NURSING 200 Health Assessment Exam one

NURSING 200 Health Assessment Exam one Ch. One The Nursing process: • Assessment: Promotes health at the highest level -Can evaluate results of vitals from a patient - All about finding an outcome for the patient • Diagnosis: Making a clinical judgment based on the assessment data provided about the pt. -Critical thinking and diagnostic reasoning • Identify outcomes: Making the most realistic goal for the patients need in order to prevent illness and promote health. • Planning: Determining resources such as pt, target interventions, and writing plan of care. • Implement: Any treatment strategies done in order to provide the best outcome for the patient • Evaluation: Based on patient’s responses from the intervention. Knowing if the outcome was made. Types of Nursing Assessments: • Emergency assessment: Occurs in a life threatening or in an unstable situation A: airway B: Breathing C: Circulation D: Disability E: Exposure • Comprehensive Assessment: Includes a complete health history and physical assessment. A head to toe assessment. (More board- occurs in admission for school or outpatient wellness check ups for example) • Focused Assessment: This occurs when your paying attention to a specific body system or part. For example- A patient has major pain on lower left leg you focus on that leg or if patient has a cough you focus on respiratory. Definition: Priority Setting- Based on a Nurse’s clinical experience, knowledge, expertise, and judgment. *In life-threatening situation always address that as ur top priority, rather than someone who need a bandage change or an elevated temperature* Frequency Assessment • Most frequent visits occur when patient is at their youngest years (Growth and development) - Long term care facilities assess once a month - Acute care facilities assess per shift - Critical/Intensive Care assess hourly SUBJECTIVE DATA VS. OBJECTIVE DATA • Subjective: Data collection based on the patient’s experiences and perceptions. The patient will describe- feelings, sensations, or expectations and the nurse will document them. • Objective Data: Is data collected based on the patient’s visual appearance, as well as taking vital signs and assessing on peripheral circulation(Pulse). Other examples include full head to toe. And appearance/behaviors *Collecting Subjective and Objective data is ESSENTIAL for legal documentation, accurate findings, as well as communicating with others for these findings (EX: fam members/ PCP) * Definition: SBAR communication- used in order to make recommendations about treatment that is indicated to other providers who are involved with the same patient. Cultural Competent Care • Based on combinations of knowledge, attitudes, skills, a health care provider uses to deliver care to that patient. Some cues to look for: 1.)Dress 2.)Food 3.)Religion 4.)Family Health Models • Health Belief Model- Health behavior determined by the Person’s personal beliefs/ perceptions about the disease and strategies available in order to decrease occurrence and help change their perception. ( EX. A person who doesn’t think they will get skin cancer will be less likely to apply sunscreen/skin protection) • Diagnostic Reasoning Model- Based on the nurse’s critical thinking process that is hypothesis driven and leads to a diagnosis that best explains evidence from the subjective/ objective data. Preventions (HEALTHY PPL MODEL): Risk reduction • Primary Prevention- Involves strategies aimed to prevent problems. (EX: Immunizations, health teaching, safety, nutrition counseling.) Secondary prevention- Includes early diagnosis of health problems and prompts treatment in order to prevent complications. (EX: different testing, pap smears, hearing/vision tests, etc.) Tertiary prevention: Focuses on a way to prevent further complication of an existing illness/disease in patient. (EX: Diet teaching, exercise, medications, etc.) Ch. Two Building rapport/ Communication • Communication is vital for the basis of building interpersonal relationships with patients. • Therapeutic Communication: This communication primarily focuses on the patient and the patient’s concerns. Listen to their feelings and concerns - Caring for patient provided a connection with them. Goal is to show ur interested and have respect. - Empathy is the ability to perceive, reason and communicate understand with the other person’s feelings. (EX: handing over a tissue when they are feeling sad or