NR 302 Health Assessment Final Exam Study Guide / NR302 Final Exam Study Guide: Health Ass, Study notes of Nursing

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NR 302 – FINAL EXAM STUDY GUIDE

❖ Nurses’ role in health assessment o ADPIE o A ssessment – collection of data from multiple sources ▪ Review of clinical record; interview; health history; physical examination; functional assessment; cultural/spiritual assessment; consultation; review of literature o D iagnosis – interpretation of data by identifying clusters of cues so as to make inferences ▪ Compare clusters of cues with definitions and defining characteristics ▪ Validation on inferences based on findings ▪ Identify related factors ▪ Document the diagnosis o P lanning – establish priorities based on meeting identified patient care goals ▪ Develop outcomes and set time frames for meeting proposed outcomes ▪ Identify relevant interventions and utilize interdisciplinary health care team members in the care planning process for the patient ▪ Document plan of care o I mplementation – determine patient readiness and involve patient in health care process ▪ Review planned interventions with interdisciplinary health care team members to facilitate collaborative effort ▪ Utilize principles of delegation, being mindful of supervision and evaluation ▪ Counsel person and significant others ▪ Refer to continuing care ▪ Document care provided o E valuation – refer to established outcomes ▪ Evaluate individual’s condition and compare actual outcomes with expected outcomes ▪ Summarize results of evaluation ▪ Identify reasons for failure to achieve expected outcomes ▪ Take corrective action to modify plan of care ▪ Document evaluation in plan of care o Outcome Identification – identify expected outcomes related to patient individualization ▪ Ensure outcomes are realistic and measurable ▪ Specify short-term and long-term goal measurement criteria ❖ Interview and Health History o Interview – subjective data collection; patient perception of health; first step in therapeutic relationship o Techniques of communication ▪ Introducing the interview ▪ Working phase

• Data-gathering phase
• Verbal skills include questions to patient and your responses to what’s said

▪ TWO types of questions

• Open-ended
• Closed
• Each has a different place and function in interview o Open-ended questions ▪ Ask for narrative responses ▪ State topic only in general terms ▪ Use in following situations:
• Begin interview
• Introduce a new section of questions
• Whenever the patient introduces a new topic o Closed/Direct Questions ▪ Ask for specific information ▪ Elicit short one- or two-word answers, a yes or no answer, or a forced choice ▪ Use in following situations:
• After opening narrative to fill in details person may have left out
• When you need many specific facts about past health problems or during review of systems
• To move the interview along o Age appropriate style of questions ▪ Interviewing the caregiver ▪ Communicating with different ages across the life cycle
• Infants
• Toddlers and preschoolers
• School-age children
• Adolescents
• Adults and older adults ▪ Interviewing people with special needs
• Hearing impaired
• Acutely ill
• Under influence of street drugs/alcohol
• Those who must be asked personal questions
• Sexually aggressive
• Crying
• Angry/threatening violence
• Anxious ▪ Culture and Genetics
• Gender – being aware of maintaining cultural norms during interview and exam process; maintaining privacy/modesty
• Sexual orientation – maintaining neutrality related to patient’s presentation by being mindful of communication patterns; being aware of your own personal bias and baggage o History Taking ▪ Health history sequence

• Biographical data
• Source of history
• Reason for seeking care
• Present health or history of present illness
• Past health
• Family history
• Review of systems
• Functional assessment including ADLs ▪ Biographical Data
• Name; address/phone number; age/DOB; birthplace; sex; marital status; race; ethnic origin; occupation: usual and present ▪ Source of History
• Who furnished info
• Judge reliability of informant and how willing he/she is to communicate
• Note any special circumstances, such as use of interpreter ▪ Reason for Seeking Care
• Brief spontaneous statement in person’s own words describing reason for visit
• Symptom (subjective) – subjective sensation person feels from disorder
• Sign (objective) – objective abnormality that can be detected on physical examination/lab reports ▪ Subjective data – what patient says about him/herself during history taking ( symptoms) o Identify the common problems in all body systems ▪ General – significant gain/loss of weight, fatigue, weakness/malaise, fever, chills, sweats, night sweats ▪ Skin – history of skin disease, birthmarks, skin disease, pigment/color change, mottling, change in mole, pruritus, rash, lesion, acne, easy bruising/petechiae, easy bleeding, changes in hair/nails, excessive dryness/moisture ▪ Hair/Nails : recent hair loss or change in texture; nails – change in shape, color, or brittleness ▪ Head – headache, head injury, dizziness, vertigo ▪ Eyes – strabismus, diplopia, pain, redness, discharge, cataracts, vision changes, reading problems, difficulty with vision, glaucoma
• Is the child able to see the board at school?
• Does the child sit too close to the tv? ▪ Ears – earaches, infections, discharge/characteristics, tinnitus/vertigo ▪ Nose and sinuses – discharge and characteristics, frequency of colds, nasal stuffiness, nosebleeds, allergies, changes in sense of smell, nasal obstruction ▪ Mouth and throat – mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth/tongue, dysphagia, hoarseness/voice change, tonsillectomy, altered taste ▪ Neck – pain, limitation of motion, lumps/swelling, enlarged/tender nodes, goiter

▪ Breast – pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts ▪ Axilla – tenderness, lump/swelling, rash ▪ Respiratory system – history of lung diseases, chest pain with breathing, wheezing/noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color/amount), hemoptysis, toxin/pollution exposure ▪ Cardiovascular – chest pain, pressure, tightness/fullness, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary heart disease, anemia ▪ Peripheral vascular – coldness, numbness/tingling, swelling of legs, discoloration in hands/feet, varicose veins/complications, intermittent claudication, thrombophlebitis, ulcers ▪ Gastrointestinal – appetite, food intolerance, dysphagia, heartburn, indigestion, pain, other abdominal pain, pyrosis, nausea/vomit, vomiting blood, history of abdominal disease, flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation/diarrhea, black stool, rectal bleeding, rectal conditions ▪ Urinary system – frequency, urgency, nocturia, dysuria, polyuria/oliguria, hesitancy/straining, narrowed stream, urine color, incontinence, history of urinary disease, pain in flank, groin, suprapubic region/lower back ▪ Male genital system – penis/testicular pain, sores/lesions, penile discharge, lumps, hernias ▪ Female genital system – menstrual history, vaginal itching, discharge/characteristics, age at menopause, menopausal signs/symptoms, postmenopausal bleeding ▪ Sexual health

• Are you presently in a relationship involving intercourse?
• Are the aspects of sex satisfactory to you and your partner?
• Are condoms used routinely?
• Is there any dyspareunia (female) or any changes in erection/ejaculation (male)?
• Are contraceptives used?
• Is the contraceptive method satisfactory?
• Are you aware of contact with a partner who has any STIs? ▪ Musculoskeletal system – history of arthritis/gout, ( joints ) pain stiffness, swelling, deformity, limitation of motion, noise with joint motion, (muscles) pain, cramps, weakness, gait problems, problems with coordinated activities, ( back ) pain, stiffness, limitation of motion, history of back pain or disk disease ▪ Neurologic system – history of seizure disorder, stroke, fainting, blackouts, ( motor function ) weakness, tic/tremor, paralysis, coordination problems, ( sensory function ) numbness, tingling (parathesia); ( cognitive function ) memory

disorder, ( mental status ) nervousness, mood change, depression, history of mental health dysfunction, hallucinations ▪ Hematologic system – bleeding tendency in skin/mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents/radiation, blood transfusion/reactions ▪ Endocrine system – history of diabetes/diabetic symptoms, history of thyroid disease, intolerance to heat/cold, change in skin pigmentation/texture, excessive sweating, relationship between appetite/weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy o Medications ▪ Some older persons take large number of drugs prescribed by different physicians ▪ Person may not know drug name or purposes

• Ask person to bring drug in to be identified ▪ When person is unable to afford drug, he/she may decrease dosage or not refill immediately ▪ Travel to pharmacy may present a problem (social determinant of health) ▪ May use OTC medications for self-treatment ▪ Some share medications with neighbors/friends o Objective Information – observed when inspecting, percussing, palpating, and auscultating patient during physical examination ❖ Skills of Assessment o General Survey, Vital Signs (VS), Pain o General Survey – study of the whole person ▪ Intro to physical exam – should give an overall impression, a “ gestalt ” of person ▪ Objective parameters are used to form general survey, but apply to whole person, not just to one body system ▪ CONSIDER THESE : physical appearance, body structure, mobility, behavior o Pain – highly complex/subjective experience, originating from CNS, PNS, or both ▪ Nociceptors – specialized nerve endings designated to detect painful sensations ▪ Nociception – describes how noxious stimuli are perceived as pain; divided into 4 phases
• Transduction (phase I) – noxious stimulus takes place in periphery; inflammatory response; propagate pain message
• Transmission (phase II) – pain impulse moves from level of spinal cord to brain
• Perception (phase III) – conscious awareness of painful sensation
• Modulation (phase IV) – pain message inhibited; descending pathways from brainstem-spinal cord produce 3rd^ set of neurotransmitters that slow down/impede pain impulse, producing analgesic effect o VS ▪ Temperature – cellular metabolism requires a stable core (“ deep body ”) temp of an average 37.2C (99F) ▪ Body maintains temp by feedback mechanism in hypothalamus of brain

▪ Balances heat production with heat loss ▪ Normal temp is influenced by

• Diurnal cycle
• Menstrual cycle
• Exercise
• Age ▪ Oral temp – accurate/convenient
• Normal oral temp – 37C (98.6F), with a range of 35.8C (96.4F) to 37.3C (99.1F) ▪ Rectal Temp – use only when other routes are not practical
• Wear gloves and insert lubricated rectal probe cover on an electronic thermometer only 2 - 3 cm (1 inch) into adult rectum, directed toward umbilicus
• Measures 0.4-0.5C (0.7F-1F) higher ▪ Axillary Temp – safe/accurate for infants/young children when environment is reasonably controlled ▪ TEMPERATURE CONVERSION
• DEGREES C = 5/9 (F – 32)
• DEGREES F = (9/5 X C) + 32 ▪ Blood Pressure – force of blood pushing against side of vessel wall
• Strength of push changes with event in cardiac cycle
• Systolic pressure – maximum pressure felt on artery during LEFT VENTRICULAR contraction ( systole )
• Diastolic pressure – elastic recoil ( resting ) pressure that blood exerts constantly between each contraction
• Pulse pressure – difference between systolic/diastolic; reflect stroke volume
• Mean arterial pressure (MAP) – pressure forcing blood into tissues, averaged over cardiac cycle ▪ BP Procedure – measured with stethoscope and aneroid sphygmomanometer
• Cuff is inflatable bladder inside a cloth cover
• Width of rubber bladder should equal 40% of circumference of person’s arm; length of bladder should equal 80% of this circumference.
• Bare arm, supporting at heart level (person may sit/lay down)
• Center deflated cuff about 1 in (2.5 cm) above brachial artery
• Inflate cuff until artery pulsation obliterated and then 20 - 30 mmHg beyond
• Deflate cuff quickly/completely; wait 15 - 30 seconds before reinflating so blood trapped in veins can dissipate
• Place bell of stethoscope over site of brachial artery ▪ BP Factors
• Average BP in adults is 120/80 mmHg, varies w/ many factors o Age – gradual rise

o Gender – post-puberty, females show a lower BP than males ; post-menopause, females are higher o Race – African-American adult’s BP usually higher than white person’s of same age ▪ Incidence is twice as high in Blacks than Whites

• Level of BP determined by 5 factors o Cardiac output – if heart pumps more blood into blood vessels, pressure on container wall increases o Peripheral vascular resistance – opposition to blood flow through arteries; when vessels become smaller/constricted pressure needed to push becomes greater o Volume of circulating blood – refers to how tightly blood’s packed into arteries; increasing contents in vessels increases pressure o Viscosity – “thickness” of blood determined by its formed elements, blood cells; when contents thicker, pressure increases o Elasticity of vessel walls – when vessels stiff and rigid, pressure needed to push increases ▪ Pulses
• Stroke volume – amount of blood every heart beat pumps into aorta