NUR 2092 Final Exam Study Guide Health Assessment
1. Geriatrics: functional assessment-what is being tested, best approach to testing; caregiver
concerns; IADLs, ADLs; disability concerns; tools to assess
What is being tested -Identify strengths
-Identify limitations – so interventions can be recognized
-Independence and prevention of functional decline
Best approach to testing
Caregiver concerns -Decrease in attention, memory, orientation, language, planning and
making decisions
-Depression is not a normal change
-Persistent depression – is concerning if it interferes with ADL’s
-Eating
IADLs Instrumental activities of daily living
-measures functional abilities necessary for independent community living
-includes shopping, meal preparation, house-keeping, laundry, managing
finances, taking medications, and using transportation
ADLs Activities of daily living
-tasks necessary for self-care
-measure domains of eating/feeding, bathing, grooming, dressing, toileting,
walking, using stairs, and transferring
Disability concerns
Tools to assess -Katz Activities of Daily Living
-The Lawton Instrumental Activities of Daily Living Scale
-Hospital Admission Risk Profile
-Geriatric Depression Scale (short form)
-Inspect for lesions and moles – irregular shapes, change in size or color
-Check for pressure ulcers especially sacrum, heels & trochanters
-Clubbing – cardiac or pulmonary disorder
-Pitting/transverse groves – peripheral vascular disease, arterial
insufficiency, or diabetes
-Brittleness – decreased vascular supply
-Yellow or brown nails – fungal infection
-Look for limited range of motion – arthritis or muscle weakness causing
pain and discomfort
-While assessing range of motion – watch for reports of pain, dizziness,
jerky or abnormal movements: may indicate fractured vertebrae,
Parkinson’s disease, transient ischemic attack, or stroke
-Look for facial symmetry (asymmetry may indicate a stroke)
-Bowel sounds; Look for hernias, pulsatile masses
-Evaluate muscles for atrophy, tremors, and involuntary movements
-Note warmth, swelling, tenderness, crepitus and deformities
2. Cultural assessment: culturally competent care; definition of ethnicity; spirituality; concepts
such as assimilation, acculturation, etc.
Culturally competent care -Know self, understand own heritage
-Identify meaning of health to someone else
-Understand health care delivery system
-Gain knowledge re social backgrounds of clients
-Be familiar with language, resources for interpreters, resources within
, community
Ethnicity Associated with culture; awareness of belonging to a group in which
certain characteristics differentiate from one group to another
-Includes nationality, regional culture, language, ancestry
-Ex: Egyptian, Swedish, Mexican, Jewish, etc.
Spirituality -Borne out of each person’s unique life experience and his or her personal
effort to find purpose and meaning in life.
-Comes from person’s life experiences
-Attempt to find meaning and purpose of life
-More abstract
-Relationship of self and something larger
Ethnocentrism To believe one’s own beliefs or way of life is ‘superior’; will interfere with
collection and interpretation of data, your development of a plan of care
may be skewed; must be aware of your own biases
Acculturation Adapting to and acquiring another culture
Assimilation Developing new cultural identity and becoming like the dominant culture
Biculturalism Divided loyalty, identifies with two cultures
3. Therapeutic communication: examples of effective and ineffective techniques e.g. clarification,
reflection, blaming, etc.
Therapeutic The face-to-face process of interacting that focuses on advancing the physical and
communications emotional well-being of a patient. Nurses use therapeutic communication techniques
to provide support and information to patients.
