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NUR2092 Health Assessment Final Exam Study Guide
- Assessment – Point of Entry In an Going Process (Chapter 1)
- Subjective Data: Information that a patient says about self.
- Objective data: What the health professional observes by inspecting, percussing, palpating and auscultating during physical examination.
- (You need to know the definition of both to answer test questions) - Nursing process (Chapter 1) o Assessment: collection of data about person’s health state. ▪ Collect Data: Review of the clinical record, health history, physical examination, functional assessment, risk assessment, review of literature ▪ Use evidence-based assessment techniques ▪ Document relevant data. Comprehensive assessment : is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health status. Focused assessment : is problem oriented and may be the initial assessment or an ongoing assessment. Problem focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In focus assessments, nurse determine whether the problems still exist and whether the status of the problem has changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new, overlooked or misdiagnosed problems. In intensive care units, may perform focus assessment every few minutes. o Diagnosis: ▪ Compare clinical findings with normal and abnormal and developmental needs ▪ Interpret data: ✓ Identify clusters of clues ✓ Make hypothesis ✓ Test hypothesis ✓ Derive diagnosis ▪ Validate Diagnosis ▪ Document Diagnosis o Outcome Identification: ▪ Identify expected outcomes ▪ Individualize to the person ▪ Culturally appropriate ▪ Realistic and measurable ▪ Include a timeline ▪ Ensure outcomes have the SMART components SMART: Specific, measurable, attainable, Relevant, Time-bound o Planning: ▪ Establish Priorities ▪ Develop outcomes ▪ Set timelines for outcomes ▪ Identify interventions ▪ Integrate evidence-based trends and research ▪ Document Plan of Care o Implementation: ▪ Implement in a safe and timely manner ▪ Use evidence-based interventions ▪ Collaborate with colleagues ▪ Use community resources ▪ Coordinate care delivery ▪ Provide health teaching and health promotion ▪ Document implementation and any modification
o Evaluation ▪ Progress toward outcomes ▪ Conduct systematic, ongoing, criterion-based evaluation ▪ Include patient and significant others ▪ Use ongoing assessment to revise diagnoses, outcomes, plan ▪ Disseminate results to patient and family ▪ If outcome reached, does something else need to be done or does client no longer have this diagnosis ▪ If failure, identify reasons for not achieving expected outcomes ▪ Take corrective action to modify plan of care ▪ Document (You need to know the process to answer test questions) a. Review (Fig.1-2) Critical Thinking and the Diagnostic Process
- Chapter 2 a. Know the difference between the (Biomedical, Naturalistic, Magicoreligious) ▪ Biomedical or Scientific: Assumes all events in life have a cause and effect, that the human body functions more or less mechanically, that all life can be reduced or
divided into smaller
parts. ❖ Germ Theory: microorganisms such as bacteria and viruses cause specific disease conditions. Most educational programs embrace this. ▪ Naturalistic or Holistic : believe that human life is only one aspect of nature. Believe that the forces of nature must be kept in natural balance or harmony. ▪ Magicoreligious: basic premise that the world is an arena in which supernatural forces dominate. The fate of the world and those in it depends on the action of supernatural forces for good or evil. (Voodoo, Faith Healings..)
- Techniques of Communication (Chapter 3) Closed ended vs open ended and when to use them:
- Closed ended questions: Do you have pain? a. For specific information b. 1-2-word answers, yes/no c. Limits rapport, Elicits cold facts, neutral interaction
- Open ended questions: Tell me about; How are you doing today? What brings you to the hospital? a. Narrative answers b. Feelings, opinions c. Develops rapport
- 1 question at a time; appropriate language
- Review Chapter 3 Examiner’s Verbal Responses (Table 3-3) Facilitation – “mm-hmm”, “uh-huh”, “Go on” Silence – gives time to think Reflection – “It’s hard to get up in the morning.” “You have difficulty getting the day started.” Empathy – “I can’t do anything for myself anymore.” “It must be difficult not being independent, losing control.” Clarification –“So you have difficulty when lying down if you have to lie flat and you need several pillows to breath comfortably. Correct?” Response when you express your own thoughts & feelings Confrontation – “Before you said you don’t smoke but now you mentioned smoking with your friends.” Interpretation – “I always take this blanket with me.” “So the blanket must be very important to you.” Explanation – “You can not eat for 12 hours prior to your surgery to decrease the risk of aspiration.” Summary – Condenses the facts discussed, allows client to make corrections as needed - Health History of the Adult (Chapter 4) a. Present Health or History of Present Illness – PQRSTU:
- P = Provocative or Palliative
- • What makes the symptom(s) better or worse?
