Adult Health Assessment Study Guide for Exam 1
Content: Chapters 1-4, 8-11 & 13
Note: remember this is a guide and does not encompass your entire exam. Every class and professor is different.
Chapter 1: Evidence-Based Assessment
1. Subjective and Objective Data:
●Subjective data: what the person says about himself or herself during history taking (e.g., I have a headache)
●Objective data: what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
●Together with the patient’s record and laboratory studies, these elements form the database which we use to formulate a clinical judgement or diagnosis.
Chapter 2: Cultural Assessment
2. Know different cultures and we need to respect them, what is normal in other cultures? Cultural assessment
Understanding the basics of a variety of cultures is important in health assessment. It is important to provide culturally relevant health care that incorporates cultural beliefs and practices. By providing culturally competent care, we are able to provide high quality care to our patients including their beliefs.
●Asians: believe in the yin/yang theory, in which health exists when all aspects of the person are in perfect balance. It states that all organisms and objects in the universe consist of yin and yang energy forces. Yin energy represents the female
and negative, yang energy represents are male and positive. Asians may visit herbalists, acupuncturists, or bonesetters
●Many Hispanic, Arab, and Asian groups embrace the hot/cold theory, which consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. According to this theory, the person is a whole ●Hispanics may rely on curandero (ra), espiritualista (spiritualist), yerbo (ba), (herbalist), or partera (lay midwife)
●Blacks may mention having assistance from a houngan (a voodoo priest or priestess), spiritualist, or “old lady”
●American Indians may seek assistance from a shaman or a medicine man or woman
●Amish: the term braucher refers to folk healers who use herbs and tonics
●Native American: shaman or medicine man or woman
●Making direct eye contact with others is offensive in many cultures
Cultural assessment: instead of narrowly defining what to expect from a certain
race or ethnic group, health care providers should complete a cultural assessment by asking questions and providing culturally congruent care.
Chapter 3: The Interview & Chapter 4: The Complete Health History
3. Know the difference between verbal and nonverbal behaviors.
●Nonverbal communication: is as important as verbal communication. Includes posture, gesture, face expression, eye contact, foot tapping. nonverbal communication is under less conscious control than verbal communication, it may be more reflective of true feelings.
●Verbal communication: The words you speak, vocalization and tone of voice.
4.What is empathy?
Empathy means viewing the world from the other person's perspective while remaining in you. Recognition and acceptance of the other person's feelings without criticism. Empathy is the ability to recognize how someone perceives his or her world. This is helpful when treating patients so you can understand them and their culture. 5.Know what to ask during the interview process, know past medical history, what are you evaluating? This is the interview process
●Interview Process : introduce yourself and state your role, state location, time, cost, expectation, purpose and participation
●Working Phase: gathering data phase, use combination of open ended and closed ended questions
●Termination Phase : ending of an interview. Typically ask the patient if they have any questions before leaving the room and let them know when you will return.
Past Health History: surgeries, illness including childhood and chronic illnesses,
accidents or injuries, obstetric history, immunizations, last examination date, prescription medications, herbal supplements, and over the counter drugs. Allergies, food, latex, drugs, or contact agents. Use of tobacco, caffeine, or recreational drugs.
●Family History: includes immediate and blood relatives.
●Psychosocial History: patient’s support system and how they cope with stress.
●Spiritual Health: assess rituals and religious practice that patients use to express their spirituality.
●Review of systems (ROS): ask the patient about the normal functioning of each body system and any noted changes.
●Observation and Patient Behavior: observation includes a patient’s level of
function, their physical, developmental, psychological, and social aspects of everyday living.
●Diagnostic and Lab Data: the results of diagnostic or lab tests.
6.Open and closed questions & examples
●Open-Ended Questions: asks for narrative information.
➔Do you have any religious/spiritual preferences that we can support?
➔What brings you to the hospital?
➔How does this make you feel? ●Closed or Direct Questions: ask for specific information. The answer could
be a “two-word answer”, a “yes” or “no”, or a forced choice.
➔Are you angry?
➔Are you Catholic or Christian? ➔ Do you exercise?
Chapter 8: Assessment Techniques
7.What are the skills you need to use to get your data during assessment?
Physical examination requires use of technical skills through senses to obtain data (sight, smell, touch, hearing). The skills necessary for the physical examination are:
1.Inspection
2.Palpation
3.Percussion
4.Auscultation
8.What is the most common assessment tool you use? How to inspect?
The most common assessment tool is inspection, it always comes first. When you inspect, you use your eyes and sense of sight, it is concentrated watching.
9.Know the order of assessment, what skill goes with what sense? (e.g., palpation=touch) Order of assessment:
Regular:
1.Inspection: Eyes, sense of sight.
2.Palpation: Hands, sense of touch.
3.Percussion: Ears, sense of hearing.
4.Auscultation: Ears, sense of hearing.
