Health Assessment/SBAR - dont use smh Flashcards
What are the four phases of interview? Describe each phase.
- Prepatory: Review records, ensure pt privacy, ask approriate questions
- Introduction: Build rapport, explain procedure, encourage open communication
- Working: Use focused & open-ended questions to gather detailed info
- Termination: Summarize findings, address concerns, outline next steps
Why is it important to interview patients?
- Assess health status, strengths, risks, values, beliefs and spiritual resources
- Identify actual & potential problem for appropriate interventions
Josh is interviewing his patient and asks them, “You must be feeling a lot of pain in your knee, right?”
What is wrong with Josh’s question? What type of questions should he ask instead?
Josh is asking his patient a leading question and pushing towards a specific response.
Instead Josh should ask open-ended questions to encourage the patient to give a detailed response.
- Ex: Can you describe the pain you’re feeling in your knee?
Who are the primary and secondary sources for obtaining health history data?
- Primary: Patient
- Seconday: Family, caregivers, & medical records
A 68-year-old patient is admitted for chest pain. When the nurse asks about his symptoms, he sighs heavily, looks away, crosses his arms, and mumbles, “It’s nothing, I’ve had worse. Just let me go home.”
What cues should the nurse pay attention to in this interaction? What clues do these cues give the nurse?
Nonverbal Cues
- Sighs
- Looks away
- Crossed Arms
- Mumbles
Based of of the pateints cues, the nurse notices the patient is uncomfortable, dismissive and downplaying their symptoms.
Wat are the (6) key components of effective health history? Describe each component.
- Rapport: Builds trsut, reduces anxiety, & maintains positive attitude
- Listening: Actively listen to words,emotions & observe nonverbal cues
- Questions: Prioritize main concerns, use open-ended cues, avoid leading questions
- Observation: Use all senses and assess verbal & nonverbal behaviors
- Termination: Warn before ending, summarize findings, and confirm understanding
- Validation: Clarify responses, esure accuracy, and avoid biases & misinterpretation
What are the elements of healthy history?
- Present health status
- Past health history
- ADLs: Abilities and Needs
- Learning Needs & Preferences
- Psychological, Social, Cultural & Spiritual Needs
What can be considered a part of a patients present health status? Select all that apply.
A. Beginning, duration & intensity of symptoms
B. Medication
C. Allergies
D. Family history
E. Current conditions and treatments
A, B, C, & E
What can be considered a part of a patients past health history? Select all that apply.
A. Family History
B. Immunizations & health screenings
C. Current Medication Perscriptions
D. Surgeries, hospitalizations & injuries
E. Childhood/Adult illnessess
F. Chronic Diseases
A, B, D, E & F
What is the difference between BADLs and IADLs?
- BADLs (Basic Activities of Daily Living): Eating, bathing, dressing, toileting, mobility
- IADLs (Instrumental Activities of Daily Living): Housekeeping, cooking, medications, transportation, finances
You __ __ transfer a patient unless you know transfer status from a physician
DO NOT
When assessing a patients abilities and needs, it is important to ________________.
assess functional changes, caregiver needs, and quality of life
Match the following needs with their meaning:
- Psychological
- Social
- Cultural
- Spiritual
A. Diet, health beliefs, alternative medicine
B. Coping, depression, anxiety, stressors (look into family support)
C. Religious beliefs & healthcare impact
D. Supprt system, relationships, finances (abuse problems can be identifies if present)
- Pscyhological Needs: (B) Coping, depression, anxiety, stressors (look into family support)
- Social Needs: (D) Supprt system, relationships, finances (abuse problems can be identifies if present)
- Cultural Needs: (A) Diet, health beliefs, alternative medicine
- Spiritual Needs: (C) Religious beliefs & healthcare impact
What is the purpose of doing a head-to-toe assessment?
Collect data to assess health, identify problems, and guide interventions.
Before beginning a physical assessment, what should you always ask the patient?