- Q = Quality
- • Describe the symptom(s).
- R = Region or Radiation
- • Where in the body does the symptom occur? Is there radiation or extension of the
- symptom(s) to another area of the body?
- S = Severity
- • On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? Another visual scale
- may be appropriate for patients that are unable to identify with this scale.
- T = Timing
- • Does it occur in association with something else (i.e. eating, exertion, movement)?
- U = Understand patient perception of the problem b. Past medical history (Comprehensive health history): Surgical history, OB /GYN Nutritional Hx, cancer, measles, mumps, any vaccine related disease, hospitalizations, accidents, serious or chronic illness c. Review of Systems: all systems, skin, hair, head, eye, ears, nose mouth, neck, etc d. Nutritional History (Chapter 4 & Chapter 11) diet recall 24 hours Methods of assessing nutrition: ➢ 24-hour recall: Questionnaire or interview to recall everything eaten within the last 24 hours. Advantage is that it can elicit specific information about dietary intake over a specific period of time. Sources of error: may not be able to recall the type or amount of food eaten; intake may be atypical of usual intake; the individual or family member may alter the truth for a variety of reasons; and snack items and use of gravies, sauces, and condiments may be underreported. ➢ Food diaries: ask the individual or family member to write down everything consumed for a certain period of time. Three days (i.e., two weekdays and one weekend day) are customarily used. A food diary is most complete and accurate if you teach the individual to record information immediately after eating. Potential problems with the food diary include noncompliance, inaccurate recording, atypical intake on the recording days, and conscious alteration of diet during the recording period. ➢ Direct observation ➢ Questions re weight loss? Wt. gain? ➢ How does age factor into nutritional intake? ➢ Food habits and customs ➢ Meal patterns ➢ Food beliefs and skills ➢ Supplement use ➢ Medical conditions affecting nutritional status ➢ Anthropometric measurements ➢ Swallowing assessment prn ➢ Lab tests - Review Assessment Techniques (Chapter 8) Inspection:
- Visual examination of body
- Part of every assessment
- Avoid preconceptions
- requires good lighting, adequate exposure
- Instruments facilitate process Palpation : Use of hands, Texture, Size. Slow and systematic, calm and gentle. Shape Consistency Location
- Palmar surface of fingers/finger pads
- Position, texture, size, consistency, masses, fluid, crepitus,
- Ulnar surface
- Vibration
- Dorsal surface
- Temperature
- Bimanual technique used for kidneys, uterus, or adnexa Percussion: To evaluate size, borders, consistency, tenderness, extent of fluid - Direct
- Sinuses, CVA tenderness - Indirect:
- Thorax, abdomen Auscultation is listening to sound produced by the body (respiratory, cardiac,
- Following characteristics of sound can be noted:
- Pitch
- Loudness
- Duration
- Quality
- Typically done with aid of a stethoscope (You need to know the order) - The General Survey (Chapter 9) (What are you assessing in a general survey)
- General impression of client: Age, sex, level of consciousness, skin color, facial features a. Physical appearance/hygiene: Facial expression, speech, dress, hygiene b. Body structure : Stature, nutrition, symmetry, posture, position, body build c. Body movement: Gait, range of motion, assistive devices, involuntary movements d. Emotional and mental status and behavior: Mood/affect, speech, appropriate behavior for setting Pain (Chapter 10) Know the difference Referred Pain & Acute Pain & Phantom Pain & Chronic Pain Acute:
- Short Term, Self-Limiting
- Tissue damage
- Self-protective mechanism
- Mild – moderate pain = sympathetic nervous system response
- Severe pain = parasympathetic nervous system response Chronic: Over 6 months in duration
- Adaptive responses
- Does not stop when injury heals
- outlasts protective purpose
- Abnormal processing of pain fibers from peripheral & Central sites Referred: Felt at site different from organ affected. Same spinal nerve, brain can’t differentiate Phantom pain
- Pain where limb used to exist
- Brain still getting message
- Review picture of the most common shapes and configurations of lesions Chapter 12 pages 227- Patterns of lesions:
Discreate: Linear: Grouped: Pinpointed: Annular: Zosteriform: Polycyclic: Confluent: Discrete: distinct, individual lesions that remain separate: MOSQUITO BITE Linear: scratch, steak, line, or stripe Grouped: clusters of lesions Confluent: lesions run together, hives Annular: circular, begins in center and spreads to periphery, ringworm Zosteriform : linear arrangement along a unilateral nerve route Polycyclic: annular lesions grow together Confluent: lesions run together, hives Gyrate: twisted, coiled spiral, snakelike Target: resembles iris of eye, erythema Review Pressure Ulcer on page 223 (look at the pictures and read all the stages and review the pictures) Stage 1: Intact skin appears red but unbroken. Localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure). Dark skin appears darker but does not blanch. Stage 2: Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. Fat and deeper tissues not visible Stage 3: Full thickness, extends into subcu tissue, looks like a crater. Fat visible, may have slough, undermining & tunneling possible Stage 4: Full thickness, all skin layers, exposed muscle, bone, tendon; may have slough or eschar Undermining, tunneling, rolled edges often occur. If slough or eschar may be unstageable.
