Health Assessment Flashcards
What is the role of nursing assessment in identifying client needs?
–collect comprehensive data pertinent to the patient’s health or situation. (p.1)
–analyze the assessment data to determine diagnoses or issues (p.1)
Definition and Purpose of Health Assessment
Collect holistic subjective & objective data
Analyze and synthesize data to determine overall indiv. health state and then make –clinical judgments– and eval. pt. care outcomes (p.3 & 4)
What is the first step in the nursing process?
Assessment (most critical phase) (p.3)
What are the end results/goals of health assessment?
- form nursing dx & care plan
- identify collab. & medical problems
- note pt. teaching needs
What type of data does the nurse collect during a health assessment?
Holistic approach:
- physiological (physician’s primary focus
- psychological
- sociocultural
- developmental
- spiritual
p. 4)
What are the 4 TYPES of health assessment?
1) Initial
2) Ongoing or Partial
3) Focused/Prob.-oriented
4) Emergency
- each varies in amt. and type of data collected
(p. 5)
What factors affect which type of assessment the nurse chooses?
a. Clinical situation
b. Client status
c. Time available
d. Purpose of data collection
What are the characteristics of an INITIAL Comprehensive Assessment?
- -done upon admission
- *performed by RN w/i 24h**
- -incl health hx & phys. exam
- -subj. & obj. data about functional health and body systems
- -serves as baseline
(p. 5)
What are the characteristics of an ONGOING/PARTIAL Assessment?
- -after initial assess.; f/up
- -mini-overview of body sys & holistic health patterns
- -RE-assess “problems”
- -RE-assess normal systems
- -ex: Abbrev. Head-to-Toe
(p. 5 & 6)
What are the characteristics of a FOCUSED/PROBLEM-ORIENTED Assessment?
- -does not replace comprehensive assessment
- -collect data about specif. prob. already identified
- -narrow scope & short time frame
- -prob. still exist? changed?
- -any new prob.?
(p. 6)
What are the characteristics of an EMERGECY Assessment?
- -rapid assessment
- -for life-threatening situat.
- -immediate intervention
- -(choke, cardiac arr., drown)
- -det. status of pt. life-sustaining phys. functions
- -resp., circ., or neuro. problems or emergency psychosocial situations
(p. 6)
What are the 4 STEPS of health assessment?
- Collect subjective data
- Collect objective data
- Validate data
- Document data
(5. Analyze data)
(p.6)
How does a nurse PREPARE for the assessment?
-Review record, if possible
(to guide interactions and educate self abt. dx, tests)
- Consult w/ other members
- Examine own feelings (be objective and open minded; avoid prejudgments)
- Obtain & organize materials needed
(p. 6 & 7)
What are the components of collecting SUBJECTIVE data?
–sensations or symptoms; feelings; perceptions; ideas; beliefs; preferences; personal information
–elicited and verified ONLY by client/pt.
–obtained by INTERVIEW
(hx of present health concern, personal health hx, family hx, health/lifestyle)
(p.7)
Comparing Objective & Subjective Data:
Characteristics of SUBJECTIVE DATA
Subjective Data:
–description–provided/verified by pt.
–source–
obtain from pt., record, or other healthcare providers
–methods–
interview
–skills needed–
interview & therapeutic communication; caring, empathy; listening
–examples:
“I have a headache”
“It frightens me”
“I am not hungry”
(Table 1-2, p.8)
Comparing Objective & Subjective Data:
Characteristics of OBJECTIVE DATA
Objective Data:
–description–directly/indirectly obs. through measurement
–source–
observation/phys. assess. findings; documentation of assess. in pt. record; obs. made by pt family/sig. other
–methods–
observation & phys. exam.
–skills needed–
“IPPA”»_space; inspect, palpate, percuss, auscultate
–examples:
respirations 16 per minute
BP180/100, apical pulse 80
X-ray film reveals fractured pelvis
(Table 1-2, p.8)
What are the 4 Phases of the Health History Interview?
- Pre-introductory Phase
- Introductory Phase
- Working Phase
- Summary&Closing Phase
(p. 12)
What are the characteristics of the PRE-INTRODUCTORY (Pre-interaction) PHASE of the Health History Interview?
- -Practice interviewing skills
- -Review chart, if possible
- -Reason for visit?
- -Prepare environment
(p. 12)
What are the characteristics of the INTRODUCTORY PHASE of the Health History Interview?
- -introduce self & role
- -explain purpose, types of ?s
- -est. rapport, alleviate anxiety
- -provide comfort, privacy, & confidentiality
- -use active listening
- -begin w/ open-ended ?s
- -devel. verbal contract (goals)
(p. 13)
What are the characteristics of the WORKING PHASE of the Health History Interview?
- -obtain SUBJECTIVE data
- -observe cues
- -interpret & validate info
- -collab. w/ pt. to identify prob. and develop goals
(p. 13)
What are the characteristics of the SUMMARY/CLOSING PHASE of the Health History Interview?
- -summarize info
- -validate problems & goals
- -identify & discuss plans to resolve problems
- -allow pt. time to express feelings & ask ?s
(p. 13)
What are the components of collecting OBJECTIVE data?
