Assessment Techniques

Question 1

Precautions for a normal assessment?

Answer 1

Standard precautions. Gloves when exposed/potentially exposed to blood, body fluids, mucous membranes.

Question 2

What is the order of assessment and types of techniques to use?

Answer 2

Head to toe order

Inspection, palpation, percussion, auscultation

Question 3

Explain inspection of the patient

Answer 3

Thinking and observing. Compare the sides of the patient for symmetry. Make sure there’s good lighting, room or a penlight. Adequate exposure of the patient. Instruments other than eyes, otoscope/opthalmoscope/specula

Question 4

What is being checked for when palpating?

Answer 4

Temp, texture, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps, masses, tenderness, pain

Question 5

What are spasticity and crepitation?

Answer 5

Spasticity may reduce the range of the muscles. It’s a tightness.
Crepitation is a rattling or crunching sound. Arthritis or other changes may produce this along with a non-smooth movement of the joints.

Question 6

Palpating on the abdomen?

Answer 6

Light palpation, depressing 1-2 cm, about half an inch. This gives an idea of the musculature, whether there’s any pain, etc.
Deep palpation for the viscera. 5-8 cm, about 2-2.5 inches.
Bimanual for liver.

Question 7

Sounds that may be heard when percussing?

Answer 7

Airfilled: resonant/hyperresonant for the lungs. Tympany for the abdomen.
Dull: dense organs like the spleen or liver
Flat: muscle or bone

Question 8

What does Erickson think about older adults?

Answer 8

Integrity vs despair. Retrospective appraisal of lives. Losses including physical function. Social changes, including retirement and changing roles. Impending death.

Question 9

3 phases of the interview?

Answer 9

Introduction
Working (open ended, close ended)
Closing

Question 10

Different types of responses to what the patient says?

Answer 10

Facilitation(go on, continue)
Silence
Reflection (echoing patient’s words and feelings)
Empathy
Clarification
Confrontation (discordance between words and signs)
Interpretation (repeat in your own words)
Explanation
Summarize

Question 11

Traps of interviewing?

Answer 11

Providing false assurance or reassurance, giving unwanted advice, authority, avoidance language, engaging in distancing, profession jargon, leading or biased questions, talking too much, interrupting, “why” questions

Question 12

Nonverbal skills and body language?

Answer 12

Appearance, position/posture, eye contact, facial expressions, appropriate touch, voice/tone, gestures

Question 13

Health People 2020 goals for older adults?

Answer 13

Increase of number of people with chronic diseases maintaining their condition, activity for cognitively impaired, diabetes self-management, geriatric certifications for healthcare workers. Decrease in the number with moderate to severe functional limitations.

Question 14

What is health literacy?

Answer 14

the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health

Question 15

Health issues to watch out for in older adults?

Answer 15

Heart disease, cancer, COPD, stoke, smoking, alcohol abuse, nutrition, dental issues, exercise, falls, sensory impairment, pain

Question 16

What is orthostatic hypotension? Causes in older adults?

Answer 16

A drop in systolic or diastolic BP greater than 20 mm HG within three minutes of changing to upright position May be cause by the inability of blood vessels to vasoconstrict after being dilated when sitting.

Question 17

Geriatric syndromes: SPICES and other

Answer 17

Sleep disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown 
Other includes impaired mobility, dizziness, falls and falling

Question 18

What are the parts of evidence based practice?

Answer 18

Best evidence from research, patient preferences, clinician’s experience, physical examination and assessment

Question 19

This is the totality of information available about a patient. May contain labs, objective/subjective data, medical records. Situational. 4 types?

Answer 19

The database.
Complete: total health history and physical examination, coping, functional ability, interaction patterns, health goals.
Focused: limited problem
Follow-up: reassessing an issue
Emergent: rapid collection; possible life-threatening problem.

Question 20

What is the core of nursing according to the holistic model of health? What are the components of a holistic assessment?

Answer 20

Health promotion and disease prevention. Biophysical, emotional, cultural and religious, socioeconomic, coping patterns, ADL’s, social interaction, health beliefs, environment, available resources, growth and development

Question 21

What are the levels of health promotion and disease prevention?

Answer 21

Primary, preventing the problem from ever occurring. Secondary, working with the patient to detect early diseases before they become readily apparent. Tertiary, treating disease to prevent or minimize complications.

Question 22

The shared beliefs, values, customs, behaviors, and artifacts that members of a society use in their lives. Four basic concepts?

Answer 22

Culture. Transmitted from generation to generation through learning. Adapted through environmental needs and so is dynamic. Learned, shared, adapted, dynamic

Question 23

How does culture affect healthcare?

Answer 23

Defines how health is perceived, how healthcare information is received, what is considered a health problem, how symptoms are perceived, and the types of treatment provided.

Question 24

Social changes that take place as the result of merging the traditional and prevailing culture.

Answer 24

Acculturation. Biculturalism.

Acculturative stress may occur as there are losses and changes associated with the integrative experience.

Question 25

Heritage consistency

Answer 25

The degree to which an individual’s lifestyle reflects her or her traditional heritage.

Question 26

Formulas for BMI?

Answer 26

LB/(inches)squared X 703

Kg/(meters)squared

Question 27

What waist circumferences increase the risks for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease in people with a BMI between what?

Answer 27

Greater than or equal to 35 inches in women
Greater than or equal to 40 inches in men
BMI between 25 and 35

Question 28

Significant weight loss formula?

Answer 28

(usual weight - current weight) x100/usual weight

> 5% over 1 month
7.5% over 3 months
10% over 6 months

Question 29

BMI categories?

Answer 29

Under: <18.5
Normal: 18.5-24.9
Over: 25-29.9
Obese: >30