NUR 2092 Health assessment
Exam 1 study Guide
Nursing Process steps- assessment, diagnosis, outcome identification, planning, implementation,
evaluation
Communication: open ended questions ask for a narrative response use in following situations:
to begin interview, introduce new section of interview, whenever the patient introduces a new
topic. Closed ended questions ask for specific information, use in following situations: after
opening narrative questions, when you need specific facts about past health problems, to move
interview along. These are yes and no questions.
o Therapeutic communication techniques: active listening, communication validation,
assurance, empathy, support
Keys to this are active listening, full attention, avoid interruptions, evidence of
understanding, validating concerns
o Barriers to communication: the ten traps of interviewing- providing false assurance or
reassurance, giving unwanted advice, using authority, using avoidance language,
engaging in distancing, using professional jargon, using leading or biased questions,
talking too much, interrupting, using why questions.
Communication barrios: blaming, patronizing, false reassurance, failure to
listen, changing the subject or topic
Pain:
o Types of pain: Acute pain is short term and self-limiting, often follows a predictable
trajectory, will dissipate after the injury heals. Chronic or persistent pain is diagnosed
when pain continues for 6 months or longer. Chronic pain can be further divided into
malignant (cancer related) and nonmalignant. Referred pain also called reflective pain,
pain perceived at a location other than the site of the painful stimulus. Phantom pain:
pain sensations are described as perceptions that an individual experiences relating to a
limb or an organ that is not physically part of the body.
o How to assess pain: Where is your pain? When did your pain start? What does your pain
feel like? (ex: burning, sharp, stab, shooting, dull) How much pain do you have now?
What makes pain better or worse? How does pain limit your activities? What does this
pain mean to you? How do you act in pain, how do others know you are in pain? pick
pain rating tool appropriate for patient population ( numeric scale, Wong baker, oucher,
Cries)
o Initial pain assessment
o Brief pain inventory: asks patient to rate pain within past 24hours on graduated scales
(0-10)
o Short form McGill pain questionnaires: asks patient to rank list of descriptors in terms
of their intensity and to give an overall intensity rating to his or her pain
o Neuropathic pain: indicates types of pain that does not adhere to typical phases
inherent in nociceptive pain
o Nociceptive pain: the instant pain response to touching something hot, protects body
from injury
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:49:27 GMT -05:00
https://www.coursehero.com/file/34513691/NUR-2092-Health-assessment-test-1-study-guidedocx/
, o Numeric rating scales: ask patient to choose a number that rates level of pain
o Verbal descriptor scales: have the patient use words to describe the pain
o Visual analog scales: have the patient mark the intensity of the pain on a horizontal line
from no pain to worst pain
o Physiologic changes with pain: patient can become withdrawn, act out, aggressive,
grimacing, diaphoresis, guarding, and vocalizing location of pain. Behaviors to pain are
influenced by nature of pain, age, cultural and gender expectations as well.
Alcohol and substance abuse:
o How to assess: Cage test: have you ever thought you should CUT down on drinking.
Have you ever been ANNOYED by criticism of your drinking? Have you ever felt GUILTY
about your drinking? Do you drink in the morning, an EYE opener?
Domestic violence/ human trafficking: is the patient comfortable with who they are in the
room? What is their behavior towards person they are with? Stall- do not let patient leave with
person they are with. Follow facility protocols for reporting instance. Call 911 if in immediate
danger. These screenings should be done every office visit.
Nutrition: refers to the degree of balance between nutrient intake and nutrient requirements.
o Factors that can affect nutritional status: undernutrition is when nutritional needs are
not met or depleted. Vulnerable groups are infants, children, pregnant women, recent
immigrants, persons with low income, hospitalized patients, aging adults—this places
the preceding people at risk for impaired growth and development, lowered resistance
to infections and disease, delayed wound healing, longer hospital stays, higher health
care costs. Over nutrition- is caused by consumption of nutrients in excess from what
the body needs. This can lead to heart disease and hypertension, type II diabetes, stroke,
gallbladder disease, sleep apnea, certain cancers, osteoarthritis
o Methods of assessing nutrition in health history: knowing what the patient typically
eats, what do they drink, what is their religion? Admission nutrition screening tool.
Dietary history and clinical information. Physical examination for clinical signs,
anthropometric measures, lab tests.
24hr recall
Food frequency questionnaires
Food diary
During hospitalization, documentation of nutritional intake can best be achieved
through calorie counts of nutrients consumed or infused
Subjective data: Eating patterns, usual weight, changes in appetite, taste, smell
chewing, swallowing, recent surgery, trauma, burns, infection, chronic illnesses,
vomiting, diarrhea, constipation, food allergies or intolerances, medications or
nutritional supplements, self-care behaviors, alcohol or illegal drug use, exercise
and activity patterns
o Issues that affect nutrition status across the lifespan:
o How to calculate BMI: kilograms divided by meters
Vital signs:
o Normal vital signs: Normal oral temp is 96.4-99.1F, pulse is 60-100, respirations 12-20,
BP 120/80, o2- 90-100% on RA
o Abnormal vital signs- temp < 96.4 or <99.1F, pulse is <60 or <100, resps <12 >25, BP
>130/90 or < 90/60, <90% on RA with no respiratory disease
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:49:27 GMT -05:00
https://www.coursehero.com/file/34513691/NUR-2092-Health-assessment-test-1-study-guidedocx/
Exam 1 study Guide
Nursing Process steps- assessment, diagnosis, outcome identification, planning, implementation,
evaluation
Communication: open ended questions ask for a narrative response use in following situations:
to begin interview, introduce new section of interview, whenever the patient introduces a new
topic. Closed ended questions ask for specific information, use in following situations: after
opening narrative questions, when you need specific facts about past health problems, to move
interview along. These are yes and no questions.
