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NUR 131 --Test 1 > Health Assessment > Flashcards

Health Assessment Flashcards

1
Q

What is the role of nursing assessment in identifying client needs?

A

–collect comprehensive data pertinent to the patient’s health or situation. (p.1)

–analyze the assessment data to determine diagnoses or issues (p.1)

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2
Q

Definition and Purpose of Health Assessment

A

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)

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3
Q

What is the first step in the nursing process?

A

Assessment (most critical phase) (p.3)

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4
Q

What are the end results/goals of health assessment?

A
  • form nursing dx & care plan
  • identify collab. & medical problems
  • note pt. teaching needs
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5
Q

What type of data does the nurse collect during a health assessment?

A

Holistic approach:

- physiological (physician’s primary focus
- psychological
- sociocultural
- developmental
- spiritual
p. 4)

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6
Q

What are the 4 TYPES of health assessment?

A

1) Initial
2) Ongoing or Partial
3) Focused/Prob.-oriented
4) Emergency

  • each varies in amt. and type of data collected
    (p. 5)
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7
Q

What factors affect which type of assessment the nurse chooses?

A

a. Clinical situation
b. Client status
c. Time available
d. Purpose of data collection

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8
Q

What are the characteristics of an INITIAL Comprehensive Assessment?

A
  • -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)
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9
Q

What are the characteristics of an ONGOING/PARTIAL Assessment?

A
  • -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)
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10
Q

What are the characteristics of a FOCUSED/PROBLEM-ORIENTED Assessment?

A
  • -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)
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11
Q

What are the characteristics of an EMERGECY Assessment?

A
  • -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)
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12
Q

What are the 4 STEPS of health assessment?

A
  1. Collect subjective data
  2. Collect objective data
  3. Validate data
  4. Document data
    (5. Analyze data)

(p.6)

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13
Q

How does a nurse PREPARE for the assessment?

A

-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)
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14
Q

What are the components of collecting SUBJECTIVE data?

A

–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)

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15
Q

Comparing Objective & Subjective Data:

Characteristics of SUBJECTIVE DATA

A

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)

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16
Q

Comparing Objective & Subjective Data:

Characteristics of OBJECTIVE DATA

A

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”&raquo_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)

17
Q

What are the 4 Phases of the Health History Interview?

A
  1. Pre-introductory Phase
  2. Introductory Phase
  3. Working Phase
  4. Summary&Closing Phase
    (p. 12)
18
Q

What are the characteristics of the PRE-INTRODUCTORY (Pre-interaction) PHASE of the Health History Interview?

A
  • -Practice interviewing skills
  • -Review chart, if possible
  • -Reason for visit?
  • -Prepare environment
    (p. 12)
19
Q

What are the characteristics of the INTRODUCTORY PHASE of the Health History Interview?

A
  • -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)
20
Q

What are the characteristics of the WORKING PHASE of the Health History Interview?

A
  • -obtain SUBJECTIVE data
  • -observe cues
  • -interpret & validate info
  • -collab. w/ pt. to identify prob. and develop goals
    (p. 13)
21
Q

What are the characteristics of the SUMMARY/CLOSING PHASE of the Health History Interview?

A
  • -summarize info
  • -validate problems & goals
  • -identify & discuss plans to resolve problems
  • -allow pt. time to express feelings & ask ?s
    (p. 13)
22
Q

What are the components of collecting OBJECTIVE data?

A
  • 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)
23
Q

What are the 4 PHYSICAL Examination techniques?

A

“IPPA”

- -Inspection
- -Palpation
- -Percussion
- -Auscultation
p. 8

24
Q

What is the purpose of VALIDATING assessment data?

A

–to ensure that assessment does not end before all relevant data are collected
and
–to prevent documentation of inaccurate data
(p.8)

25
Q

What is the purpose of DOCUMENTING assessment data?

A
  • -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)
26
Q

What are the 2 types of Communication Techniques and their purpose?

A
  • Verbal* & Nonverbal communication techniques are used to –promote an effective and productive interview–
    (p. 14)
27
Q

What are the types of NONVERBAL communication?

A

–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)
28
Q

What are the types of VERBAL communication?

A

–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)
29
Q

What types of nonverbal communication should be AVOIDED?

A

–excessive or insufficient eye contact (also consider cultural variations p.16)

–distraction and distance (mentally and physically)

  • -standing
    (p. 15)
30
Q

What types of verbal communication should be AVOIDED?

A

–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)
31
Q

What are the 3 special considerations (variations) of interviewing?

A
  • -cultural variations
  • -emotional variations
  • -lifespan variations
    (p. 16)
32
Q

What are some of the CULTURAL variations in communication?

A
  • -language
  • -physical differences
  • -risk factors
  • -perceptions
  • -use/meaning of nonverbal communication
  • -open express./reluctance
    (p. 16 & 17)
33
Q

What are some of the EMOTIONAL variations in communication?

A
  • -anger (be calm, allow vent)
  • -anxiety/fear (be simple)
  • -depression (be interested)
  • -ulterior motive (set limits)

(p.17; see Box 2-3, p.18)

34
Q

What are some of the LIFESPAN variations in communication?

A

GERIATRIC

  • -low voice, speak toward
  • -brief instructions
  • -est. trust and privacy
  • -speak w/ caregiver separately
    (p. 16)

PEDIATRIC
–can interview parent
&raquo_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)

35
Q

When interviewing TODDLERS/PRE-SCHOOLERS:

A
  • -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

36
Q

When interviewing SCHOOL-AGED & ADOLESCENTS:

A
  • -allow control/choices
  • -respect views/feelings
  • -more detailed explanations
  • -speak to adoles. alone
  • -be open, honest, nonjudg.

-validate discrepancies or missing info

37
Q

What types of Health History questions are asked in the assessment?

A

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

38
Q

What is covered in the Head to Toe Assessment?

A

(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

NUR 131 --Test 1 (4 decks)

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