- uses the 4 phys. exam techniques: “IPPA”
- can reference pt. record for observations by other health care professionals
- Directly observe:
- -physical characteristics
- -body functions (ex: <3 rate)
- -appearance (ex: hygiene)
- -behavior
- -measurements (ex: BP, temp., ht. & wt.)
- -results of laboratory tests
(p. 8)
What are the 4 PHYSICAL Examination techniques?
“IPPA”
- -Inspection
- -Palpation
- -Percussion
- -Auscultation
p. 8
What is the purpose of VALIDATING assessment data?
–to ensure that assessment does not end before all relevant data are collected
and
–to prevent documentation of inaccurate data
(p.8)
What is the purpose of DOCUMENTING assessment data?
- -to form the database for the nursing process
- -to provide data for other members of health care team
- -to ensure valid conclusions are made when the data are analyzed
(p. 8 & 9)
What are the 2 types of Communication Techniques and their purpose?
- Verbal* & Nonverbal communication techniques are used to –promote an effective and productive interview–
(p. 14)
What are the types of NONVERBAL communication?
–appearance (professional)
–demeanor (poise, prepared)
–facial expressions (will show thoughts; be neutral)
–attitude (nonjudgmental)
–silence (nurse & pt reflect/organize thoughts)
- -listen effectively (eye contact, open body pos. & mind)
(p. 14)
What are the types of VERBAL communication?
–open-ended ?s (elicit pt. feelings/perceptions in more than 1 word; “how/what?”)
–closed-ended ?s (get facts)
–laundry list (list of words for pt. to choose from to describe symptoms, conditions, and feelings)
–rephrasing (clarify/reflect on info provided by pt.)
–well-placed phrases (“mhm, yes, I agree;” shows that you’re listening)
–inferring (can elicit more/verify data)
- -providing information (answer ?s thoroughly as possible)
(p. 15 & 16)
What types of nonverbal communication should be AVOIDED?
–excessive or insufficient eye contact (also consider cultural variations p.16)
–distraction and distance (mentally and physically)
- -standing
(p. 15)
What types of verbal communication should be AVOIDED?
–biased or leading ?s (may get false answers)
–rushing through interview (doesn’t show interest in pt’s health)
- -reading the question (impersonal interview process)
(p. 15)
What are the 3 special considerations (variations) of interviewing?
- -cultural variations
- -emotional variations
- -lifespan variations
(p. 16)
What are some of the CULTURAL variations in communication?
- -language
- -physical differences
- -risk factors
- -perceptions
- -use/meaning of nonverbal communication
- -open express./reluctance
(p. 16 & 17)
What are some of the EMOTIONAL variations in communication?
- -anger (be calm, allow vent)
- -anxiety/fear (be simple)
- -depression (be interested)
- -ulterior motive (set limits)
(p.17; see Box 2-3, p.18)
What are some of the LIFESPAN variations in communication?
GERIATRIC
- -low voice, speak toward
- -brief instructions
- -est. trust and privacy
- -speak w/ caregiver separately
(p. 16)
PEDIATRIC
–can interview parent
»_space;build rapport, obs. hesitation & attitude/tone; anticipatory guidance, info. exchange
–can interview child/adoles.
»use play (p. 742), speak @ eye level, listen/make child comfortable; praise/reward
> > explain interview & assessment process, be honest, encourage ?s
> > consider developmental level (p. 748)
(p.746-748)
When interviewing TODDLERS/PRE-SCHOOLERS:
- -info provided by parent
- -include child
- -obs. parent-child interact.
- -allow child to be close to parent
- -simple explanations/terms
- -visual aides; acknow. toys
- *attn. span: 5-10 mins**
-validate discrepancies or missing info
When interviewing SCHOOL-AGED & ADOLESCENTS:
- -allow control/choices
- -respect views/feelings
- -more detailed explanations
- -speak to adoles. alone
- -be open, honest, nonjudg.
-validate discrepancies or missing info
What types of Health History questions are asked in the assessment?
Health Perception - Health Management
Nutritional – Metabolic
Elimination
Activity – Exercise
Sexuality – Reproduction
Sleep – Rest
Cognitive – Perceptual
Role – Relationship
Self-Perception - Self-Concept
Coping - Stress Tolerance
Value –Belief
(ref. Lab 1 Material)
https: //rchc-moodle.com/pluginfile.php/29766/mod_folder/content/0/Health%20History%20Questions.docx?forcedownload=1
What is covered in the Head to Toe Assessment?
(first: Wash Hands & Clean Stethoscope; Introduction)
- -vitals
- -orientation (A&O x4)
- -pupil check (PERRLA)
- -neck veins
- -heart tones (apical)
- -bilateral checks (radial pulses, hand strength, pedal pulses, cap. refill for fingers & toes)
- -skin (turgor, color, temp)
- -breath sounds (ant. & post.)
- -bowel sounds (4 quads)
- -assess for pain (COLDSPA)
- -check for skin breakdown
- -Homan’s sign (assess DVT)
(last: closure)
(ref head to toe checklist)
https://rchc-moodle.com/mod/resource/view.php?id=21041
