NR 302 HEALTH ASS Exam 1 Latest updated,100% CORRECT

NR 302 HEALTH ASS Exam 1 Latest updated Exam 1 Concepts Chapter 1: Evidence-Based Assessment • Define and recognize examples of Subjective and Objective data o Objective is obtained through observation and is verifiable; information gathered from the patient by the use of observation, palpation, percussion, and auscultation, as well as the use of instruments and techniques that provide specific measurements o Subjective is information that the patient shares about his or her health situation. They are gathered through the patients report and are verifiable only by the patient. • Identify order and tasks of each step of the Nursing Process o ADPIE o Assessment- information collection/ gathering data o Diagnosis- information interpretation, stating problems & strengths o Plan/ Outcome- setting nursing goals desired outcomes and planning interventions o Implementation- performing nursing interventions o Evaluation- patient’s status and effectiveness of nursing interventions • Recognize the difference between different levels of Nursing Experience o Novice: starting out in an area of learning; uses rules to guide performance o Competency: building on 2 to 3 years of clinical experience; see actions in the context of patient goals or plans o Proficient: adding to time and experience; understands the patient situation as a whole rather than individual parts-apply long term goals o Expert: attained mastery of an area of learning; performs clinical judgement using intuitive analysis • Define and identify examples of Levels of Priority: 1st, 2nd, and 3rd levels o 1st level: emergent, life threatening, and immediate; like airway, breathing, and circulation o 2nd level: next in urgency, requiring attention so as to avoid further deterioration; mental status changes, acute pain, infection risk, abnormal laboratory values, and elimination problems o 3rd level: important to patient’s health but can be addressed after more urgent problems are addressed; like lack of knowledge, mobility problems, and family coping o Collaborative problems: approach to treatment involves multiple disciplines • Define the Four Types of Databases: Complete, Focused, Follow-Up, and Emergency o Complete total health database describes current and past health state and forms baselines to measure all future changes; complete physical examination; yields first diagnosis o Focused or problem-centered database: collect “mini” database, smaller scope and more focused than complete database; short term problem o Follow-up database: status of all identified problems should be evaluated at regular and appropriate intervals; follows up with both short- term and chronic health problems; What change has occurred? Is the problem getting better or worse? o Emergency database: rapid collection of data often complied concurrently with lifesaving measure; diagnosis must be swift and sure Chapter 4: The Complete Health History • Identify components and purpose for o Collect subjective data to combine with objective data from physical exam and lab studies to from the database o Provides a complete picture of patients past and present health status o Can be used as a screening tool for detection of abnormalities o Printed or electronic format that is available for review, validation, and updates o Sequence may vary in terms of obtained information o Those in primary care settings may use all of it, whereas those in a hospital may focus primarily on the history of present illness and the functional, or patterns of living, data. HEALTH HISTORY SEQUENCE o Biographic data: ▪ Name, address, and phone number ▪ Age, birth date, and birthplace ▪ Gender (identification) and relationship status ▪ Race and ethnic origin ▪ Occupation: usual and present ▪ Primary language o Source of history: ▪ Record who furnished information, usually the person, although source may be relative or friend ▪ Judge reliability of informant and how willing he or she is to communicate • Reliability leads to consistency of information ▪ Note any special circumstances, such as use of interpreter • Identify how to perform a Review of Systems o Evaluate past and present state of each body system ▪ Assess that all pertinent data relative to each body system have been noted ▪ Avoid writing in negative for body systems as you want to record either presence of absence of symptoms o Do not include objective data o Limit to patient statements or subjective data o Include all relevant body systems • Approach: o General overall health state – weight gain/loss, fatigue, weakness, fever, chills o Skin and hair – history of skin disease (eczema, hives) pigment or color change ▪ amount of sun exposure, method of self care for skin & hair o Head – frequent or severe headache, head injury, dizziness, vertigo ▪ Eyes – difficulty with vision, eye pain, double vision, watering, discharge, • wear glasses or contacts , last vision check or glaucoma test ▪ Ears – earaches, infections, discharge, and its characteristics • hearing loss, hearing aid use, method of cleaning ears, etc. ▪ Nose and sinuses - discharge, and its characteristics, frequent or severe colds, sinus pain, nosebleeds, change in sense of smell ▪ Mouth and throat – mouth pain, frequent sore throat, bleeding