NR302 Health Assessment Final Exam Concepts latest updated,100% CORRECT

NR302 Health Assessment Final Exam Concepts latest updated Chapter 1: Evidence-Based Assessment • Understand the tasks or the role of the RN with the Nursing Process. As it relates to: The Nursing Process Know the difference between Priority Levels of Care: • 1st level: Emergent, life threatening, and immediate • 2nd level: Next in urgency, requiring attention to avoid further deterioration acute urinary elimination problems • 3rd level: important to patient’s health but can be addressed after more urgent problems are addressed. Know what belongs in each database: • Complete total health database: Describes current and past health state and forms baseline to measure all future changes. On admission this is done • Episodic or problem-centered database: Collect “mini” database, smaller scope and more focused than complete database. This is used in all health care settings focused on a specific area or part of the body • Follow-up database: Status of all identified problems should be evaluated at regular and appropriate intervals. Following up with a primary care doctor • Emergency database: Rapid collection of data often compiled concurrently with lifesaving measures Chapter 3: The Interview Be able to describe the best type of: Physical Environment • set the room temperature at comfortable level • provide enough lighting so that you can see each other clearly but avoid strong, direct lighting that can cause squinting • secure a quite environment. Turn off televisions, radios, and any unnecessary equipment. • Remove distance between you and the client at 4 to 5 feet personal space is any space within 4 feet of a person. Encroaching on personal space can cause anxiety, but if you position yourself farther away, you may seem aloof and distant the personal reaction bubble depends on variety of factors including culture, gender, and age. Chapter 4: The Complete Health History Know what type of data is collected in each section of the health history (adult client) • Biographic data: name, address, and phone number; age and birth date, birthplace, gender, relationship status, race, ethnic origin; and occupation, person primary language • Source of history: Record who furnishes the information, are they reliable judge how reliable the informant seems. A reliable person always gives the same answers, even when questions are rephrased or repeated later in the interview. Note whether the person appears well or ill; a sick patient may communicate poorly. • Reason for seeking care: Symptom: subjective sensation person feels from disorder documented in quotes Sign: objective abnormality that can be detected on physical examination or in laboratory reports • Present health or history of present illness: Collect all provided data and identify eight critical characteristics. Make sure that collected data are precise and accurate. Use standardized indicators to document findings • Past health: health history in the pass childhood illness, accidents or injuries, serious or chronic illnesses, hospitalization, obstetric history, immunizations, las examination date, allergies, current meds • Family history: family history like cancer or diseases that a patient may be at risk for • Review of systems: The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices. • functional assessment including activities of daily living (ADLs): sleep and rest, activity and exercise, personal habits, intimate partner violence, coping and stress management, illicit or street drugs. Know CAGE assessment: • Cut down: Have you ever thought you should Cut down on you drinking • Annoyed: have you have been Annoyed by criticism of your drinking • Guilty: have you ever felt Guilty about you drinking? • Eye-opener: do you drink in the morning (Eye opener Know how you would perform the assessment: When was your last drink of alcohol? How much did you drink that time? In the past 30 days, about how many days would you say that you drank alcohol? Has anyone ever said that you had a drinking problem? If the person answer “yes” to two or more questions, you should suspect alcohol abuse and continue with a more complete substance- abuse assessment Chapter 5: Mental Status Assessment Alert: awake or readily aroused; orientated, fully aware of external and internal stimuli and responds appropriate’ conducts meaningful interactions. Lethargic: not fully alert; drifts of to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to question or commands but thinking seems slow and fuzzy; inattentive; losses train of thought Coma: completely unconscious no response to pain or any external stimuli Delirium (Levels of Consciousness): clouding of consciousness (dulled cognition, impaired alertness) incoherent conversation impaired recent memory agitated and having visual hallucinations, disoriented. Chapter 8: Assessment Tech. and Safety in the Clinical Setting • Know the order and how to apply the assessment techniques: 1. Inspection: Close, scrutiny, first of individual as a whole and then of each body system begins when you first meet person with a general survey need good lighting and adequate exposure 2. Palpation: Palpation applies sense of touch to assess the following texture, temperature and moisture, lumps, masses, tenderness or pain a. Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps b. Fingers and thumb: detection of position, shape, and consistency of an organ or mass c. Dorsa of hands and fingers: best for determining temperature because skin here is thinner than on palms d. Base of fingers or ulnar surface of hand: best for vibration 3. Percussion: Tapping person’s skin with short, sharp strokes to assess underlying structures • Mapping location and size of organs • Signaling density of a structure by a characteristic note • Detecting a superficial abnormal mass 4. Auscultation: Tapping person’s skin with short, sharp strokes to assess underlying structures Stethoscope does not magnify sound, but it blocks out extraneous sounds eliminate extra noise • A Safer Environment Know the Standard Precautions and how you would teach your client o Hand hygiene ▪ Key factor in decreasing spread of infection ▪ Before and after patient care ▪ Protocols for visibly or not visibly soiled o Use of protective equipment ▪ Gloves, gown, mask, eye protection, or face shield o Respiratory hygiene/cough etiquette ▪ Education, posted signs, and source control measures Chapter 9: General Survey and Measurements • The General Survey Know what you would assess Physical appearance • Age: person appears his or her stated age • Level of consciousness: person alert and oriented, attends to your questions and responds appropriately • Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion • Facial features: symmetric with movement • Overall appearance: provide general statement r/t presence or absence of distress behavior sections • Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling) • Mood and affect person comfortable and cooperative with examiner and interact pleasantly • Speech: articulation (ability to form words) clear and understandable Chapter 10: Vital Signs Know each the following vital signs and how you would assess each one below: Pulse • palpable flow felt in the periphery as a result of pressure wave generation from stroke volume • Using pads of the first three fingers, palpate radial pulse at flexor aspect of wrist laterally along radius bone until strongest pulsation is felt. • If rhythm is regular, count number of beats in 30 seconds and multiply by 2. • The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. 60 to 100 beats per minute (bpm) Heart force: • 3+ Full, bounding • 2+ Normal • 1+ Weak, thread • 0 Absent Respirations • Normally person’s breathing is relaxed, regular, automatic, and silent • Because most people are unaware of their breathing, do not mention that you will be counting respirations, because sudden awareness may alter normal pattern. • Instead, maintain your position of counting radial pulse and unobtrusively count respirations. • Count for 30 seconds or a full minute if you suspect an abnormality • Adult normal rate 10-20 Orthostatic (postural) Vital Signs: • Take serial measurements of pulse and blood pressure in the following situations: • You suspect volume depletion. • Person is known to have hypertension or taking antihypertensive medications. • Person reports fainting or syncope. • Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur. • Have person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and then repeat with person sitting and then standing Know how the vital signs change in the: The Aging Adult • Temperature: changes in body’s temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia Temperature is less reliable index of older person’s true health state; sweat gland activity is also diminished. • Pulse: normal range of heart rate is 60 to 100 bpm, but rhythm may be slightly irregular Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain. Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is easier to palpate. • Respirations: aging causes decrease in vital capacity and decreased inspiratory reserve volume You may note shallower inspiratory phase and an increased respiratory rate. • Blood pressure: aorta and major arteries tend to harden with age As heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure. In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension. Know how to define Hypotension and the number value • Hypotension: Seen in acute myocardial infarction (AMI), shock, hemorrhage, vasodilation, and/or Addison’s disease Blood pressure lower than 95/60mmHg Know the cardiovascular risk: Major risk factors • Prevention and management • Weight loss • Limit alcohol use • Increase aerobic exercise activity pattern • Reduce sodium intake • Maintain adequate sources of dietary potassium, calcium and magnesium • Smoking cessation • Reduce intake of saturated fats and cholesterol Know the Lifestyle Modifications for Hypertension Prevention and Management • Lose weight • Limit alcohol intake to no more than 1 oz (30ml) • Increase aerobic physical activity (30-45min most days of the week) • Reduce sodium • Maintain adequate intake of dietary potassium and calcium and magnesium • Stop smoking and reduce intake of saturated fat and cholesterol for cardio health Chapter 11: Pain Assessment • Recognize and understand: PQRSTU o Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse? o Quality/quantity: How does it look, feel, sound? How intense/severe is it? o Region/radiation: Where is it? Does it spread anywhere? o Severity: How bad is it (on a scale of 0 to 10)? Is it getting better, ▪ Worse, staying the same o Timing: Onset—exactly when did it first occur? Duration—How long ▪ Did it last? Frequency—how often does it occur? o Understanding: Onset— Known the difference between: Acute: Short-term and self-limiting: Often follows a predictable trajectory, and dissipates after an injury heals Nonverbal response in acute pain • Exhibit the following behaviors: • Guarding, grimacing • Vocalizations such as moaning, agitation, restlessness, stillness • Diaphoresis, • Change in vital signs Chronic: Chronic pain can be further divided into malignant (cancer related) and nonmalignant. In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond. Nonverbal response in chronic pain • Bracing, rubbing • Diminished activity • Sighing • Change in appetite Know the clinical manifestations of pain in Nociceptors: are the nerves which sense and respond to parts of the body which suffer from damage Neuropathic: Pain due to a lesion or disease in the somatosensory system • Dementia Patient’s Dementia does not impact the ability to feel pain, but it does impact the person's ability to effectively use self-report tools they communicate pain through behavior agitation, pacing, repetitive yelling • Known the Physiologic responses to pain Chapter 12: Nutritional Assessment • Know the difference between the types of Nutritional Assessments: o Food Frequency: Advantage obtains information about multiple time frames. Disadvantage: (1) it does not always quantify amount of intake, and (2) like the 24-hour recall, it relies on the individual’s or family member’s memory for how often a food was eaten. o Food diaries: A food diary is most complete and accurate if you teach the individual to record information immediately after eating. Disadvantage: (1) noncompliance, (2) inaccurate recording, (3) atypical intake on the recording days, and (4) conscious alteration of diet during the recording period. o Direct observation: Increasingly, mobile devices and applications are being used to assess and monitor intake, including taking photos of meals and tracking weight changes and dietary adherence. o 24-hour recall: Advantage: specific information about dietary intake can be collected over a specific period of time. Disadvantage: (1) the individual or family member may not be able to recall the type or amount of food eaten • Anthropometric Measures o Known the BMI scale and risk factors BMI interpretation for adult • 18.5= underweight • 18.5-24.9=normal weight • 25-29.9=overweight • 30-39.9=obesity • 40= extreme obesity Know the Waist – hip ratio / waist circumference measurements and risk factors • A wait –to-hip ratio of 1.0 or greater in men or 0.8 or greater in women indicates android (upper body obesity0 • A WC 35 in women and 40 inches in men increases risk for heart disease, type 2diabetes, and metabolic syndrome Chapter 13: Skin, Hair, Nails • Developmental competence Know the changes to the skin in the Aging adult: • Elasticity Loses elasticity; skinfolds and sags • Sweat and sebaceous gland Decrease in number and function, leaving skin dry • Senile purpura Discoloration due to increasing capillary fragility • Skin breakdown due to multiple factor Cell replacement is slower and wound healing is delayed. • Hair matrix Functioning melanocytes decrease, leading to gray fine hair Objective data • Temperature: use backs of hands to palpate person skin should be warm and temperature equal bilaterally; warmth suggests normal circulatory status • Moisture: diaphoresis (sweat) and dehydration • Texture: normal skin feels smooth and firm with even surface • Thickness: observe for thickened areas (callus formation) • Edema: assess for fluid accumulation in interstitial space • Mobility and turgor: asses skin elasticity • Vascularity or bruising: assess for presence of tattoos and variations Skin Pallor (pale) anxiety or fear • light skin: Generalized pallor • Dark skin: brown skin appears yellow-brown, dull; black skin appears ashen gray, dull; skin lose its glow check areas with least pigmentation such as conjunctivae, mucous membranes Cyanosis (blue) tissue have high levels of deoxygenated blood • Light skin: Dusty blue • Dark skin: dark but dull, lifeless, only sever cyanosis appears in skin check conjunctivae, oral mucosa, nail beds Jaundice (yellow) • Light skin: yellow in sclera, hard palate, mucous membranes, then over the skin • Dark skin: check sclera for yellow near limbus; do not mistake normal yellowish fatty deposits in the scleral periphery for jaundice; jaundice best noted in junction of hard and soft palate, also palms Erythema (red) fever, localized inflammation, increase skin temp • Light skin: red, bright pink • Dark skin: Purplish tinge but difficult to see, palpate for increased warmth with inflammation, taut skin, and hardening of deep tissues. Mobility and Turgor: pinch up large fold of skin on the anterior chest under the clavicle mobility is the ease of skin to rise, and turgor is its ability to return