o Therapeutic communication techniques: active listening, communication validation,
assurance, empathy, support
Keys to this are active listening, full attention, avoid interruptions, evidence of
understanding, validating concerns
o Barriers to communication: the ten traps of interviewing- providing false assurance or
reassurance, giving unwanted advice, using authority, using avoidance language,
engaging in distancing, using professional jargon, using leading or biased questions,
talking too much, interrupting, using why questions.
Communication barrios: blaming, patronizing, false reassurance, failure to
listen, changing the subject or topic
Pain:
o Types of pain: Acute pain is short term and self-limiting, often follows a predictable
trajectory, will dissipate after the injury heals. Chronic or persistent pain is diagnosed
when pain continues for 6 months or longer. Chronic pain can be further divided into
malignant (cancer related) and nonmalignant. Referred pain also called reflective pain,
pain perceived at a location other than the site of the painful stimulus. Phantom pain:
pain sensations are described as perceptions that an individual experiences relating to a
limb or an organ that is not physically part of the body.
o How to assess pain: Where is your pain? When did your pain start? What does your pain
feel like? (ex: burning, sharp, stab, shooting, dull) How much pain do you have now?
What makes pain better or worse? How does pain limit your activities? What does this
pain mean to you? How do you act in pain, how do others know you are in pain? pick
pain rating tool appropriate for patient population ( numeric scale, Wong baker, oucher,
Cries)
o Initial pain assessment
o Brief pain inventory: asks patient to rate pain within past 24hours on graduated scales
(0-10)
o Short form McGill pain questionnaires: asks patient to rank list of descriptors in terms
of their intensity and to give an overall intensity rating to his or her pain
o Neuropathic pain: indicates types of pain that does not adhere to typical phases
inherent in nociceptive pain
o Nociceptive pain: the instant pain response to touching something hot, protects body
from injury
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:49:27 GMT -05:00
https://www.coursehero.com/file/34513691/NUR-2092-Health-assessment-test-1-study-guidedocx/
, o Numeric rating scales: ask patient to choose a number that rates level of pain
o Verbal descriptor scales: have the patient use words to describe the pain
o Visual analog scales: have the patient mark the intensity of the pain on a horizontal line
from no pain to worst pain
o Physiologic changes with pain: patient can become withdrawn, act out, aggressive,
grimacing, diaphoresis, guarding, and vocalizing location of pain. Behaviors to pain are
influenced by nature of pain, age, cultural and gender expectations as well.
Alcohol and substance abuse:
o How to assess: Cage test: have you ever thought you should CUT down on drinking.
Have you ever been ANNOYED by criticism of your drinking? Have you ever felt GUILTY
about your drinking? Do you drink in the morning, an EYE opener?
Domestic violence/ human trafficking: is the patient comfortable with who they are in the
room? What is their behavior towards person they are with? Stall- do not let patient leave with
person they are with. Follow facility protocols for reporting instance. Call 911 if in immediate
danger. These screenings should be done every office visit.
Nutrition: refers to the degree of balance between nutrient intake and nutrient requirements.
o Factors that can affect nutritional status: undernutrition is when nutritional needs are
not met or depleted. Vulnerable groups are infants, children, pregnant women, recent
immigrants, persons with low income, hospitalized patients, aging adults—this places
the preceding people at risk for impaired growth and development, lowered resistance
to infections and disease, delayed wound healing, longer hospital stays, higher health
care costs. Over nutrition- is caused by consumption of nutrients in excess from what
the body needs. This can lead to heart disease and hypertension, type II diabetes, stroke,
gallbladder disease, sleep apnea, certain cancers, osteoarthritis
o Methods of assessing nutrition in health history: knowing what the patient typically
eats, what do they drink, what is their religion? Admission nutrition screening tool.
Dietary history and clinical information. Physical examination for clinical signs,
anthropometric measures, lab tests.
24hr recall
Food frequency questionnaires
Food diary
During hospitalization, documentation of nutritional intake can best be achieved
through calorie counts of nutrients consumed or infused
Subjective data: Eating patterns, usual weight, changes in appetite, taste, smell
chewing, swallowing, recent surgery, trauma, burns, infection, chronic illnesses,
vomiting, diarrhea, constipation, food allergies or intolerances, medications or
nutritional supplements, self-care behaviors, alcohol or illegal drug use, exercise
and activity patterns
o Issues that affect nutrition status across the lifespan:
o How to calculate BMI: kilograms divided by meters
Vital signs:
o Normal vital signs: Normal oral temp is 96.4-99.1F, pulse is 60-100, respirations 12-20,
BP 120/80, o2- 90-100% on RA
o Abnormal vital signs- temp < 96.4 or <99.1F, pulse is <60 or <100, resps <12 >25, BP
>130/90 or < 90/60, <90% on RA with no respiratory disease
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:49:27 GMT -05:00
https://www.coursehero.com/file/34513691/NUR-2092-Health-assessment-test-1-study-guidedocx/