gums, voice change, lesion in mouth or tongue • Pattern of daily dental care, use of dentures, bridge, last dental check ▪ Neck – pain, limitation of motion, lumps or swelling, tender nodes, goiter ▪ Breast and axilla – pain lump, nipple discharge rash, tenderness o Focus on body systems looking at specific indicators and focusing on health promotion ▪ Respiratory – lung diseases, wheezing, cough ▪ Cardiovascular – chest pain, pressure, edema ▪ Peripheral vascular – coldness, numbness, swelling of legs ▪ Gastrointestinal – appetite, heartburn, nausea ▪ Urinary – frequency, urgency, urine color ▪ Musculoskeletal – hist. of arthritis or gout, pain in the joints ▪ Neurologic – hist. seizure disorder, stroke, fainting, motor functions (paralysis, tic or tremor), cognitive function (memory disorder) ▪ Hematologic – bleeding tendency of skin or mucous membranes ▪ Endocrine – history of diabetes or thyroid disease, intolerance to heat/cold, change in skin pigmentation/texture o Focus on systems specific to gender looking at specific indicators an focusing on health promotion ▪ Male genital – penis, testicular pain, sores, lesions, discharge • Testicular self examination, how frequently? ▪ Female genital – menstrual history, vaginal itching, discharge & its characteristics, age at menopause (or symptoms of) • Last gynecologic checkup and pap test ▪ Sexual health – Are you presently in a relationship involving intercourse? Is protection used? Contact with someone with STI? • Identify notations necessary when collecting allergy information o Note both the allergen and the reaction. For drug allergies, list only those that are true allergic reactions, not unpleasant side affects • Identify how to appropriately document a Reason for Seeking Care o Brief spontaneous statement in person’s own words describing reason for visit o Document reported findings; symptom: subjective sensation feels from disorder documented in quotes; sign: objective abnormality that can be detected on physical examination or in laboratory reports o Reason for care is not a diagnostic statement o Focus on patients prioritized reasons for seeking care • Identify and understand each component of mnemonic PQRSTU o P= provocative or palliative- What brings it on? What were you doing when you first noticed it? What makes it better/ worse? o Q= quality or quantity- How does it look, feel, sound? How intense/ severe is it? o R= region or radiation – where is it? Does it spready anywhere? o S= severity scale: 1 to 10 o T= timing or onset- exactly when did it first occur? Duration- how long did it last? Frequency- How often does it occur? o U= understand patients’ perception of problem – what do you think it means? • Determine how to verify reliability of the Source of History o Reliability leads to consistency of information o Willing to communicate o Always gives the same answers, even when questions are rephrased or repeated later in the interview • Identify components of the CAGE assessment and when further evaluation is necessary o Have you ever though you should CUT down your drinking? o Have you ever been ANNOYED by criticism of your drinking? o Have you ever felt GUILTY about your drinking? o Do you drink in the morning, and EYE opener? ▪ If the person answers “YES” to two or more of the questions, we should suspect alcohol abuse and continue with more complete substance-abuse assessment • How to assess Stress and Coping in the Functional Assessment o Functional assessment measures a person’s self-care ability in the area of general physical health; ADL such as bathing, dressing, toileting, eating, walking, o Types of stress in life, especially in the past year; any change in lifestyle or any current stress; methods tried to relieve stress and whether these have been helpful • HEADADSSS o Home environment o Education and employment o Eating o Peer related activities o Drugs o Sexuality o Suicide/ depression o Safety from injury and violence • Medication reconciliation: comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit Chapter 5: Mental Status Assessment • Define Alert, Lethargy, Coma, and Delirium o Alert: awake or readily arouse; oriented fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions o Lethargic: not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal choice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased o Coma: completely unconscious no response to pain or any external or internal stimuli; light coma has some reflex activity but no purposeful movement; deep coma has not motor response o Delirium: clouding of consciousness; inattentive; incoherent convo; impaired recent memory and confabulatory for recent events; often agitated and having visual hallucinations; disoriented, with confusions worse at night when environmental stimuli decreased • Define ABCT and differentiate the components involved within each level o Appearance ▪ Posture- erect and position relaxed ▪ Body movements- body movements voluntary, deliberate, coordinated, and smooth and even ▪ Dress- appropriate for setting, season, age, gender, and social group ▪ Grooming and hygiene- congruence between grooming and age o Behavior ▪ Level of consciousness- person is awake, alert, aware of stimuli from environment and within self, and responds appropriately