to place promptly when releases. This reflects the elasticity of the skin. Know the ABCDEF of pigmented lesions and how it is applied ABCDEF of pigmented lesions A: asymmetry B: border irregularity C: color variation D: diameter greater than 6 mm E: elevation or evolution F: funny looking- “ugly duckling: - different from the others Nails Know a normal nail shapes and contour • Shape and contour: Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees • Consistency: Observe for smooth, regular, not brittle or splitting, uniform nail thickness. Translucent nail plate to pink nail bed below • Note ethnic variations How to assess profile sign and clubbing and when you may see clubbing • Clubbing of the nail occurs with congenital cyanotic heart disease, lungs cancer, and pulmonary disease in the early clubbing the angle straightened out 180 degrees and the nail base feels spongy to palpation then the nail becomes convex as digit grows. Know how to assess Color (capillary refill) and what you are assessing for when checking capillary refill • Capillary refill: should be 2-3 sec if not you should suspect inadequate Profusion Looking for peripheral circulation Know the stages, risk factors and sites of: Stages Stage 1: Intact skin appears red, but unbroken. Skin does not blanch. Stage 2: Partial-thickness skin erosion with loss of epidermis or dermis. Superficial ulcer appears shallow like an abrasion or open blister with a red-pink wound base Stage 3: Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater Stage 4: Full-thickness pressure ulcer involves all skin layers and extends. Exposes muscle, tendon or bone. Necrosis Risk factors • Impaired mobility • Thin fragile skin • Decrease sensory perception • incontinent • shearing skin • poor nutrition (decrease protein in diet) • infection Common sites • heel • ischium • sacrum • elbow • scapula • vertebra • ankle • hip • rib • shoulder Chapter 14: Head, Face, and Neck, Including Regional Lymphatics • Know the differences: Primary Headaches o Migraine: commonly one-side but may occur on both sides pain is often behind the eyes throbbing, pulsating moderate-to-sever pain o Cluster: always one- sided often around the eye, temple, forehead, cheek continuous, burning, piercing abrupt onset, peaks in min last 45-90 min o Tension: usually in both sides across frontal no throbbing gradual onset last 30 min to days • Know the difference in clinical manifestations of: Graves’ Disease/Hyperthyroidism: • Goiter • Eyelid retraction • Exophthalmos (large eyes) • Excess sweating • Muscle cramps • Tachycardia • Heat intolerant Myedema/Hypothyroidism • Puffy edematous face • Periorbital edema • Coarse facial features • Coarse hair and eyebrows • Fatigue • Cold intolerant • Weight gain • Know the difference between Abnormal Faces with Chronic Illness • Bell’s palsy: Paralysis on one side of the face as a result of LMN lesion cranial never Vll paralysis of facial muscles • Person cannot wrinkle forehead, raise eyebrow, close eye lids, whistle, or show teeth on the left side • Usually present with a smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, and pain behind the ears • Can improve if corticosteroids and antivirals are given within 72 hours of onset. • Stroke or brain attack: UMN lesion leading to paralysis of lower facial muscles • Ask the patient to smile Note paralysis of the lower facial muscles but also note to up half of the face’s person can still wrinkle their forehead and close Chapter 15: Eyes DEVELOPMENTAL COMPETENCE Know the difference in the Aging Adult abnormal eye conditions: • Presbyopia: the decrease in ability to accommodate for near vision • Cataract: Or lens opacity, resulting from a clumping of proteins in lens • Glaucoma: Or increased intraocular pressure; chronic open-angle glaucoma is most common type tunnel vision can be treated with lens replacement surgery • Primary open-angle Glaucoma is leading cause of blindness in African Americans and Hispanics. Chronic might lead to tunnel vison slow progression • Primary angle close: medical emergency calls the doctor sudden eye pain seeing halos. Acute and can lead to blindness • Age-related macular degeneration (AMD): Or breakdown of cells in macula of retina; loss of central vision loss central vision • Diabetic retinopathy: Leading cause of blindness in adults ages 25 to 74 years of age Review the Snellen chart and how to document results: most commonly used accurate measure of visual acuity. It has lines letter in decreasing size. • 20/20 means I can read from 20 feet when a normal with vison can also read at 20 feet top number always refers to the patient bottoms is normal vision • Legal blindness is 2200 Chapter 16: Ears External Ear Abnormalities • Otitis Externa: swimmers ear infection of the outer ear severe pain tragus, redness and swelling of pinna and canal, scanty purulent discharge, scaling, itching, fever, and enlarge tender regional lymph nodes rubbing alcohol or 2% acetic ear drops after ever swim • Acute otitis media: middle ear fluid is infected Redness and bulging are noted earache and fever deep throbbing pain and hearing loss Chapter 17: Nose, Mouth & Throat • Know the clinical manifestations of: Measles: rash appears first