giving them a hung) - Self concept- being aware of ur own biases, values, personality, culture, and communication style. • Non Verbal communication - Avoid closed closed positions (Don’t cross arms) - Give eye contact *Some cultures- prolong contact can be threatening * - No eye contact at all = uninterested • Verbal Communication: - Too soft= embarrassment/ discomfort - Too loud= powerful/controlling - Too fast= feeling rushed - Too slow= make pt think they have impaired cognitive ability - Hearing impairment= focus on lip reading - Language impairment= be simple and clear not too loud • Active Listening: Focus on patient and their perspective. If patient is sad it is appropriate to place ur hand over theirs and give facial expression that shows care/compassion • Restate: If patient says I have a knot on my chest= nurse says so you have a knot on chest? Patient will then elaborate and further explain. • Elaborate: Make sounds and gestures to have patient continue speaking (Uh-hum, go on, yes) Interview Process Phases • Preinteraction phase- Before meeting your patient, you gather and collect data from medical record including, past history of illness, surgeries, medication list, problem list. • Beginning Phases: Introduce urself to the patient and introduce the purpose of the interview. • Working phase- collect data by asking specific questions -Closed Ended Questions: specific yes and no questions or ask “is pain sharp or dull” - Open ended questions: this includes more board responses example is “What does your pain feel like?” - Nurse charts patient’s health history and problems before going onto physical assessment. • Closing phase- Is a summary based on the most important patterns and problems discussed. -Review what was documented and discussed and make notes for future interventions Definitions: Primary Data- The main source is the patient themselves Secondary Data- sources from charts, labs, and family members Components of Health History • Demographic data- Collected first - Collecting name, DOB, address, age, sex, Occupation, billing info (health insurance) • Seeking Care- Ask patient why they are here and record objective/subjective info and symptoms • History of Preset Illness: Assessing present illness O- onset P-palliative L-locations Q-quality D-duration R-region C-characteristic S-severity A-aggravating factors T-timing R-relieving factors U-understanding T-time S-severity C-character O-Onset L-location D-duration S-severity P-pattern A-pain assessment • Past Health History- -Childhood Illness -Past Illness Surgeries -Injury -Trauma -Health screening -Genomics: Family and marriage Ch. Five Components of general survey • Begins the moment you encounter the patient. It is apart of interview phase of the health assessment (first component) • When preparing assessment let patient rest 5 min/ lose anxiety *No food, drink, smoking for 30 mins because vitals will fluctuate* - Consists of: - First impression - Observation - Health history collection - Data collection • Assess: - Dress - Hygiene - Range of motion (joint movement) - Speech - Level of consciousness - Skin color - Behavior - Facial expression - Development - Body structure - Posture - Gait - Tape measure- infant head circumference Anthropometric Measurement • Measure the patient’s height and weight • Provides a baseline of measurement *Muscle heavier than fat * Vital Signs/Objective data • Make sure pt is relaxed for 5 mins • No food, drink, smoke for 30 mins prior examination • Patient can be sitting or laying supine (Can decrease BP tho) when taking vitals (no legs crossed) • Equipment needed: -Scale: weight -Height Bar: Height -Steth: auscultate heart and lung sounds -Therm: measure pt’s body temp -watch with second hand -BP cuff: measure pt’s bp -Pulse OX- measure pt’s O2 • Most accurate when doing on bare skin. • Sometimes only one vital can be done (ex: cardiac- focus on BP, heart rate, fever- temperature) Temperature • Hypothalamus is the body’s thermostat. • Overall Normal temp (ORAL) = 36.5-37 degree Cel or 97.7-98.6 F • RECTAL - 37.1- 38.1 - MOST ACCURATE (CORE) - Do not use when= rectal surgery, diarrhea, hemorrhoids, low WBC, cardiac problem - Mainly used on infants • ORAL - Most commonly used - No fever= AFBRIL - DO not use when = oral surgery, mental status, mouth breathing, smoking. - Chemo patient use other route bc mouth temp is warmer than normal • TEMPORAL - DO not use when= diaphoresis • TYMPANIC -Do not use when= ear