendages – Hair, Sebaceous glands, sweat glands (eccrine and apocrine), nails Developmental care o Infants – Lanugo, vernix caseosa. Ineffective temperature regulation o Pregnant female – linea nigra, chloasma, striae gravidarum o Aging adult – Senile purpura, aging changes in skin elasticity, hair graying o Cross-cultural care – Skin conditions in Black individuals. Increased risk for melanoma in White individuals. Subjective data o Health history questions to ask – rationales and abnormal conditions (right column ) o Specific history for infants/children and aging adults Preparation for Exam: o Know the person’s normal skin coloring, baseline; ask about usual color o Complete exam: Integrated throughout the complete exam, not a separate step. Assess hands, fingernails to ease into exam; look at outer skin first then areas with skinfolds, abdomen, groin o Regional Exam: Focused skin exam – assess the skin and any issues, lesions, rash. Objective data: ( Abnormal data in right column ). o Preparation – Skin exam performed by itself and in each body system; need good lighting; Begin with assessing the client’s hands and fingernails, nonthreatening o Know how to perform the exam techniques – specific to adults, infants/children, aging adults o Inspection and palpation of skin
- Color:^ General^ pigmentation^ (actual^ color)
- Benign^ pigmentation^ changes,^ Widespread^ color^ change (^) Pallor (^) Erythema (^) Cyanosis (^) Jaundice (^) See Table 12-2 light-skin v. dark-skin assessment
- Mnemonic^ ABCDE^ for^ signs^ of^ melanoma
- Temperature,^ Moisture,^ Texture,^ Thickness,^ Edema,^ Mobility/Turgor (expected and normal findings)
- Oral^ mucous^ membranes^ –^ assess^ for^ signs^ of^ hydration^ v.^ dehydration
- Vascularity^ or^ Bruising
- Lesions^ –^ how^ to^ describe^ (p.^ 216) o Inspection and palpation of hair
- Color,^ texture,^ distribution^ (vellus^ v.^ terminal)
- Lesions
- Abnormal^ findings o Inspect and palpate the nails
- Shape^ and^ contour
- Profile^ sign^ (nail^ angle^ approx.^160 normal;^ clubbing^180 or^ more)
- Consistency,^ Color,^ Capillary^ refill^ (less^ than^2 seconds^ normal) o Developmental Competence and complete exam
- Infants Mongolian spot Café au lait
(^) Skin color changes – erythema toxicum, Acrocyanosis, jaundice (^) Texture, thickness, mobility & turgor, vascularity – Storkbite v. hemangiomas. Moisture – vernix caseosa. Texture (milia) Mobility and turgor – test on the abdomen).
- Adolescents (^) Acne
- Pregnant^ Female (^) Linea nigra, chloasma, vascular spiders
- Aging^ adult (^) Senile lentigines (^) Keratoses – seborrheic and actinic (^) Skin tags o Acanthosis Nigricans (from my slide). Assess as precursor to diabetes mellitus. (^) ABNORMAL FINDINGS: END OF CHAPTER MATERIAL TO KNOW: Table 12-2 Color changes in light and dark skin Table 12-3 Common shapes and configurations of lesions (Also See Lab Guide Table) Table 12-4 Primary skin lesions (Also see Lab Guide Table) o (^) Focus on Freckles, Nevi, Wart, Mongolian spot, Vitiligo, Café au lait spot, Chloasma, psoriasis, Nodule (intradermal nevi), wheal – often from allergic reaction), Tumor (Lipoma). Urticaria (Hives), Vesicle (chicken pox); Bulla (Blister), Cyst (sebaceous cyst), Pustule (impetigo, acne). Table 12-5 Secondary skin lesions (Also see Lab Guide Table) o (^) Crust (impetigo after ruptured), scab after abrasion. Scale (psoriasis, dry skin). o (^) Ulcer (pressure ulcer), excoriation (scratching an insect bite), Scar (healed area from surgery), Keloid (hypertrophic scar) Table 12-6 Pressure Ulcer (Decubitus Ulcers) o (^) Know basics of each stage 1- Table 12-7 Lesions caused by trauma or abuse: Pattern injury, hematoma, contusion. Table 12-8 Vascular lesions o (^) Port wine stain o (^) Strawberry mark (hemangioma) o (^) Purpuric lesions - Petechiae - Purpura Table 12-9 Skin lesions in children o (^) Impetigo o (^) Eczema (Atopic dermatitis) o (^) Candidiasis o (^) Chickenpox o (^) Measles Table 12-10 Common skin lesions o (^) Tinea corporis (ringworm) o (^) Allergic drug reaction o (^) Psoriasis - Know^ the^ differences^ between^ psoriasis^ and^ eczema o (^) Herpes zoster (shingles) o (^) Lyme Disease Table 12-11 Malignant lesions o (^) Basal Cell Carcinomia o (^) Squamous Cell Carcinoma o (^) Melanoma Table 12-12 Abnormal Conditions of Hair o (^) Seborrheic dermatitis o (^) Tinea capitis (ringworm) o (^) Alopecia areata o (^) Trichotillomania
Table 12-13 Abnormal Conditions of the Nails