behind the ears and spread over the face and the over neck, trunk, arm and legs kolpik spots in the mouth bluish white Epistaxis: nosebleed occurs with trauma pinch nose lean forward Chapter 19: Thorax and Lungs • Know the position and surface landmarks o Lobes of the lungs: RUL RML RLL, LUL LLL • Developmental Competence: Know the changes of the Aging Adults: Aging adult • Decreased vital capacity and increased residual volume based on structural changes • Histologic changes lead to decreased gas exchange. Know the difference between Breath sounds: • Bronchial, sometimes called tracheal or tubular: around the trachea and larynx loud high pitch harsh, hollow tubular. • Bronchovesicular: over the bone scapula over fewer alveoliare located posterior between scapulae especially on right side anterior around upper stemum in the 1st and 2nd intercostal space. Moderate mixed sounds. • Vesicular: auscultation most often Vesicular sounds over peripheral lung where air flows through smaller bronchioles and alveoli. Rustling like the sound of the wind in the trees • Know the difference between Abnormal Respiratory Patterns: Hypoventilation: An irregular shallow pattern caused by an overdose of narcotics or anesthetics Hyperventilation: increased in both rate and depth • Know the difference between Adventitious lung sounds: Stridor: high- pitched airway obstruction from swollen, inflamed tissues or lodged foreign body. Crackles: high-pitched short crackling, popping sounds heard during inspiration that are not cleared by coughing Wheezes: low-pitched may clear somewhat by coughing monophonic, single note, musical snoring, moaning sounds; they are heard throughout the cycle • Know the difference between the assessment of Common Respiratory Conditions and the clinical manifestations: Lobar Pneumonia: infection in lungs: chills reparations greater than 24 beats per min fever and chest pain cough may have blood Sputum chills shortness of breath fatigue Pulmonary Embolism: undissolved (thrombus or air bubbles, fat globules) originating Leg or pelvis detach and travel through venous system, retuning blood to right heart, and lodge to occlude pulmonary vessels. Sudden chest pain and dyspnea Asthma: an allergic hypersensitivity to certain inhaled allergens which produce a complex bronchospasm and inflammation, edema in wall of bronchioles and secretion of highly viscous mucus. Wheezing, dyspnea, and chest tightness. COPD (Chronic Bronchitis/Emphysema): chronic bronchitis: caused by smoking hacking, rasping, cough, productive of thick mucoid sputum chronic dyspnea fatigue cyanosis possible clubbing. Emphysema: caused by cigarette smoking 80-90% barrel chest tripod position SOB respiratory distress tachypnea Chapter 20: Heart and Neck Vessels Position and surface landmarks Know where the cardiac fields are located • Second right interspace: aortic valve area • Second left interspace: pulmonic valve area • Left lower sternal border: tricuspid valve area • Fifth interspace at around left midclavicular line: mitral valve area Developmental competence Know the changes in the Aging adult Know the difference of the Cardiac Cycle: S1/S2 ▪ First heart sound (S1) ▪ Second heart sound (S2) Heart Sounds Know the definition of the Normal heart sounds ▪ First heart sound (S1) ▪ Occurs with closure of AV valves—signals beginning of systole ▪ Mitral component of first sound (M1) slightly precedes tricuspid component (T1). ▪ Second heart sound (S2) ▪ Occurs with closure of semilunar valves—signals end of systole ▪ Aortic component of second sound (A2) slightly precedes pulmonic component (P2). ▪ S2 loudest at base Murmurs (general definition and indication): Gentle, blowing, swooshing sound that can be heard on chest wall Conditions that create turbulent blood flow and collision currents Know how to assess the Neck Vessels • Carotid artery pulse: Position a person supine anywhere from a 30- to a 45-degree angle, wherever you can best see pulsations. • Estimate pressure. • Observe for possible distention • Palpate only one at a time Developmental considerations ▪ Culture and genetics: Although all adults have some potential CVD risk, some groups, defined by race, ethnicity, gender, socioeconomic status, and educational level carry an excess burden of CVD. ▪ Recommend favorable lifestyle: no current smoking, no obesity, physical activity at least once a week and a healthy diet ▪ Consider access to care Know the cardiovascular risk factors ▪ HTN ▪ Smoking ▪ Serum cholesterol ▪ Physical activity ▪ Sex and gender differences Differential Diagnosis of Chest Pain Know the difference between the (Angina/Acute Coronary Syndrome) and the clinical manifestations of: • Angina pectoris: pressure like chest pain resolved with rest medication tightness wheezing SOB. • Acute coronary syndrome: heaviness swelling crushing chest not relived with rest or medicine indigestion and • Clinical Portrait of Heart Failure o Know the clinical manifestations Murmurs Caused by Valvular Defects • Stenosis: narrowing of vales blood had a hard time passing occurs when there is calcification of the valve makes it hard for blood to pass • Regurgitation: blood backs up in the valve because they are weak and back flow occurs