and reasonably soon to stimuli ▪ Facial expression- appropriate to situation changes appropriately with topic; comfortable eye contact unless precluded by cultural norm ▪ Speech- judge the quality of speech, noting that person makes sounds effortlessly and shares conversation appropriately. Pacing, articulation, and word choice ▪ Mood and affect- judge by body language and facial expression and by direct questioning. Mood should be appropriate to persons place and condition and should change appropriately with topics; person is willing to cooperate. o Cognition ▪ Orientation • Person: own name, age, who examiner is, type of worker • Time: day of week, date, year, season • Place: where person lives, address, phone number, present location, type of building, name of city and state ▪ Attention span • Check person’s ability to concentrate ▪ Recent memory • Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency • Ask questions you can corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss ▪ Remote memory • In the context of the interview, ask the person verifiable past events; for example, ask to describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person • Remote memory is lost when cortical storage are for that memory is damaged, such as in Alzheimer’s disease, dementia, or any disease that damages cerebral cortex o Aging adults’ orientation ▪ Cognitive functions: orientation • Check sensory status before assessing mental status • Aging persons may be considered oriented if they know generally where they are and the present period • Consider them oriented to time of year and month are correctly states • Orientation to place is accepted with correct identification of the type of setting • Glasgow Coma Scale: quantitative tool that us useful in testing consciousness • The Mini-Cog: reliable, quick and easily available instrument to screen for cognitive impairment o Though processes- Does the client make sense? ▪ Can I follow what the person is saying? • Logical • Relevant • Complete a thought • Aware of reality ▪ Perception ▪ Screen for anxiety disorders ▪ Screen for depression ▪ Screen for suicidal thoughts Chapter 8: Assessment Tech. and Safety in the Clinical Setting • Define and recognize the order of Assessment Techniques: Inspection, Palpation, Percussion, Auscultation o Inspection: ▪ close, careful scrutiny, first of individual as a whole and then of each body system ▪ begins when you first meet person with a general survey ▪ as you proceed through examination, start assessment of each body system with inspection ▪ inspection always comes first ▪ inspection requires • good lighting • adequate exposure • occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view o Palpation: ▪ Applies sense of touch to assess the following: • texture, temp and moisture • organ location and size • swelling, vibration, pulsation or crepitation • rigidity or spasticity • presence of lumps or masses • presence of tenderness or pain ▪ Should be performed slow and systematic • start with light and proceed to deep • bimanual palpation is used for certain body parts or organs ▪ Palpation Techniques: • Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps • Fingers and thumb: detection of position, shape, and consistency of an organ or mass • Dorsa of hand and fingers: best for determining temperature because skin here is thinner than on palms • Base of finger or ulnar surface of hands: best for vibration o Percussion: ▪ Tapping person skin with short, sharp strokes to asses underlying structures ▪ Percussion has following uses: • Mapping location and size of organs • Signaling density of a structure by a characteristic note • Detecting a superficial abnormal mass o Auscultation: ▪ Listening to sounds produced by body ▪ Stethoscope does not magnify sound, but it blocks out extraneous sounds ▪ Fit and quality of the stethoscope is important ▪ Basic principles: • 1. Eliminate extra noise • 2. Keep environment warm and warm your stethoscope • 3. Avoid listening over hairy body areas • 4. Never listen through a patient’s gown or clothing • 5. Avoid your own artifact • Identify purpose of bell and diaphragm of Stethoscope o Diaphragm- flat edge, high pitch sounds (breath, bowel, normal heart) o Bell- deep, hollow cuplike shape, soft pitched sounds (extra heart sounds/ murmurs) • Identify Standard precautions components and when they apply to patients o Hand hygiene: key factor in decreasing spread of infection; before and after patient care o Uses 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 General survey is a study of the whole person; cover general health state and any obvious physical characteristics, provides an overall impression, includes objective parameters that apply to the whole body, includes areas of physical appearance, body structure, mobility, and behavior • Identify components of Physical appearance o Age: person appears his or her stated age o Level of consciousness: person alert and oriented, attends to your questions and responds appropriately o Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion o Facial features: symmetric with movement o Overall appearance: provide general statement r/t presence or absence of distress • Identify components of Behavior o Facial expressions: person maintains