Introduction to Health Assessment
What are the steps of the Nursing Process?
Assessment
Analysis
Planning
Implementation
Evaluation
Temporal
Carotid
Radial
Brachial
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibial
What are the three stages of the interview process?
Opening-introduction & reason for the interview
Information gathering stage-use therapeutic communication techniques to collect and document client data
Closing stage-thank the client and summarize the collected information.
Name two examples of a macule; a nonpalpable, skin color change, smaller than 1 cm.
Freckle
Petechiae
What is a pulse deficit and how would you assess for a Pulse Deficit?
Pulse deficit: The difference between the apical rate and the radial rate.
What are the types of Assessments?
Comprehensive
Focused
Identifying data includes what is in the demographic information of the health history.
● Name, address, contact information
● Birth date, age
● Gender
● Race, ethnicity
● Relationship status
● Occupation, employment status
● Insurance
● Emergency contact information
● Family, others living at home
● Advance directives
Using effective skills and techniques in therapeutic communication describes one clarifying technique that a nurse uses to determine whether the message the client received is accurate.
Restating: Uses the client’s exact words
Reflecting: Directs the focus back to the client for them to examine their feelings
Paraphrasing: Restates the client’s feelings and thoughts for them to confirm what they have communicated
Exploring: Allows the nurse to gather more information about important topics the client mentioned
What is an example of a Nodule; palpable, circumscribed, deep, firm, 1 to 2 cm.
Wart
During the Analyze Cues (Analysis) what is the expected response and behavior of the nurse?
Analyze expected and unexpected findings in health data.
Identify client problems and related health alternatives.
Analyze client needs.
Identify potential complications.
Identify how pathophysiology relates to clinical presentation.
Identify data that is of immediate concern.
Past Health History and Current Health Status includes what?
● Childhood illnesses, both communicable and chronic
● Medical, surgical, obstetrical, gynecological, psychiatric history, including time frames, diagnoses, hospitalizations, treatments
● Current immunization status, dates and results of any screening tests
● Allergies to medication, environment, food
● Current medications including prescription, over-the-counter, vitamins, supplements, herbal remedies, time of last dose(s)
● Habits and lifestyle patterns (interests and social activities)
● Substance use (alcohol, tobacco, caffeine, recreational drugs)
The general survey is a written summary or appraisal of overall health. What information is Assessed (5) for the General Survey?
PHYSICAL APPEARANCE
BODY STRUCTURE
MOBILITY
BEHAVIOR
VITAL SIGNS
What does PQRST mean for a pain assessment?
P-Pattern or precipitating factors
Q-Quality
R-Radiates
S-Severity
T-Time and Treatment
Name three types of vesicle; serious fluid filled, smaller than 1 cm lesion.
Blister
Herpes Simplex
Varicella
Older Adults should follow these 7 age-related guidelines for screening.
Hearing
Fecal occult blood test
Digital rectal and prostate-specific antigen (males)
Dual-energy x-ray absorptiometry (DXA) scanning for osteoporosis
Eye examination for glaucoma
Mental Health Screening for depression
Cholesterol and diabetes screening
What are four nursing techniques used in Objective Data Collection?
Inspection
Palpation
Percussion
Auscultation
Name three nursing interventions for Hyperthermia an abnormally elevated body temperature.
● Obtain specimens for blood, urine, sputum, or wound cultures as needed.
● Assess/monitor white blood cell counts, sedimentation rates, and electrolytes.
● Ensure prescribed cultures are obtained before administering prescribed antibiotics, to promote test accuracy.
● Provide fluids and rest. Minimize activity. Use a cooling blanket.
● Children and older adults are at particular risk for fluid volume deficit.
● Provide antipyretics (aspirin, acetaminophen, ibuprofen). Do not give aspirin to manage fever for children and adolescents who have a viral illness (influenza, chickenpox) due to the risk of Reye’s syndrome.
● Prevent shivering, as this increases energy demand.
● Offer blankets during chills and remove them when the client feels warm.
● Provide oral hygiene and dry clothing and linens.
● Keep environmental temperature between 21° and 27° C (70° to 80° F).
What is the meaning of an open-ended question and give one example.
Open ended questions allow the client to relay information that is important to them and give you an opportunity to actively listen and observe the client. They convey caring and interest by the nurse.
Describe how you are feeling.
What symptoms brought you to the hospital today?
What does the ABCDE system to detect possible skin cancer mean?
A-Asymmetry of shape
B-border irregularity
C-color variation within one lesion
D-diameter greater than 6 mm
E-evolving or chang in color, elevation, shape, size, or development of itching, crusting, or bleeding
During the Generate Solutions (Planning) what is the expected response and behavior of the nurse?
Collaborate with members of the interprofessional healthcare team and the client to establish client outcomes and the plan of care.
Identify optimal client outcomes.
Prioritize plan of care to achieve optimal client outcomes.
Prioritize nursing care when caring for multiple clients.
Modify a plan of care to ensure the achievement of optimal client outcomes when indicated.
Determine the potential impact of selected interventions.
During the Recognize Cues (Assessment) what is the expected response and behavior of the nurse?
Identify and recognize relevant subjective/objective client data related to the client's condition.
Name 7 assessment skills that are part of the General Survey
Appearance
Behavior
Body Structure
Mobility
Height & Weight
Vital Signs
Pain Assessment
What are the Key Elements of the health interview using the acronym PLEASE
P-Past medical history
L-Last oral intake
E-Events leading to illness
A-Allergies and reactions
S-Symptoms of chief complaint
E-Each prescribed medication; OTC; & herbal
Edema is an accumulation of fluid in the tissues. The depth of pitting edema reflects the degree of edema. How is this graded?
1+ Trace 2mm rapid skin response
2+ Mild 4 mm 10-15 second skin response
3+ Moderate 6 mm prolonged skin response
4+ Severe 8 mm prolonged skin response
For most body systems, follow the sequence of first inspecting, then palpating, followed by percussion, and finally auscultation. What focused system assessment is a different sequence used?
The exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds.