NUR 2180 Physical Assessment

NUR 2180 Physical Assessment Module 3 Quiz Study Guide Rasmussen College 2022 update 1. Know the difference between subjective and objective data o Subjective data (symptom) - is what the client (or family member) tells you o Objective data (sign) - is measurable like vital signs or lab results, or what the nurse observes, feels, hears, and smells. 2. Know the components of General Survey, Past Health History, and Comprehensive Health History o General survey – physical appearance, body structure, mobility, and behavior o Past health history – childhood illnesses, hospitalization/surgeries, accidents/injuries, major diseases/illnesses, immunizations, recent travel/military services, and date of last examination o Comprehensive health history – health history, past health history, family history, review of symptoms, HEENT, respiratory, cardiovascular, breast, gastrointestinal, genitourinary, female/male reproductive, musculoskeletal, and neurological, and psychosocial profile 3. Remember not to provide false assurances to patients, only facts 4. Familiarize yourself with cultural competence o Cultural competence – caregivers apply a universal concept of understanding to all contextual aspects of care 5. Study the different types of nutritional assessments (food diary, 24-hour recall, calorie count, etc.) o History – the nurse needs to consider items such as eating patterns, changes in appetite or taste, illnesses, food allergies, medications, family history, etc o Food diary – The food diary is the most comprehensive method. It requires the client to write down everything they eat and drink over a period, e.g. a week or month. It gives a very complete picture of their intake taking into consideration days of variance due to holidays, illness, etc. o Food frequency questionnaire - A food frequency questionnaire is used to find out how many servings of different foods a client eats such as vegetables, protein, fruits. It allows easy comparison with a food pyramid to see if the client is getting a balanced diet. o 24-hour recall - The 24-hour recall is the fastest method of assessing intake. The client is asked to report everything they had to eat and drink over the past 24 hours. o Objective measurement - anthropometric data, e.g. height, weight, calculate BMI 6. Know the difference between open-ended and close-ended questions o Open-ended questions - Open-ended questions allow for collection of more information. It gives the client permission to elaborate on a topic and, perhaps, indicate their concerns that might not be otherwise addressed, you appear more interested in them. Examples of this type of question might be, “What were you doing at the time of your accident?” or “Tell me more about your pain.” The disadvantages are that they take time, the client may go off topic, or it might be more difficult to sort out the important information. o Close-ended questions - A closed-ended question allows for only a “yes” or “no” answer. An example would be, “Do you have a headache?” This is useful if you do not have much time, helps to avoid irrelevant information, and may help a client answer a question on an uncomfortable topic. The disadvantages are that it does not allow for the development of a relationship, forces decisions a client might not make otherwise, and does not provide descriptive information. 7. Know the barriers to communication o Are you towering over your client? o Do you stand in the doorway as if you are going to leave any minute? o Do you present a closed posture with arms crossed in front of you? o Do you only look at the chart or computer as you talk with them? 8. Understand the different assessment techniques: inspection, percussion, palpation, auscultation and what is determined by each (what are you assessing for with each technique) o Inspection - Inspection is using our eyes to assess different aspects about a client o Percussion - Percussion is a method that can determine two things – density of tissue or tenderness. This method is performed by striking the client in different ways to elicit tenderness or create vibrations that will create different sounds depending on the density of the underlying tissue. There are two types of percussion: direct and indirect. With direct percussion, the nurse taps their hand directly onto the client’s sinuses or over the kidney areas to determine if there is tenderness. With indirect percussion, the nurse puts either a hand or finger between the client and the striking hand. o Palpation - Palpation is the method of pressing the fingers on the client’s body to determine tissue consistency, shape, size, movement, tenderness, texture, and location. o Auscultation - Auscultation is the act of listening, usually with a stethoscope 9. Understand therapeutic responses o When nurses communicate with their clients and their families, they do so to develop a trusting relationship with them, obtain histories, comfort them, and educate them. 10. Understand the differences and signs and symptoms of acute and chronic pain o Acute pain is of sudden onset and is usually the result of a clearly defined cause such as an injury. Acute pain resolves with the healing of its underlying cause. Chronic pain persists for weeks or months and is usually associated with an underlying condition, such as arthritis. 11. Understand what a review of systems means o General overall health state o Focus on body systems looking at specific indicators and focusing on health promotion o Focus on systems specific to gender looking at specific indicators and focusing on health promotion 12. Understand the communication techniques: clarification, reflection, validation, and selection listening o Clarification – asking for conformation o Reflection – echoes to help express meaning o Validation - o Selection listening -