eye contact, expressions appropriate to situations; note expressions both while face is at rest and while person is talking o Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly o Speech: articulation (ability to form words) clear and understandable; stream of talking is fluent, with an even pace; conveys ideas clearly; word choice appropriate to culture and education; person communicates in prevailing language easily by himself or herself or with interpreter o Dress: appropriate to climate, looks clean and fits body, and is appropriate to person’s culture and age group; for example, normally: Amish women wear clothing from 19th century; Indian women may wear saris; culturally determined dress should not be labeled as bizarre by western standards or by adult expectations o Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group Chapter 10: Vital Signs • Identify how to assess a Pulse (Rate, Rhythm, and Force) o Pulse: palpable flow felt in the periphery as a result of pressure wave generation from stroke volume ▪ Provides indicator of rate and rhythm of heartbeat as well as local data on condition of artery ▪ Palpation technique • 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 • For irregular pulse, count for full minute • Assess pulse for rate, rhythm, force, and elasticity o Heart rate ▪ In resting adult, normal heart range is 60 to 100 beats per minute • Rate normally varies with age; infant and childhood more rapid, moderate during adult and older years • Rate also varies with gender; after puberty, females have slightly faster rate than males o Adults with a heart rate less than 50 bpm is bradycardia o Occurs normally in well-trained athletes whose heart muscle develops along with skeletal muscle • Stronger, more efficient heart muscle pushed out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output o A more rapid heart rate, over 100 bpm, is tachycardia ▪ Occurs normally with anxiety or with increased exercise to match body’s demand for increased metabolism o Heart rhythm ▪ Rhythm of pulse normally has regular, even tempo • Sinus dysrhythmia: one irregularity commonly found in children and young adults • Heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration • Inspiration momentarily causes a decreased stroke volume from left side of heart • To compensate, heart rat increases ▪ If any other irregularities are felt, auscultate heart sounds for a more complete assessment o Heart force ▪ Force pulse is strength of hearts stroke volume ▪ Weak thready pulse reflects a decreased stroke volume ▪ Full bounding pulse denoted increased stroke volume, as with anxiety, exercise, and some abnormal conditions ▪ Pulse force: • 3+ full, bounding • 2+ normal • 1+ weak, thready • 0 absent • Identify steps and important assessments when taking an Oral Temperature o Normal oral temp is (98.6 F), with a range of (96.4 F to 99.1 F) o Oral temp accurate and convenient o Placement: place it at base of tongue in either of posterior sublingual pockets; not in front of tongue o Instruct: person to keep his or her lips closed o Leave: in place 20 to 30 seconds o Wait: 15 minutes if person has just taken hot or iced liquids and 2 minutes if he or she has just smoked • Identify vital sign changes in the Aging Adult o Temperature: change sin body’s temp regulatory mechanism leaves aging person less likely to have fever but at greater risk for hypothermia ▪ Temp is less reliable index of older persons true health state; sweat gland activity is also diminished o Pulse: normal range of heart is 60 to 100bpm, 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 actually easier to palpate o Respirations: aging causes decrease in vital capacity and decreased inspiratory reserve volume ▪ You may note shallower inspiratory phase and an increased respiratory rate o Blood pressure: aorta and major arteries tend to harder with age ▪ As heart pumps against a stiffer aorta, systolic pressure increase, 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 • Identify how to assess an abnormal Respirations o count for a full minute if you suspect abnormal respirations o do not mention that you will be counting respirations, because sudden awareness may alter normal pattern o can put hands on the patient’s chest • Identify physiologic changes that result in Hypertension o Abnormally high BP o 120-129/80 = elevated • Identify equipment differences when taking a Rectal versus Oral Temperature o Rectal temp is usually red and small thermometer; most accurate o 2 different types of oral thermometers; most convenient • Identify Major Risk Factors for Patients with Hypertension o Smoking o Dyslipidemia o Diabetes mellitus o Age60 yr o Gender (men and postmenopausal women) o Family history of cardiovascular disease: women 65 vr or men55 yr • Identify Lifestyle Modifications for Hypertension Prevention and Management o Weight loss o Limit alcohol use o Increase aerobic exercise activity pattern o Reduce sodium intake o Maintain adequate sources of dietary potassium, calcium and magnesium o Smoking cessation o Reduce intake of saturated fats and cholesterol • Identify the rationale for Hypotension with Myocardial Infarctions o Decreased: Cardiac output Chapter 11: Pain Assessment • Identify Physiological Responses to Poorly Controlled