Examples of -Open ended questions: tell me about, how are you doing today
Therapeutic -Closed ended questions: do you have pain
communications -Facilitation: nodding yes, uh-huhh
-Encourages client to say more; shows person you are interested
-Reflection: echoes words, repeat part of what was said
-Clarification: summarize, simplify
-Useful when patient’s word choice is ambiguous and confusing
-Silence: Communication that client has time to think; silence can be uncomfortable;
provides you w/ chance to observe client and note nonverbal cues
-Empathy: Names a feeling and allows its expression
-Consider your body language; consider cultural differences
Barriers to -Lack of interest or attention/lack of respect
communication -Physical barriers: a curtain, a door, a computer, a monitor, pain, room temperature
-The patient’s inability to hear you, hearing deficit, or language barrier
-Language/ use of jargon, or speaking above someone’s educational level
-Safety: fear
-Psychological barriers: embarrassment, disbelief, shock, anger, fear, grief, fatigue,
hostility
1. Geriatrics: functional assessment-what is being tested, best approach to testing; caregiver
concerns; IADLs, ADLs; disability concerns; tools to assess
What is being tested -Identify strengths
-Identify limitations – so interventions can be recognized
-Independence and prevention of functional decline
Best approach to testing
Caregiver concerns -Decrease in attention, memory, orientation, language, planning and
making decisions
-Depression is not a normal change
-Persistent depression – is concerning if it interferes with ADL’s
-Eating
IADLs Instrumental activities of daily living
-measures functional abilities necessary for independent community living
-includes shopping, meal preparation, house-keeping, laundry, managing
finances, taking medications, and using transportation
ADLs Activities of daily living
-tasks necessary for self-care
-measure domains of eating/feeding, bathing, grooming, dressing, toileting,
walking, using stairs, and transferring
Disability concerns
Tools to assess -Katz Activities of Daily Living
-The Lawton Instrumental Activities of Daily Living Scale
-Hospital Admission Risk Profile
-Geriatric Depression Scale (short form)
-Inspect for lesions and moles – irregular shapes, change in size or color
-Check for pressure ulcers especially sacrum, heels & trochanters
-Clubbing – cardiac or pulmonary disorder
-Pitting/transverse groves – peripheral vascular disease, arterial
insufficiency, or diabetes
-Brittleness – decreased vascular supply
-Yellow or brown nails – fungal infection
-Look for limited range of motion – arthritis or muscle weakness causing
pain and discomfort
-While assessing range of motion – watch for reports of pain, dizziness,
jerky or abnormal movements: may indicate fractured vertebrae,
Parkinson’s disease, transient ischemic attack, or stroke
-Look for facial symmetry (asymmetry may indicate a stroke)
-Bowel sounds; Look for hernias, pulsatile masses
-Evaluate muscles for atrophy, tremors, and involuntary movements
-Note warmth, swelling, tenderness, crepitus and deformities
2. Cultural assessment: culturally competent care; definition of ethnicity; spirituality; concepts
such as assimilation, acculturation, etc.
Culturally competent care -Know self, understand own heritage
-Identify meaning of health to someone else
-Understand health care delivery system
-Gain knowledge re social backgrounds of clients
-Be familiar with language, resources for interpreters, resources within
, community
Ethnicity Associated with culture; awareness of belonging to a group in which
certain characteristics differentiate from one group to another
-Includes nationality, regional culture, language, ancestry
-Ex: Egyptian, Swedish, Mexican, Jewish, etc.
Spirituality -Borne out of each person’s unique life experience and his or her personal
effort to find purpose and meaning in life.
-Comes from person’s life experiences
-Attempt to find meaning and purpose of life
-More abstract
-Relationship of self and something larger
Ethnocentrism To believe one’s own beliefs or way of life is ‘superior’; will interfere with
collection and interpretation of data, your development of a plan of care
may be skewed; must be aware of your own biases
Acculturation Adapting to and acquiring another culture
Assimilation Developing new cultural identity and becoming like the dominant culture
Biculturalism Divided loyalty, identifies with two cultures
3. Therapeutic communication: examples of effective and ineffective techniques e.g. clarification,
reflection, blaming, etc.
Therapeutic The face-to-face process of interacting that focuses on advancing the physical and
communications emotional well-being of a patient. Nurses use therapeutic communication techniques
to provide support and information to patients.
Examples of -Open ended questions: tell me about, how are you doing today
Therapeutic -Closed ended questions: do you have pain
communications -Facilitation: nodding yes, uh-huhh
-Encourages client to say more; shows person you are interested
-Reflection: echoes words, repeat part of what was said
-Clarification: summarize, simplify
-Useful when patient’s word choice is ambiguous and confusing
-Silence: Communication that client has time to think; silence can be uncomfortable;
provides you w/ chance to observe client and note nonverbal cues
-Empathy: Names a feeling and allows its expression
-Consider your body language; consider cultural differences
Barriers to -Lack of interest or attention/lack of respect
communication -Physical barriers: a curtain, a door, a computer, a monitor, pain, room temperature
-The patient’s inability to hear you, hearing deficit, or language barrier
-Language/ use of jargon, or speaking above someone’s educational level
-Safety: fear
-Psychological barriers: embarrassment, disbelief, shock, anger, fear, grief, fatigue,
hostility