Primary and Secondary Lesions: Primary: Original lesion, (Mole, freckle, cyst) Secondary: Results from changes or trauma to original lesion (Scar, melanoma) Keloids : Overgrowth of tissue, secondary lesion from trauma to original lesion
- Chapter 13 Lymph Nodes (Review the picture page 260) Expected findings: Only inflamed limps nodes are palpable Normal cervical lymph nodes are less than 1 cm Acute infection: bilateral, enlarged, warm, tender and firm bur freely movable. Chronic inflammation: in tuberculosis the nodes are clumped. Cancer: Nodes are hard >3cm, unilateral, non-tender, matted and fixed
- Chapter 14 Eyes (Know PERRLA) & Snellen Chart (Cataracts, Glaucoma s/s)
- PERRLA – P upils E qual, R ound, R eactive to L ight and A ccommodation (CN II & III)
- Pupils constrict to light
- Pupils Constrict for Close vision, Dilate for Distance
- Snellen Chart: Visual acuity (far) CN II Glaucoma: I n creased intraocular pressure due to fluid build up
- Damages optic nerve
- Acute (emergent) or chronic
- Clouding of vision, eye pain, halos around lights Cataract (Opacity of Lens): Risk factors: -Aging -Excessive light exposure -Hypertension -Overweight -Diabetes -Excess alcohol -Hereditary - Chapter 15 Ears (Know how to test for hearing) (What is a Phantom sound of the ear?) When there is wax (cerumen) in the ear, there is conductive hearing loss Phantom : low or high pitch in one or two ears, may not be able to hear external sounds
- Middle and inner ear – need to use an otoscope (Dr. only) -Identify if the client can hear you. (whisper test or finger rub) (CN VIII) Whisper test : abc, 123 etc. Finger rub : gross hearing -Rinne test (for hearing loss) ( test air conduction) -Weber test (for hearing loss) (test for bone conduction)
- Chapter 16 Nose, Mouth and Throat If uvula and tonsils are touching =abnormal, needs to come out Nasal Assessment : patency, deviated septum, drainage, septum midline
- Chapter 17 Breasts and Regional Lymphatics (Know your risk factors for breast cancer and abnormal findings review pg. 393) (PowerPoint slides) Abnormal signs: 🐀 Pain or discomfort? Burning, pulling, cyclic, localized or general 🐀 Changes in nipples? Discharge, inverted, everted 🐀 Changes observed in breast tissue? Redness, dimpling, rash, change in size or contour Risk factors for breast cancer: Non-Modifiable:
- Age:
- Family/Personal history
- Race
- Radiation
- Reproductive history
- Menstrual history
- Genetic factors
- Treatment with DES Modifiable:
- Overweight and obesity
- Alcohol
- Oral contraceptive
- Hormonal replacement therapy Screening: (Mammograms) Average risk (American Cancer Society, 2015): ● Age 40: Discuss starting mammograms with MD ● Age 45: Begin annual mammograms ● Age 55+: either every other year, if desired, or annual ● Self and MD exams no longer recommended.