When you start with the abdomen:
●Inspection
●Auscultation
●Palpation
●Percussion
Content: Chapters 1-4, 8-11 & 13
Note: remember this is a guide and does not encompass your entire exam. Every class and professor is different.
Chapter 1: Evidence-Based Assessment
1. Subjective and Objective Data:
●Subjective data: what the person says about himself or herself during history taking (e.g., I have a headache)
●Objective data: what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
●Together with the patient’s record and laboratory studies, these elements form the database which we use to formulate a clinical judgement or diagnosis.
Chapter 2: Cultural Assessment
2. Know different cultures and we need to respect them, what is normal in other cultures? Cultural assessment
Understanding the basics of a variety of cultures is important in health assessment. It is important to provide culturally relevant health care that incorporates cultural beliefs and practices. By providing culturally competent care, we are able to provide high quality care to our patients including their beliefs.
●Asians: believe in the yin/yang theory, in which health exists when all aspects of the person are in perfect balance. It states that all organisms and objects in the universe consist of yin and yang energy forces. Yin energy represents the female
and negative, yang energy represents are male and positive. Asians may visit herbalists, acupuncturists, or bonesetters
●Many Hispanic, Arab, and Asian groups embrace the hot/cold theory, which consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. According to this theory, the person is a whole ●Hispanics may rely on curandero (ra), espiritualista (spiritualist), yerbo (ba), (herbalist), or partera (lay midwife)
●Blacks may mention having assistance from a houngan (a voodoo priest or priestess), spiritualist, or “old lady”
●American Indians may seek assistance from a shaman or a medicine man or woman
●Amish: the term braucher refers to folk healers who use herbs and tonics
●Native American: shaman or medicine man or woman
●Making direct eye contact with others is offensive in many cultures
Cultural assessment: instead of narrowly defining what to expect from a certain
race or ethnic group, health care providers should complete a cultural assessment by asking questions and providing culturally congruent care.
Chapter 3: The Interview & Chapter 4: The Complete Health History
3. Know the difference between verbal and nonverbal behaviors.
●Nonverbal communication: is as important as verbal communication. Includes posture, gesture, face expression, eye contact, foot tapping. nonverbal communication is under less conscious control than verbal communication, it may be more reflective of true feelings.
●Verbal communication: The words you speak, vocalization and tone of voice.
4.What is empathy?
Empathy means viewing the world from the other person's perspective while remaining in you. Recognition and acceptance of the other person's feelings without criticism. Empathy is the ability to recognize how someone perceives his or her world. This is helpful when treating patients so you can understand them and their culture. 5.Know what to ask during the interview process, know past medical history, what are you evaluating? This is the interview process
●Interview Process : introduce yourself and state your role, state location, time, cost, expectation, purpose and participation
●Working Phase: gathering data phase, use combination of open ended and closed ended questions
●Termination Phase : ending of an interview. Typically ask the patient if they have any questions before leaving the room and let them know when you will return.
Past Health History: surgeries, illness including childhood and chronic illnesses,
accidents or injuries, obstetric history, immunizations, last examination date, prescription medications, herbal supplements, and over the counter drugs. Allergies, food, latex, drugs, or contact agents. Use of tobacco, caffeine, or recreational drugs.
●Family History: includes immediate and blood relatives.
●Psychosocial History: patient’s support system and how they cope with stress.
●Spiritual Health: assess rituals and religious practice that patients use to express their spirituality.
●Review of systems (ROS): ask the patient about the normal functioning of each body system and any noted changes.
●Observation and Patient Behavior: observation includes a patient’s level of
function, their physical, developmental, psychological, and social aspects of everyday living.
●Diagnostic and Lab Data: the results of diagnostic or lab tests.
6.Open and closed questions & examples
●Open-Ended Questions: asks for narrative information.
➔Do you have any religious/spiritual preferences that we can support?
➔What brings you to the hospital?
➔How does this make you feel? ●Closed or Direct Questions: ask for specific information. The answer could
be a “two-word answer”, a “yes” or “no”, or a forced choice.
➔Are you angry?
➔Are you Catholic or Christian? ➔ Do you exercise?
Chapter 8: Assessment Techniques
7.What are the skills you need to use to get your data during assessment?
Physical examination requires use of technical skills through senses to obtain data (sight, smell, touch, hearing). The skills necessary for the physical examination are:
1.Inspection
2.Palpation
3.Percussion
4.Auscultation
8.What is the most common assessment tool you use? How to inspect?
The most common assessment tool is inspection, it always comes first. When you inspect, you use your eyes and sense of sight, it is concentrated watching.
9.Know the order of assessment, what skill goes with what sense? (e.g., palpation=touch) Order of assessment:
Regular:
1.Inspection: Eyes, sense of sight.
2.Palpation: Hands, sense of touch.
3.Percussion: Ears, sense of hearing.
4.Auscultation: Ears, sense of hearing.
When you start with the abdomen:
●Inspection
●Auscultation
●Palpation
●Percussion