Pain for the Cardiac and Pulmonary Systems o Cardiac: tachycardia, elevated BP o Pulmonary: hypoventilation, decreased cough • Pain in the Aging Adult: What does pain signify? o Pain is common among individuals 65 years of age and older; it is not normal process of aging. It indicates pathology or injury o Older adults fear becoming dependent, undergoing invasive procedures, taking pain medications, and having financial burden o Most common pain-producing conditions for aging adults include pathologies such as arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic constipation o Dementia does not impact ability to feel pain, but impact person’s ability to effectively use self-report tools ▪ Communicate pain through agitation, pacing, repetitive yelling • Identify how to appropriately assess pain o Initial pain assessment questions ▪ Do you have pain? • Discomfort, soreness, or “ouch: ▪ Where is your pain? • Tell me about all of the places that have pain ▪ When did your pain start? • What were you doing when the pain started? • Is it constant or does it come and go? ▪ What does your pain feel like? • Burning, stabbing, aching, throbbing, fire like, squeezing, cramping, sharp, itching, tingling, shooting, crushing, sharp, dull ▪ How much pain do you have now? • Pain rating scales are one-dimensional and are intended to reflect pain intensity • Numeric rating scales, 0 being no pain and highest anchor 10 indicating worst pain • Verbal descriptor scales have the patient use words to describe pain • Visual analog scales have the patient mark the intensity of the pain on a horizontal line from “no pain” to “worst pain” • Descriptor scales in which patients are asked to indicate their pain by using selected pain term words ▪ PQRST Method of Pain Assessment: series of questions for each initial are asked to help qualify patients self-report of clinical symptoms • P= provocation/ palliation • Q= quality/ quantity • R= region/ radiation • S= severity scale • T= timing • Identify Chronic Pain Behaviors o Persistent (chronic) pain behaviors ▪ Often live with experience for months and years ▪ Adaptation occurs over time ▪ Shows more variability than acute pain behaviors o Associated behaviors: ▪ Bracing, rubbing ▪ Diminished activity ▪ Sighing ▪ Change in appetite • Differentiate Acute versus Chronic Pain o Acute pain: short term and self-limiting ▪ often follows a predictable trajectory, and dissipates after an injury heals ▪ Self -protective purpose: • Acute pain was individual of actual or potential tissue damage ▪ Incident pain: • Type of acute pain that occurs predictably with certain movements ▪ Individuals experiencing moderate to intense levels of pain may exhibit the following behaviors • Guarding, grimacing • Vocalizations such as moaning, agitation, restlessness, stillness • Diaphoresis • Change in vital signs o Chronic pain: persistent pain is diagnosed when pain continues for 6 months or longer ▪ Can last 5, 15, or 20 years and beyond ▪ It can be further divided into malignant and nonmalignant ▪ Does not stop when the injury heals ▪ Outlasts its protective purpose ▪ Unfortunately, many patients with chronic pain are not believed o Breakthrough pain: transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome ▪ Can result from: • End of dose medication failure • Result of incident or episodic pain ▪ Treatment: • Shorten interval dosing and/ or increase medication Module Activities Weeks 1 and 2: • Identify communication techniques o Verbal techniques enhance professional and personal communication skills o Can be single word or a robust verbal discussion o Emotions may be included o Verbal communication is essential for understanding, questioning, and conveying intended messages o Non-verbal uses body language, facial expressions, and movements • Identify HIPPA violations o HIPPA was established to protect client rights and hold healthcare accountable with privately maintaining client information during the workday and safekeeping client records. ▪ Sharing information with coworkers who aren't involved directly in care ▪ Talking about patients on social media ▪ Looking up information on a client who the healthcare worker is not directly involved in the care of ▪ Keeping charting open for others to see if stepping away from the chart or computer ▪ Disposing of health records without proper shredding of documents ▪ Providing information to individuals not specified by client • Best practices when caring for non-English speaking patients o Use an interpreter to remove communication barriers due to language differences. o Be mindful of the differences in nonverbal communication between the client and nurse. • Causes of low and high BP readings o False high BP ▪ Cuff to tight ▪ Cuff to small ▪ Muscle contracted ▪ Cuff too narrow o False low BP ▪ Arm above heart ▪ Cuff too wide ▪ Cuff too large ▪ Cuff too loose • Actions with confidentiality violations o Room privacy: make sure the curtains are pulled on both sides or door is closed o Document privacy: information being collected is safeguarded and not exposed o Speech level: speak in a lower voice so other clients won’t hear your patient’s information o Other staff members: need to leave the room when client is giving person information like there health history