Download NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ and more Exams Nursing in PDF only on Docsity! NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ Exam #1 Study Guide 1. Importance of Health Assessment CH1 a. Attention to details, use of appropriate questions, and a keen awareness of what a person says and does shape the plan of care to optimize each individual's health status throughout the lifespan. b. Determine a patient's health status, risk factors, and need for education as basis for developing a nursing plan of care 1.Components of Health Assessment CH1 NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ A.Identifies many contributing factors to individual's health: ( 7 Facets) B.Spends time w/patient: identify concerns/changes (deviations noted) C.Notes used to determine health problems/potential problems D. Development of nursing care plan E.Once plan in place, NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ ii. Physical findings iii. Factual/descriptive : Signs A.Nursing Process CH 2 A.Broad systematic framework provides methodical base for nursing practice. B.Addresses the human responses and needs of patient, family, and community NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ C.Scaffold that the American Nurses Association uses to develop the Standards of Nursing Practice. i. Assessment: a.Subjective/objective data gathered during initial health history/physical exam b.Essential for devising plan of care c.Therapeutic communication is essential to elicit pertinent info d.Continues through entire encounter ii. Diagnosis a.Based on real/potential health problems or human NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ responses to health problems b.Uses clinical reasoning to formulate diagnoses based on assessment data and patient's problem list. c.Sets stage for remainder of care plan ii. Planning a.Devising best course of action to address patient's diagnoses. b.Nurse/patient select goals for each diagnosis in order to alleviate, decrease or prevent problem NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ to our own work w/patients. Set aside bias. ii. Review patient record: Understand there could be discrepancies iii. Set interview goals: Goals range from health care issues, new problems/ completing forms. Balance provider- centered goals w/ patient- centered goals. iv. Review own clinical behavior and appearance B.Introduction: put the patient at ease and establish trust i. Greet the patient and establish rapport NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ ii. Establish the agenda for the interview B. Working: Obtain patient info i. Invite the patient's story ii. Identify and respond to emotional cues ( Nures: Naming, Understanding, Respecting) iii. Expand and clarify the patient's story (OLDCART- OPQRST) iv. Generate and test diagnostic hypotheses NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ Patient Perspective: A.Patient's FEELINGS, fears/ concerns about problem B.Patient's IDEAS about the nature and the cause C.Effect problem has on patient's life and FUNCTION D. Patient's EXPECTATIONS of disease, health care NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ vii. Use reflection B. Nonverbal communication i. Eye contact, facial expression, posture, head position/movement ii. Some universal while others culturally bound iii. Matching position to patient's position can signify increased rapport B. Empathic Response i. Identify the patient's feelings ii. Respond with understanding and acceptance B. Validation NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ i. Acknowledge legitimacy of the emotional experience B. Reassurance i. Identify/acknowledge patient feelings ii. Reassurance comes later when you convey info in competent manner, making sure patient feels confident that problems are fully understood and will be addressed. B. Summarizing i. Give capsule summary of patient's story during interview ii. Allows you to organize your clinical reasoning and NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ convey it to patient making relationship more collaborative B. Transitions i. Put patient's at ease, tell them when you are changing directions during interview. ii. Gives patient better sense of control B. Empowering the Patient i. Patient perspective ii. Interest in person not just problem iii. Validate emotional content NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ patient concerns, health status, risk factors, and health promotion Initial info: A. Date/time of history B. Identifying data (age, gender, birth date, occupation, source of history) C. Reliability: doc reliability of person providing info "patient vague when describing symptoms and detail confusing" Chief Complaints D. Attempt to quote the patient's own words History of Present Illness NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ E. OLDCART F. Chronologic account of problems prompting patient to seek care G. Self-treatment for symptoms by patient H. Past occurrences of symptoms I. Pertinent positives/negatives from review of symptoms J. Risk factors related to symptoms Past History K. Allergies L. Medications M. Childhood Illnesses N. Adult Illnesses O. Health Maintenance Alcohol/Drugs NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ P. CAGE QUESTIONAIRE A. "Have you felt the need to CUT down on drinking?" B. "Have you ever felt ANNOYED by criticism of your drinking?" C. "Have you ever felt GUILTY about drinking?" "Have you ever taken a drink first thing in the morning (EYE- OPENER) to steady your nerves/get rid of hangover?" • Two or more affirmative answers suggest alcohol misuse NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ teeth/gums, dentures, last NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ dental exam, sore tongue, dry mouth, frequent sore throats • Neck: swollen gland; goiter, lumps, stiffness in neck • Breasts: lumps, pain, nipple discharge, self-exam