NUR 2092 HEALTH ASSESSMENT FINAL EXAM STUDY GUIDE 2021
Communication and Health Promotion
*Barriers to Communication
-Lack of interest or attention / lack of respect
-Physical barriers – curtain, door, computer, monitor, pain, room temp
-Patients inability to hear you – hearing deficit; receptive aphasia
-Safety fear
-Psychological barriers – embarrassment, disbelief, shock, anger, fear, grief,
fatigue,
hostility
-language/use of medical jargon, or speaking above someone’s educational
level
*What is clarification, reflection, ordering?
-Clarification: clarifying what the patient has said
-Reflection: what the patient said word for word
-Ordering: sequencing what has happened with the patient
*How do you deal with
-Anger:
-Crying: Usually the patient doesn’t want to talk while crying so just say
“ok, I’ll come
back and check on you in a little while”.
-Someone who talks too much: Use closed ended questions, redirecting
questions.
-Not following a plan of care: find out why (may not have funds or
transportation)
*What are the different levels of health promotion?
-Primary: Prevents health problems [Examples: safety glasses, vaccines,
exercise]
-Secondary: Screening – catch problems early, reduce impact of problem
[Example: mammograms, blood glucose]
-Tertiary: Decreases impact of an ongoing illness or injury [Example:
cardiac rehab,
support groups]
,History & Communication, General Survey
*What is included in a health history? (subjective data)
-Two primary components of health assessment:
*Health history (Subjective data)
*Physical examination (Objective data)
-Comprehensive Body System Health History
*Biographic data
*Reason for seeking care
*Present health status:
Medications, immunizations, what improves it, what makes it
worse
*Past medical history:
Surgical history, OB/GYN, Nutritional history
*Family history
*Personal and psychological history
Support, living environment, substances, safety
*Review of body systems
*What is included in the general survey? (objective data)
-Begins with first contact
-General impression:
Age, sex, level of consciousness, skin color, facial features
-Physical appearance/hygiene
Facial expression, speech, dress, hygiene
-Body structure
Stature, nutrition, symmetry, posture, position, body build
-Body movement
Gait, range of motion, assistive devices, involuntary movements
-Emotional and mental status and behavior
mood/affect, speech, appropriate behavior for setting
*Closed ended questions: Do you have pain
-For specific information
-1-2 word answers, yes/no
-Limits rapport, neutral interaction
*Open ended questions: Tell me about; How are you doing today?
-Narrative answers
, -Feelings, opinions
-Develops rapport
*What is redirecting, silence, restating?
-Redirecting – going back to something a client had said a few minutes ago
-Silence – giving the client time to open up
-Restating – Rewording something a client told you
*What is included in social history?
-Where do they live
-Are they safe
-Do they have clean water, heat, air conditioning
-Do you work, do you feel safe
-Smoke, alcohol, recreational drugs
-Safety devices – drive with seat belt, texting
-Do you exercise? Safety equipment (lawn, woodworking, sports)
-Sun screen
*What is included in family history?
-Diseases or illness that can be found
*Subjective data
-What patient says about themselves during history taking
*Objective data
-Observed with inspecting, percussing, palpating, and auscultating during
physical
examination
Communication and Health Promotion
*Barriers to Communication
-Lack of interest or attention / lack of respect
-Physical barriers – curtain, door, computer, monitor, pain, room temp
-Patients inability to hear you – hearing deficit; receptive aphasia
-Safety fear
Communication and Health Promotion
*Barriers to Communication
-Lack of interest or attention / lack of respect
-Physical barriers – curtain, door, computer, monitor, pain, room temp
-Patients inability to hear you – hearing deficit; receptive aphasia
-Safety fear
-Psychological barriers – embarrassment, disbelief, shock, anger, fear, grief,
fatigue,
hostility
-language/use of medical jargon, or speaking above someone’s educational
level
*What is clarification, reflection, ordering?
-Clarification: clarifying what the patient has said
-Reflection: what the patient said word for word
-Ordering: sequencing what has happened with the patient
*How do you deal with
-Anger:
-Crying: Usually the patient doesn’t want to talk while crying so just say
“ok, I’ll come
back and check on you in a little while”.
-Someone who talks too much: Use closed ended questions, redirecting
questions.
-Not following a plan of care: find out why (may not have funds or
transportation)
*What are the different levels of health promotion?
-Primary: Prevents health problems [Examples: safety glasses, vaccines,
exercise]
-Secondary: Screening – catch problems early, reduce impact of problem
[Example: mammograms, blood glucose]
-Tertiary: Decreases impact of an ongoing illness or injury [Example:
cardiac rehab,
support groups]
,History & Communication, General Survey
*What is included in a health history? (subjective data)
-Two primary components of health assessment:
*Health history (Subjective data)
*Physical examination (Objective data)
-Comprehensive Body System Health History
*Biographic data
*Reason for seeking care
*Present health status:
Medications, immunizations, what improves it, what makes it
worse
*Past medical history:
Surgical history, OB/GYN, Nutritional history
*Family history
*Personal and psychological history
Support, living environment, substances, safety
*Review of body systems
*What is included in the general survey? (objective data)
-Begins with first contact
-General impression:
Age, sex, level of consciousness, skin color, facial features
-Physical appearance/hygiene
Facial expression, speech, dress, hygiene
-Body structure
Stature, nutrition, symmetry, posture, position, body build
-Body movement
Gait, range of motion, assistive devices, involuntary movements
-Emotional and mental status and behavior
mood/affect, speech, appropriate behavior for setting
*Closed ended questions: Do you have pain
-For specific information
-1-2 word answers, yes/no
-Limits rapport, neutral interaction
*Open ended questions: Tell me about; How are you doing today?
-Narrative answers
, -Feelings, opinions
-Develops rapport
*What is redirecting, silence, restating?
-Redirecting – going back to something a client had said a few minutes ago
-Silence – giving the client time to open up
-Restating – Rewording something a client told you
*What is included in social history?
-Where do they live
-Are they safe
-Do they have clean water, heat, air conditioning
-Do you work, do you feel safe
-Smoke, alcohol, recreational drugs
-Safety devices – drive with seat belt, texting
-Do you exercise? Safety equipment (lawn, woodworking, sports)
-Sun screen
*What is included in family history?
-Diseases or illness that can be found
*Subjective data
-What patient says about themselves during history taking
*Objective data
-Observed with inspecting, percussing, palpating, and auscultating during
physical
examination
Communication and Health Promotion
*Barriers to Communication
-Lack of interest or attention / lack of respect
-Physical barriers – curtain, door, computer, monitor, pain, room temp
-Patients inability to hear you – hearing deficit; receptive aphasia
-Safety fear
