HEALTH ASSESSMENT(HA) Exam 5 Study Guide QUESTIONS AND ANSWERS 100% CORRECT

Ch. 1 Diagnostic Reasoning process of analyzing health data & drawing conclusions to identify diagnoses Hypothesis forming & Deductive Reasoning: 1.) attending to cues (piece of info) 2.) forming diagnostic hypothesis 3.) gathering relative data 4.) evaluating & arriving at final diagnosis Nursing Process assessment diagnosis outcome identification planning implementation evaluation Novice nurse has no experience w specific pt populations & uses rules to guide performance. Competency nurse *2 to 3 years post graduation *Ability to see actions in context of arching goals or daily plans for pts Proficient nurse understands pt situation as whole rather than list of tasks, attends to assessment data pattern, & acts w/out consciously labeling it Expert nurse vault over steps & arrive at a clinical judgment in one leap *has intuition (knowledge received as a whole) First-level priority problems emergent, life-threatening, & immediate, such as establishing an airway or supporting breathing Second-level priority problems those next in urgency requiring prompt intervention to forestall further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results Third-level priority problems those important to pt's health but can be addressed after more urgent health problems are addressed -interventions to treat these problems are more long term, & response takes more time (Knowledge deficit, altered family processes, low self esteem) Collaborative Problems those in which approach to treatment involves multiple disciplines -nurses have primary responsibility to diagnose onset & monitor change in mental status -once identified problem, identify expected outcomes & work to achieve Principles of Setting Priorities 1.) Make complete list of current meds, medical problems, allergies, & reasons for seeking care. Refer to frequently, bc may affect how to set priorities. 2. Determine relationships among problems: If problem Y causes problem Z, problem Y takes priority over problem Z Setting priorities is a dynamic, changing process; at times, order of priority changes, depending on seriousness & relationship of problems Steps to Setting Priorities 1. Assign First-level priority problems (immediate priorities): "ABCV" A- airway problems B- breathing problems C- cardiac/circulation problems V- vital sign concerns 2. Next, Second-level priority problems: -Mental status change (confusion, decreased alertness) -Untreated med problems requiring immediate attention (diabetic who has not had insulin) -Acute pain, Acute urinary elimination problems -Abnormal lab values -Risks of infection, safety, or security 3. Address Third-level priority problems (later priorities): lack of knowledge, family coping, rest Evidence-Based Practice (EBP) combination of: -pt preferences & values -evidence from research -physical exam & assessment -clinical expertise to make decisions about care & treatment Complete (Total Health) Database Includes complete health history & full physical exam Describes current & past health state & forms baseline to measure all future changes Yields first diagnoses Focused or Problem-Centered Database used for a limited or short-term problem. smaller in scope & more targeted than complete database: "mini" database Follow-Up Database used in all settings to monitor progress of short-term or chronic health problems Emergency Database rapid collection of the database, often compiled concurrently w lifesaving measures Holistic Health view that mind, body, & spirit are interdependent and function as a whole w/in environ. Guide to Exam: 1.) Screening history: dietary intake, physical activity, tobacco/alcohol/drug use 2.) Physical exam: height & weight, BP, & screening for cervical cancer & HIV 3.) Counseling: for physical activity & risk prevention (second-hand smoke, seatbelt use) 4.) Depression screening 5.) Healthy diet: counseling, including lipid disorder screening & obesity screening 6.) Chemoprophylaxis: include multivitamin w folic acid (females planning or pregnant) Ch. 3: The interview 1.) gather data about pt health state -subjective & objective data 2.) establish trust 3.) teach the pt about their health state - sometimes have misunderstanding 4.) Build rapport for continuing therapeutic relationship (facilitates future diagnosis, planning, & treatment) 5.) discuss health promotion & disease prevention Interview Goals *record complete health hx *identify problems so you know what to assess, guides physical exam *mutual goal is optimal health for pt Consider interview as a ________ b/w nurse and patient. Contract Contract consists of spoken & unspoken rules for behavior: -what pt needs & expects & what health professional offers Process of Communication Awareness of internal and external factors and their influence allows you to maximize communicating skill -Internal & External factors Internal Factors *liking others *empathy -feeling with pt instead of feeling like pt *ability to listen -active listening *Self awareness -understanding personal bias, prejudices, & stereotypes External Factors Ensure privacy -be careful who you speak in front of Refuse interruptions Physical Environment -room temp comfortable -quiet room -remove distractions -place distance 4-5 ft from pt -equal-status seating (comfortable & eye level) -avoid standing bc it assumes superiority & communicates haste Dress -pt remain in reg. clothes, gown may make pt feel exposed & uncomfortable Note taking -may be unavoidable -Cant rely on memory for details -breaks eye contact -shifts attention away from pt -impedes observation -threatening to pt -keep at a minimum *Tape & Video Record -dont let become a barrier b/w pt; really look at policies Process of Communication: Sending "How you send the message" Communication is behavior, conscious & unconscious, verbal and nonverbal All behavior has meaning Body Language - way you look & hold yourself Body Language posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair Process of Communication: Receiving Awareness of messages you send is only part of process -Words & gestures interpreted in specific context to have meaning Receiver attaches meaning determined by past experiences, culture, self-concept, & current physical /emotional state Pts' health problems intensify communication bc pts depend on you to get better Successful communication requires... mutual understanding by sender & receiver Introducing the Interview 1.) address pt using surname (last) unless child or adolescent & shake hands if comfortable 2.) introduce yourself & state role (student, nurse, etc) 5.) give reason of interview 6.) ask open ended question RAPPORT IS BUILT DURING THE INTRODUCTION Working Phase of Interview *data gathering phase *verbal skills include you questions & response to pt -open & closed questions Open-Ended Questions *asks for narrative (story-like) response -unbiased, states topic to be discussed but only in general terms -ex. "Tell me how can I help you?" ; "What brings you to the hospital?" *eye contact & listen as pt answers; lean forward & look interested Closed (Direct) Questions *asks for specific info *Elicit short, one-or-two word answers, a yes or no answer, or forced choice *Used to: -to fill in details pt may have left out -When need specific facts about past health problems, or during review of systems -To move interview along 1.)ask only one direct question at a time 2.) choose language pt understands Verbal Responses *NINE different types: first 5 involve YOUR reactions to facts or feelings pt communicated: -your responses focus on pt frame of reference, yours doesnt enter into response 1.) facilitation 2.) silence 3.) reflection 4.) empathy 5.) clarification last 4 responses YOU express own feelings & thoughts: 6.) confrontation 7.) interpretation 8.) explanation 9.) summary *in first 5 responses pt leads convo, last 4 responses you lead Facilitation Response encourages pt to say more & shows youre interested -"mm-hmm, go on, uh-huh" -nodding yes -maintaining eye contact, shifting forward Silent Attentiveness Response *communicates pt has time to think; interruption can make pt lose thought *gives chance to observe nonverbal cues of pt -sitting quietly (dont fidget) -counting silently 1-10 Reflection Response *repeating what pt just said; can help pt elaborate on specific problem/phrase Empathy Response *Recognizes feeling & puts into words *Names feeling & allows expression of it -Pt feels accepted & can deal w feeling openly Clarification Response *Use when pt words are ambiguous or confusing -Used to summarize pts words & simplify to make clearer *You are asking for agreement, & pt can then confirm or deny your understanding Confrontation Response *Frame of reference shifts from pt's perspective to yours *focus on inconsistency in pt's narrative -observed a certain action, feeling, or statement & now focus pt's attention on it -give honest feedback about what you see/feel Interpretation Response *links events, makes associations, & implies cause *not based on direct observations but inference or conclusion *interpretation may be incorrect but helps promote convo *helps pt understand own feelings in relation to verbal message Explanation Response *inform pt; share factual & objective info offering reasons for requirements or actions Summary Response *Final review of what pt said; condenses facts & presents your view of health problem *type of validation that pt can agree w/ or correct; both you & pt should participate *end of interview, signals termination of interview is near Ten traps of Interviewing: 1.) Providing false assurance or reassurance 2.) Giving unwanted advice -provide approp. info, if "personal opinion" likely inapprop. 3.) Using authority -"your doctor/nurse knows best" diminishes communication -both have equal important roles 4.) Using avoidance language -euphemisms instead of discussing unpleasant topics: "passed away" instead of "died" -best way to deal w uncomfortable topics is w direct language 5.) Engaging in distancing -pt use to avoid admitting they have problem; if you use it then it imploes you are afraid of procedure disease -"there is a lump in THE left breast" ; using "the" instead of "your" 6.) Using professional jargon -important to adjust vocab to ensure understanding w/out sounding condescending 7.) Using leading or biased questions -"you dont smoke, do you?" or "you dont have unprotected sex, correct?" -shows disapproval, makes pt feel guilty 8.) Talking too much -listen more than you talk 9.) Interrupting -signals impatience or boredom 10.) Using "why" questions -implies blame or condemnation -"why did you take so much medication?" Nonverbal Skills Physical appearance Posture Gestures Facial expression Eye contact Voice Touch Closing interview gracefully not abrupt Positive Nonverbal Communication *Appropriate professional appearance *Equal-status seating *close proximity to pt *relaxed, open posture; leaning slightly foward *facial animation, interested *appropriate smiling & eye contact *moderate tone & rate of speech *appropriate touch Negative Nonverbal Communication *Appearance objectionable to pt *standing; sitting behind desk; far way; turned away *tense posture; slouched in chair *critical or distracting gestures: pointing finger, clenched fist, looking at watch *bland expression, yawning, tight mouth *frowning, lip biting *shifting, avoiding eye contact, focusing on notes *strident, high-pitch tone; rate too slow/fast *too frequent or inappropriate touch