Holistic Health Assessment Midterm 1 Questions &
Answers Solved 100% Correct!!
Before starting assessment
-Have all equipment ready
-Clean/sterilize your equipment
-Routine precautions
Tangential lighting
a source of illumination directed from an angle to the side of what is being examined;
used to make a raised lesion cast a shadow, for example
Oblique/indirect lighting
-45 degrees
*jugular pulsation
Inspection
-Compare right and left sides (symmetrical)
-Use good lighting
>Otoscope
>Ophthalmoscope
>Specula: vaginal, nasal
>Penlight
Palpation
-Slow and systemic
-Light versus deep palpation
-Intermittent pressure
-Bimanual palpation
Percussion
-Tapping: short, sharp strokes
-Assess underlying structures
Characteristic sounds:
>Resonant
>Hyperresonant
>Tympany
>Dull
>Flat
Auscultation
-Sounds produced by heart, lungs, BVs, and abdomen
-Normal sounds vs abnormal and extra sounds
Health history
-Focuses on patient concerns
-Establish a trusting relationship
-Gather info
-Assessment in nursing process
-medications
-allergies
Primary data source
,patient
Secondary data source
Patient's family and chart
>is the patient a reliable historian or inaccurate historian
>Document who provides info
Objective data
-What you see during an exam
-What you measure
-A "sign"
Subjective data
-What the client tells you
-What the client says
-A "symptom"
Components of nonverbal communication
-Physical appearance
-Facial expression
-Posture and positioning
-Gestures
-Eye contact
-Use of touch
-Personal touch
Sex vs gender
sex is biological; gender is the predetermined roles for men and women in the
community
History
-Chief concern- reason for seeking care
-Try to put it in the patients own words
-i.e. "the patient says my stomach hurts
Past history (health history)
-Childhood illnesses with potentially lasting effects: polio, varicella
Immunizations
-Medical conditions (e.g. cardiac, respiratory, kidney, liver, etc.) & treatments received
-Surgical interventions & outcomes
-Injuries
-For female pts note last menstrual period (LMP) and whether she could be pregnant
-Include dates of initial diagnoses or surgeries
Family history
-any significant illnesses that run in the patient's family
-relevant Qs to patients concern
-any immediate family?
OPQRSTUA
-Onset: when did this start
-Provocation and palliation: wha causes the symptoms and what makes them better or
worse
-Quality and/or quantity
-Region/radiation
, -Severity: on a scale of 1-10 or how does it affect ADLs
-Time: of day
-Understanding: of patient
-Associated symptoms
DADSPIES
D diet
A alcohol
D drugs
S smoking
P physical exam
I immunizations
E exercise
S stress
DADSPIES questions
-Tobacco use
for how long and how much?
Alcohol
-How much Alcohol do you drink in a day or week?
-Recreational drug
Any use? What? How often
Components of subjective assessment
-History
-Health history:past and family
-OPQRSTUA
-medications and allergies
-DADSPIES
-check for abuse
-health teaching
-functional assessment
-cultural and social considerations
-review of systems
-mental health
-sexual history and orientation
-closing interview
Closing interview
-Summarize what you found including:
>Positive health aspects
>Any identified problems
>Plans for action
-Thank client for time and cooperation
Functional assessment
-Effects of health or illness on quality of life
-Identify strengths and areas that need improvement
-Assessing ability to perform ADLs
Cultural and social considerations
Answers Solved 100% Correct!!
Before starting assessment
-Have all equipment ready
-Clean/sterilize your equipment
-Routine precautions
Tangential lighting
a source of illumination directed from an angle to the side of what is being examined;
used to make a raised lesion cast a shadow, for example
Oblique/indirect lighting
-45 degrees
*jugular pulsation
Inspection
-Compare right and left sides (symmetrical)
-Use good lighting
>Otoscope
>Ophthalmoscope
>Specula: vaginal, nasal
>Penlight
Palpation
-Slow and systemic
-Light versus deep palpation
-Intermittent pressure
-Bimanual palpation
Percussion
-Tapping: short, sharp strokes
-Assess underlying structures
Characteristic sounds:
>Resonant
>Hyperresonant
>Tympany
>Dull
>Flat
Auscultation
-Sounds produced by heart, lungs, BVs, and abdomen
-Normal sounds vs abnormal and extra sounds
Health history
-Focuses on patient concerns
-Establish a trusting relationship
-Gather info
-Assessment in nursing process
-medications
-allergies
Primary data source
,patient
Secondary data source
Patient's family and chart
>is the patient a reliable historian or inaccurate historian
>Document who provides info
Objective data
-What you see during an exam
-What you measure
-A "sign"
Subjective data
-What the client tells you
-What the client says
-A "symptom"
Components of nonverbal communication
-Physical appearance
-Facial expression
-Posture and positioning
-Gestures
-Eye contact
-Use of touch
-Personal touch
Sex vs gender
sex is biological; gender is the predetermined roles for men and women in the
community
History
-Chief concern- reason for seeking care
-Try to put it in the patients own words
-i.e. "the patient says my stomach hurts
Past history (health history)
-Childhood illnesses with potentially lasting effects: polio, varicella
Immunizations
-Medical conditions (e.g. cardiac, respiratory, kidney, liver, etc.) & treatments received
-Surgical interventions & outcomes
-Injuries
-For female pts note last menstrual period (LMP) and whether she could be pregnant
-Include dates of initial diagnoses or surgeries
Family history
-any significant illnesses that run in the patient's family
-relevant Qs to patients concern
-any immediate family?
OPQRSTUA
-Onset: when did this start
-Provocation and palliation: wha causes the symptoms and what makes them better or
worse
-Quality and/or quantity
-Region/radiation
, -Severity: on a scale of 1-10 or how does it affect ADLs
-Time: of day
-Understanding: of patient
-Associated symptoms
DADSPIES
D diet
A alcohol
D drugs
S smoking
P physical exam
I immunizations
E exercise
S stress
DADSPIES questions
-Tobacco use
for how long and how much?
Alcohol
-How much Alcohol do you drink in a day or week?
-Recreational drug
Any use? What? How often
Components of subjective assessment
-History
-Health history:past and family
-OPQRSTUA
-medications and allergies
-DADSPIES
-check for abuse
-health teaching
-functional assessment
-cultural and social considerations
-review of systems
-mental health
-sexual history and orientation
-closing interview
Closing interview
-Summarize what you found including:
>Positive health aspects
>Any identified problems
>Plans for action
-Thank client for time and cooperation
Functional assessment
-Effects of health or illness on quality of life
-Identify strengths and areas that need improvement
-Assessing ability to perform ADLs
Cultural and social considerations