practice, last health care provider, mammogram exam • Respiratory: cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, TB testing. May include asthma, bronchitis, emphysema, pneumonia • Cardiovascular: heart trouble, high blood pressure, rheumatic NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ fever, heart murmurs, chest pain/discomfort, palpitations, edema, results of past ECG cardiovascular tests • Gastrointestinal: trouble swallowing, heartburn, appetite, nausea, bowel movements, stool color/size, pain w/ defecation, rectal bleeding, hemorrhoids, abdominal pain, food intolerance, excessive belching/gas, jaundice, liver trouble • Peripheral vascular: Muscle pain w/walking, leg cramps, varicose veins, past clots in veins, swelling NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ • Endocrine: Thyroid issues, heart/cold intolerance, excessive sweating, excessive thirst/hunger B) Focused/problem oriented assessment • When patient is known to the health care facility • Focus on gathering info mostly on the patient's current problem C) Follow-up History • Is a form of focused assessment • Patient returning after problem NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ evaluated after treatment or second-shift nurse following up on problem. • Gather data to evaluate whether the treatment was successful D) Emergency History • Focused on patient's emergent problem w/systematic prioritization of need based on patient presentation • Cultural Assessment/Cultural Sensitivity CH 5 A.Systematic, comprehensive exam of individuals, families, NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ groups, NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ i. Reflect on your approach to patient ii. Adjust the lighting and the environment iii. Check that the equipment is available and in working order iv. Make the patient comfortable v. Choose the sequence of examination The Cardinal Techniques of Examination A.INSPECTION A.Close obs. Of detail of patient's appearance, NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ behavior, and movement (facial expression, mood, body build, skin conditions (petechiae or ecchymoses) eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema and gait. B. PALPATION A.Tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, or tenderness NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ B.Lymph nodes, pulses, contours and sizes of organs and masses and crepitus in the joints C.Metacarpal/phalangeal joint or ulnar surface of the hand is used to detect vibration. B. PERCUSSION A.Use of the striking, usually the third finger, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ ii. Level of consciousness a.Awake, alert, responsive to you and others b.Orientation checked by asking about person, place, time and situation ii. Facial features and expressions a.Watch facial expression at rest, during interview, during physical exam. b.Is eye contact natural, sustained and unblinking, quickly averted, absent? NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ c.Check for the stare of hyperthyroidism; immobile face of parkinsonism; flat or sad effect of depression. d.Decreased eye contact my be cultural, suggest anxiety, fear or sadness. e.Asymmetry of face could be stroke, palsy, or injury to cranial nerve ii. Demeanor and affect iii. Posture a.Assess patient before calling his/her name in the waiting room and if it changes when you are in the room. b.Patients often prefer sitting upright in left-sided heart NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ failure and learning forward w/arms braced in chronic obstructive pulmonary disease (COPD) ii. Gait iii. Motor activity a.Anxious patients appear agitated and restless. Patients in pain often avoid movement b.Look for tremors, other involuntary movements, or paralysis NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ infection. Untied laces or slipper also suggest edema d.Finger Nails: Bitten fingernails may reflect stress e.Neglected appearance may appear in depression and dementia, but should not be compared with the patient's norm A.Vital Signs: Normal and cause of variations CH 7 A.Blood pressure i. Errors that result in False HIGH Readings a.Cuff too small (narrow) b.Cuff too loose or NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ uneven c. Arm below heart level d.Arm not supported e.Inflating or deflating cuff too slowly (high diastolic) f. Deflating cuff too quickly (low systolic and high diastolic) A.Errors that result in False LOW Readings A.Cuff too large (wide) NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ B.Arm above heart level C.Repeating assessments too quickly D. Inaccurate level of inflation E.Pressing stethoscope too tightly against pulse B. Normal blood pressure A. <120/<80 JNC Blood Pressur e Classificati o ns-Adu. Older than 18 yrs Category Systolic Diast NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ therefore unreliable measurements B.Detection of an irregularly irregular rhythm suggests atrial fibrillation. C.Obtain an ECG to identify the type of rhythm B. White Coat Hypertension A.Describes hypertension in people whose blood pressure measurements are higher in the office than at home in more relaxed setting B. The Obese or Very Thin patient NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ A.Use 15 cm in width. If too short use thigh cuff, or very long cuff. B.Other option is a Doppler probe of radial artery C.For thin arm consider using pediatric cuff D. Using a small cuff overestimates systolic blood pressure in obese patients B. The hypertensive patient w/systolic Blood pressure Higher in the arms than the legs A.Assess blood pressure in the legs and "femoral delay" at least once in NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ the rhythm at cardiac apex by listening w/stethoscope. C.Examiner places stethoscope at apex and auscultates the s1 and s2, noting rate/rhythm. D. ECG should be checked to determine rhythm A.Respiratory Rate and Rhythm A.Observe the rate, rhythm, depth, and effort of breathing B.Count the number of respirations in 1 min either by visual inspection or by subtly listening over patient's trachea w/ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ stethoscope during exam of head and neck/chest C.Normal adults take 12 to 20 breaths/min in a quiet, regular patter. D. Check for prolonged expiration - common in COPD A.Temperature A.Most accurate core body temp is the blood temp in pulmonary artery. B.Everyday clinical practice relies on noninvasive routes such as oral, axillary, tympanic membrane, and temporal artery NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ RECTAL TEMP: higher than oral temp by about a degree Avg NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ measurements. C.Avg ORAL TEMP: 37 degrees C (98.6 F) - 37.3 degrees C (99.1 F) D. E.AXILLARY TEMP: are lower than oral temp by about a degree, but takes 5 to 10 minutes to register, considered less accurate than other methods. F. TYMPANIC MEMBRANE TEMP: more variable than oral/rectal. NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ firmly w/finger to see if redness temporarily blanches then refills (blanching are erythematous and suggest inflammation) ii. SIZE- measure with a ruler in millimeters/cm. iii. ELEVATION- flat, cannot palpate the lesion w/eyes closed. Raised, or pedunculated iv. NUMBER- can be solitary, multiple (how many) v. TEXTURE- palpate lesion to NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ see if it is smooth, fleshy, verrucous or warty, scaling (keratotic) vi. TYPE OF SKIN LESIONS- (Macules, papules, vesicles, nevi) vii. SHAPE AND PATTERN- round, oval, linear, clustered annular (ring), arciform (in arc), dermatomal-covering a skin band that corresponds to sensory nerve root viii. ANATOMIC LOCATION AND DISTRIBUTION- generalize? Involve exposed surfaces, the NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ skin-fold areas? Irritated by wrist bands, rings? • Vesicles in unilateral dermatomal pattern are typical of HERPES zoster • Many skin disease have typical distributions: acne (face/back), psoriasis (knees/elbow) Skin Cancer Types: • Basal Cell Carcinoma • Arising in lowest, basal, level of epidermis • Accounts for most of skin cancers • Arise in sun exposed areas, NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ • Actinic keratoses, solar lentigines (acquired brown macules on sun- exposed areas) • Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths • Severe blistering sunburns, especially in childhood • Immunosuppression from HIV or chemotherapy Melanoma Risk Assessment Tool • can be used to help patients assess their risk for melanoma. NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ • Assess individuals 5 year risk of developing melanoma based on geographic location, gender, race, age, history of blistering, sunburns, complexion, number/size of moles, freckling, and sun damage PREVNTING SKIN CANCER • AVOIDING ULTRAVIOLET RADIATION/TANNING BEDS • Increasing lifetime sun exposure correlates directly w/ increasing risk of skin cancer • Intermittent sun exposure appears to be more harmful than NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ chronic exposure • Best defense is to avoid UV radiation exposure by limiting time in sun, avoiding mid-day sun, using sunscreen and wearing sun- protective clothing • Avoid indoor tanning, especially before the age of 35, increases risk of melanoma by as much as 75% • REGULAR USE OF SUNSCREEN PREVENTS SKIN CANCER • Use at lease SPF 30 and broad spectrum protection. NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ Some have suggested adding EFG to help detect aggressive nodular melanomas bc they are often: • E for Elevated • F for Firm to palpation • G for Growing progressively over several weeks A.ACUTE AND CHRONIC PAIN A.ACUTE PAIN i. Usually associated with a physical cause and is triggered in the nervous system to alert the body to injury, disease, or inflammation. ii. Short lived NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ iii. Aids in preventing additional injury/resolves after treatment/healing take place B. CHRONIC PAIN i. Pain not associated with cancer or other medical conditions that persists for more than 3 to 6 months, 1 month beyond acute illness, pain reoccurring at intervals of months/years B. ASSESS WITH OLDCART NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ A.TYPES OF PAIN CH 7 A.Nociceptive or Somatic Pain i. Pain related to tissue damage ii. Acute/remitting or chronic/persiste nt iii. Pain mediated by afferent A- delta and C-fibers of sensory system that respond to noxious stimuli iv. Moderated by both neurotransmitters and psychological processes: endorphins, histamines, acetylcholine, monoamines: serotonin, NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ b.Rapid changes in weight over a few days suggest an increase/decrease in fluids NOT tissues c. Weight gain/swelling in lower legs may indicate water retention due to cardiac or peripheral vascular disease, not a nutritional problem ii. Anorexia iii. Changes in the senses of taste or smell iv. Difficulty chewing or swallowing B. Assessment Areas: NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ i. Food Pattern "How many meals/snacks do you eat a day?" "How many meals do you eat outside the home?" A.Personal food preferences "Are any foods particularly liked/disliked?" i. Food Preparation "who does the cooking?" "How are foods prepared?" i. Finances "Is there enough NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+ money for food?" i. Accessibility "Who does the shopping? Where? When?" "How close is your grocery store?" i. Patient health "Do you have any trouble chewing/digesting foods?" "Do you take any nutritional supplements or vitamins?" i. Exercise Pattern NURSE 108 Health Assessment Exam 1 Study Guide Latest Update 2022/2023 RATED A+