NUR 2092 Final Exam : 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
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, -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 -Know self, understand own heritage
care -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
communicatio the physical and emotional well-being of a patient. Nurses use
ns 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
communicatio -Facilitation: nodding yes, uh-huhh
ns -Encourages client to say more; shows person you are interested
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, -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
communicatio -Physical barriers: a curtain, a door, a computer, a monitor, pain,
n 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
10 Traps of 1. Providing false assurance or reassurance
Interviewing 2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions
-Advising, defending, disagreeing, disapproval, giving approval,
reassuring, requesting an explanating
4. General survey – what is included?
General -Begins with first contact
Survey -General impression of client (age, sex, loc, 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)
Temperature Normal range: 97.8°F to 99.1°F/average 98.6°F
Heart rate Normal: 50-90 beats per minute.
-Bradycardia: A resting heart rate less than 50 beats/min
-Tachycardia: A more rapid heartbeat, defined as over 95 beats/min
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, or over 100 beats/min.
Respiratory Normal: 10-20 breaths per minute; relaxed, regular, automatic, and
rate silent
Blood Normal: 90/60 mm/Hg to 120/80 mm/Hg.
pressure
5. Nutrition: Dietary assessment; abnormal eating patterns
Dietary An in-depth evaluation of both objective and subjective data related
assessment to an individual's food and nutrient intake, lifestyle, and medical
history. Once the data on an individual is collected and organized,
the practitioner can assess and evaluate the nutritional status of
that person.
· Food and fluid intake (24 hour recall is always the first thing
done)
· Nutritional status and risk factors
· Anthropometric measurements, biochemical tests, and
nutrition-focused questions
· Swallowing assessment prn
· Ask questions about nutritional health (ex: what are the
important components of a healthy diet, what are the risk
factors for poor diet, any questions about weight loss/gain?)
*Nutritional status: refers to the degree of balance between nutrient
intake and nutrient requirements (over nutrition, undernutrition,
weight loss problems, weight gain problems, difficulty
chewing/swallowing, obesity, anorexia nervosa, binge eating,
bulimia)
Abnormal -Overnutrition: overweight or obesity; can lead to obesity and risk
eating factor for: heart disease, hypertension, type 2 diabetes, stroke,
patterns gallbladder disease, sleep apnea, certain cancers, osteoarthritis
-Undernutrition: occurs when nutritional reserves are depleted or
when nutrient intake is inadequate to meet day-to-day needs or
added metabolic demands; risk for: impaired growth and
development, lowered resistance to infection and disease, delayed
wound healing, longer hospital stays, higher health care cost
-Obesity: greater energy intake than energy expenditure; caused by
genetics, overeating, and inactivity; excessive adipose tissue on
face, neck, trunk, and extremities; overweight- bmi greater than 25;
obesity- bmi greater than 30
-Hyperlipidemia: elevated serum lipids
-Anorexia Nervosa: refusing to eat; extreme thinness; other
symptoms of protein calorie malnutrition
-Binge eating: consumption of large quantities; feels of being out of
control
-Bulimia: recurrent binge-and-purge eating cycles; electrolyte
imbalances; chronic irritation or erosion of pharynx, esophagus, and
teeth
Page 4 of 44
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
Page 1 of 44
, -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 -Know self, understand own heritage
care -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
communicatio the physical and emotional well-being of a patient. Nurses use
ns 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
communicatio -Facilitation: nodding yes, uh-huhh
ns -Encourages client to say more; shows person you are interested
Page 2 of 44
, -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
communicatio -Physical barriers: a curtain, a door, a computer, a monitor, pain,
n 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
10 Traps of 1. Providing false assurance or reassurance
Interviewing 2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions
-Advising, defending, disagreeing, disapproval, giving approval,
reassuring, requesting an explanating
4. General survey – what is included?
General -Begins with first contact
Survey -General impression of client (age, sex, loc, 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)
Temperature Normal range: 97.8°F to 99.1°F/average 98.6°F
Heart rate Normal: 50-90 beats per minute.
-Bradycardia: A resting heart rate less than 50 beats/min
-Tachycardia: A more rapid heartbeat, defined as over 95 beats/min
Page 3 of 44
, or over 100 beats/min.
Respiratory Normal: 10-20 breaths per minute; relaxed, regular, automatic, and
rate silent
Blood Normal: 90/60 mm/Hg to 120/80 mm/Hg.
pressure
5. Nutrition: Dietary assessment; abnormal eating patterns
Dietary An in-depth evaluation of both objective and subjective data related
assessment to an individual's food and nutrient intake, lifestyle, and medical
history. Once the data on an individual is collected and organized,
the practitioner can assess and evaluate the nutritional status of
that person.
· Food and fluid intake (24 hour recall is always the first thing
done)
· Nutritional status and risk factors
· Anthropometric measurements, biochemical tests, and
nutrition-focused questions
· Swallowing assessment prn
· Ask questions about nutritional health (ex: what are the
important components of a healthy diet, what are the risk
factors for poor diet, any questions about weight loss/gain?)
*Nutritional status: refers to the degree of balance between nutrient
intake and nutrient requirements (over nutrition, undernutrition,
weight loss problems, weight gain problems, difficulty
chewing/swallowing, obesity, anorexia nervosa, binge eating,
bulimia)
Abnormal -Overnutrition: overweight or obesity; can lead to obesity and risk
eating factor for: heart disease, hypertension, type 2 diabetes, stroke,
patterns gallbladder disease, sleep apnea, certain cancers, osteoarthritis
-Undernutrition: occurs when nutritional reserves are depleted or
when nutrient intake is inadequate to meet day-to-day needs or
added metabolic demands; risk for: impaired growth and
development, lowered resistance to infection and disease, delayed
wound healing, longer hospital stays, higher health care cost
-Obesity: greater energy intake than energy expenditure; caused by
genetics, overeating, and inactivity; excessive adipose tissue on
face, neck, trunk, and extremities; overweight- bmi greater than 25;
obesity- bmi greater than 30
-Hyperlipidemia: elevated serum lipids
-Anorexia Nervosa: refusing to eat; extreme thinness; other
symptoms of protein calorie malnutrition
-Binge eating: consumption of large quantities; feels of being out of
control
-Bulimia: recurrent binge-and-purge eating cycles; electrolyte
imbalances; chronic irritation or erosion of pharynx, esophagus, and
teeth
Page 4 of 44