- Chapter 18 Thorax and Lungs a. Know the difference between (Bradypnea, Orthopnea, Dyspnea) Bradypnea: slow breathing, rate is 12 and under Orthopnea : too many pillows to sleep under them Dyspnea: shortness of breath and difficulty breathing while exercising or walking b. Normal breath sounds and locations to auscultate (Bronchial, Bronchovesicular, Vesicular) Anterior breath sounds: bronchial, bronchovesicular, and vesicular Posterior breath sounds: bronchovesicular and vesicular Bronchial : High pitch Bronchovesicular : medium pitch and amplitude(inspiration) Vesicular: low pitch, soft inspiration c. Read pages 424-427 for normal findings d. Know the abnormal findings of the Configurations of the Thorax: pages 442 & 443 (Review PowerPoint slides)
e. Know the difference between egophony and bronchophony Bronchophony: Normal: Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said Abnormal: Pathology that increases lung density enhances transmission of voice sounds; you auscultate a clear “ninety-nine” The words are more distinct than normal and sound close to your ear Egophony: Normal: Normally you should hear “eeeeeeee” through your stethoscope Abnormal: Over area of consolidation or compression the spoken “eeee” sound changes to a bleating long “aaaaa” sound (indication of pneumonia) f. Know tactile fremitus assess: feel vibration when say 99 increased: good vibration decreased : obstruction of vibration
g. Rhonchi, Wheezes, Stridor Wheeze —High-pitched (sibilant): Diffuse airway obstruction from acute asthma or chronic emphysema Wheeze —Low-pitched (sonorous rhonchi): Bronchitis, single bronchus obstruction from airway tumor Stridor : monophonic, craving sound, louder in necj than in chest wall. Croup and acute epiglottitis in children and foreign inhalation; obstructed airway may be life-threatening Rhonchi : bronchitis, low pitch sound
- Chapter 19 Heart and Neck Vessels a. S1 and S2 review when you auscultate the heart sounds Sounds heard are the valves closing: S1 : AV atrioventricular: Mitral and tricuspid (S1 Loudest at apex) (beginning of Systole) (coincides with the carotid artery pulse) S2: SL semilunar: aortic and pulmonic (loudest at base) (End of systole) S1 and S2 equal loudness at ERBS point (middle of chest between the breasts) b. Congestive Heart Failure Jugular venous distention: Jugular vein distention (JVD ) is a sign of Congestive Heart Failure ( CHF ) and cannot lay flat because of fluids in lungs, Unilateral distention of external jugular veins is caused by local cause (kinking or aneurysm). Full distended external jugular veins above 45 degrees signify increased CVP as with heart failure. c. Know the order of the heart valves
- Second right interspace—Aortic valve area
- Second left interspace—Pulmonic valve area
- Left lower sternal border—Tricuspid valve area
- Fifth interspace at around left midclavicular line—Mitral valve area d. Review page 481 & 482 e. Know your landmarks (Apartment M) (APe To Men)
- Chapter 20 Peripheral Vascular System and Lymphatic a. Know the location of your pulses and how to palpate Pulse locations: (Assess one side at a time) Tempor al Carotid Apical (with stethoscope) Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis
- Chapter 21 Abdomen b. Know Costovertebral Angle To assess the kidney place one hand over the 12th rib at the Costovertebral Angle on the back. Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. c. Know what is in the RUQ & LUQ quadrants RUQ : liver, gallbladder, part pancreas LUQ: stomach, spleen, part pancreas d. Know dysphagia Dysphagia=difficulty swallowing
e. Different in black tarry stools and bright red stools (where is the patient bleeding from)
Signs of GI bleeding and indications : -Black tarry stools: upper intestine (internally bleeding, may be due to ulcers or cancers -Bright red stools: lower intestine (hemorrhoids, cancer) f. Know the difference between hypoactive, absent and hyperactive bowel sounds -Hyperactive sounds (unrelated to hunger) Diarrhea, laxative use, or early intestinal obstruction
- Hypoactive, then absent: Paralytic ileus or peritonitis - Absent: Absence of paralysis (ileus) g. Abdominal aorta when auscultating and you hear noise: bruit over midline pulsation h. Risk factors for Colon Cancer Disease risk factors : 2 nd^ leading cause of cancer related deaths in US (1 in 20 average risk) Non- modifiable:
- Age: >
- Family Hx: 1 st^ degree - 2-3 X
- Ethnicity: African American
- Preexisting condition: Diabetes Modifiable:
- Smoking
- Alcohol
- Obesity
- Excessive processed & red meat
- Low fruit & vegetable intake
- Lack of dietary fiber i. Assessment findings with patients that has Hep B & C, tattoos j. Know the order of abdominal assessment (Inspection, Auscultation, Percussion and Palpation.) k. GERD s/s GERD: Gastroesophageal Reflux Disease Flow of gastric secretions up into the esophagus Heartburn, regurgitation, and dysphagia Worse with foods like chocolate, citrus, alcohol; NSAIDs, caffeine l. Cirrhosis s/s Cirrhosis: Chronic degenerative liver disease Common Causes: viral hepatitis B & C, biliary obstruction, alcohol abuse Symptoms: Nausea, vomiting, fatigue, itching, jaundice (yellow sclera of eyes, palm of hands, sole of feet), pain upper right quadrant
- Chapter 22 Musculoskeletal System (Review PowerPoint slides and page 620) a. Know the difference between lordosis, kyphosis, scoliosis Lordosis : Swayback, Exaggerated forward curvature of lumbar and cervical regions of spinal column. kyphosis : Exaggerated posterior curvature of the thoracic spine (humpback) that causes significant back pain and limited mobility. Severe deformities impair cardiopulmonary function.
Associated with aging, related to physical fitness; women with adequate exercise habits are less likely to have kyphosis. scoliosis: Lateral S-shaped curvature of the thoracic and lumbar spine, usually with involved vertebrae rotation. Note unequal shoulder and scapular height and unequal hip levels, rib interspaces flared on convex side. More prevalent in adolescent age-groups, especially girls. Mild deformities are asymptomatic. If severe (>45 degrees) deviation is present, scoliosis may reduce lung volume, and person is at risk for impaired cardiopulmonary function. Primary impairment is cosmetic deformity, negatively affecting self-image. Refer early for treatment, possible surgery. b. Osteoporosis s/s
- Loss of bone density
- Decreased bone strength
- 90% >75 years have osteoporosis
- Lack of bone density - increased risk of fractures Osteoporosis risk factors (Select all)
- Age
- Gender
- Race
- Bone structures/body weight
- Family history
- Lifestyle – smoking, alcohol
- Medications
- Estrogen deficiency
- Other diseases (lupus, RA, inflammatory bowel, celiac disease c. Osteoarthritis risk factors
- Age- 1/3 over 65
- Gender
- Obesity
- Repetitive activity
- Joint injury
- Physical inactivity d. Know Range of Motion (review PowerPoint slide) - Active – voluntary (By self) Passive: someone assists
If limitation noted of active ROM then try passive ROM e. Reflexes (Triceps and Biceps when testing) 0 Absent + diminished ++ Normal +++ Brisk (Increased) ++++ Hyperactive (Clonus may be present) Where to assess for deep tendon reflex? Knee (Patellar) Biceps Triceps
f. Skeletal Movements
- Fractures: Partial/complete break in continuity of a bone Closed/simple Open/compound Comminuted Compression Pathologic
- Chapter 23 Neurologic System a. Know the Romberg Test & Babinski (also review PowerPoint slide) Romberg Test: Ask the person to stand up with feet together and arms at the sides. Once in a stable position, ask him or her to close the eyes and to hold the position. Wait about 20 seconds. Normally a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur. (Stand close to catch the person in case he or she falls.) Positive Romberg : loss of balance that occurs when closing the eyes, occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication), loss of proprioception, and loss of vestibular function. Babinski:
b. Know Cranial Nerves (review PowerPoint slide and pages 644-647 & 678) Cranial Nerve II, III, VIII & X Cranial nerves enter and exit from brain: Name # Function Action Olfactory I Sensory Smell Optic II Sensory Vision Oculomotor III Motor Pupil reflex, movement of eye Trochlear IV Motor Eye muscle movement Trigeminal V Mixed Sensory upper part of head, sensory maxillary and mandibular areas, motor movement of mandible Abducens VI Mixed Eye muscle movement Facial VII Mixed Taste anterior 2/3 of tongue, facial movements, tear production, salivary stimulation