Holistic Health Assessment Midterm 1 Questions & Answers Solved 100% Correct!!

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 -Important health history information for new immigrants: When arrived in Canada and from where Refugee or immigrant status Effect of historical events in country of origin for older patients Spiritual resources and religion Past health (immunizations in country of origin) Health perception Nutrition (taboo foods/combinations) Review of systems description of individual body systems in order to discover any symptoms not directly related to the main problem Mental health -"Describe any changes that you have had in your mood or feelings" & "have you ever been treated for any condition with your mood or behavior?" -Always approach with a matter-of-fact approach -Avoid showing signs of judgment or embarrassment Sexual history & orientation -Are you sexually active? -How many partners? -What types of intimate contact do you have -Do you use protection? What kind? Oral temp. -30 minutes after eating, drinking, smoking or chewing gum -Gloves not necessary but make sure to dispose or probe cover in garbage -place under the patients tongue and instruct to keep lips closed tightly wit no talking for the duration of the temp. assessment -sublingual pocket -most accurate -carotid artery Tympanic temp. -The position of the adult (child 1) pinna for tympanic temp.: pull pinna up, back slightly outward to straighten the curvature -accurate -Internal carotid artery Axillary temp. -safe and accurate -Infants and young children Rectal temp. -when the other routes are not practical -lubricated rectal probe electronic thermometer -Insert 2-3cm towered umbilicus Temporal temp. -non-invasive -Infrared emissions of temporal artery -Takes 2-3 sec If pulse is irregular... auscultate apical for 1 minute Normal adult resting rate 60-100bpm bradycardia less than 60 bpm tachycardia more than 100 bpm Asystole absence of a pulse Assessing respirations -Count for 30 seconds and multiply by 2 One full inspiration and expiration= one breath (start counting at 1) Take resp. rate after pulse so pt is not aware you are assessing respirations -Take for a full minute if suspected to be abnormal -Observe the rate, rhythm, depth, and quality of the respirations Ideal respirations Expected= within normal range, regular, relaxed, no use of accessory muscle or retractions, and silent, (Eupnea) Pulse oximetry noninvasive method of measuring oxygen in the blood by using a device that attaches to the fingertip -97-99% (95%) -85-89% may be acceptable for its with chronic conditions -assess cap. refill in extremity to be used (colour returns in 3 s) -No nail polish -Assess pulse amp. in the extremity to be used (2+) -If cap. refill and pulse amp. are normal place pulse oximeter -If not normal can place on bridge of nose or earlobe Appropriate BP cuff size The width of the rubber bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference. -9x18: child -12x22: 26-33 -15-33: 33-41 -18x36: 41 CHEP (when measuring BP) -Before taking your medication -After emptying bladder and bowel if you need to -After a 5 minute rest -No tobacco, no caffeine in the hour before -No exercise 30 mins before Standard BP technique -Cuff placement Locate the brachial artery Above the antecubital fossa and medial to biceps tendon -Place the cuff so that the low edge is 2.5 cm above the elbow crease- snug not tight