If they need to use the bathroom
List the four primary assessment techniques used in a physical exam. Describe what each technique is used for
- Inspection - assess size, color, shape, position, & symmetry
- Palpation - assess sound: pitch, loudness, quality & duration
- Percussion - assess temperature, turgor, texture, moisture, tenderness, & shape
- Auscultation - assess location, shape, size, & density of tissues
Compare bilaterally for _____.
symmetry
When conducting a general survey, what are you observing?
Observing patient appearance, behavior, posture, gait, vital signs, BMI, and mental status.
When observing a patient’s skin, hair, and nails, what are you looking for?
- Color
- Texture
- Lesions
- Moisture
- Turgor
When observing a patient’s head and face, what are you looking for?
- Size
- Shape
- Symmetry
- Involutary movements
When observing a patient’s eyes, what are you looking for?
- Visual acuity
- Pupil reaction
- Extraordinary movements
When observing a patient’s ears, what are you looking for?
- External ear inspection
- Hearing ability
When observing a patient’s nose, what are you looking for?
- Patency
- Mucous membrane coulor
- Lesions
When observing a patient’s mouth and throat, what are you looking for?
- Oral mucosa
- Swallowing ability
When observing a patient’s neck, what are you looking for?
- Trachea position
- Range of motion
- Venous distention
When observing a patient’s throax and lungs, what are you looking for?
- Chest expansion
- Breath sounds (duration, pitch, & intensity)
When observing a patient’s cardiovascular health, what are you looking for?
- Heart sounds (rate, rhythm)
- Peripheral pulses
- Edema
When observing a patient’s abdomen, what are you looking for?
- Contour
- Symmetry
- Bowel sounds (before palpation)
When observing a patient’s musculoskeletal system, what are you looking for?
- Posture
- Gait
- Range of motion
- Muscle strength
When observing a patient’s neurological status, what are you looking for?
- Mental status
- Cranial nerves
- Coordination
- Sensory function
When observing a patient’s genatalia, what are you looking for?
- Size
- Placement
- Lesions
- Discharge
What are some indications that a pt suffered a stroke?
Slurred speech
Facial symmetry: facial drooping
What does the Glasgow Coma Scale (GCS) measue/assess? What is the purpose of the Glasgow Coma Scale (GCS)?
Measures/Assessess:
- Eye opening
- Verbal response
- Motor response
Purpose:
- assess the level of consciousness of a patient who suffered a brain injury
Compare normal and abnormal findings for the following:
Cardiovascular System
Normal:
- Regular HR & rhythm, clear S1 & S2, no murmurs/bruits.
-> S1: “lub” ; closure of mitral and tricuspid valves/ ventricular contraction
-> S2: “dub” ; closure of aortic and pulmonic valves/ ventricular diastole
Abnormal:
- Irregular HR, S3/S4 sounds, murmurs, bruits, abnormal BP.
Compare normal and abnormal findings for the following:
Respiratory System
Normal:
- Clear breath sounds, symmetrical chest expansion.
Abnormal:
- Wheezing, crackles, stridor, asymmetrical movement, accessory muscle use.
Describe the following abnormal lung sound. What conditions would you hear these sounds for?
Crackles (Rales)
- Crackling sounds; caused by fluid in the lungs
- Found in patients with Pneumonia, COPD, and fluid in lungs.
Describe the following abnormal lung sound. What conditions would you hear these sounds for?
Wheezes
- High-pitched, whistling sounds; caused by narrowed/ostructed airway
- Found in patients with Asthma, COPD, respiratory infection or obstruction in airway
Describe the following abnormal lung sound. What conditions would you hear these sounds for?
Friction Rub
- Scratchy, grating sound; caused by inflammation/fluid in pleural cavity
- Found in patients with Pleurisy, pulmonary embolism, or any condition causing inflammation of the pleura
Describe the following abnormal lung sound. What conditions would you hear these sounds for?
Rhonchi
- Low-pitched, snoring noises; caused by mucous in large airways
- Found in patients with COPD, cystic fibrosis, pneumonia, and chronic bronchitis
Barrel chest can come from having _____, or can happen due to ____ with _____ disease.
emphysema, aging, no lung
Compare normal and abnormal findings for the following:
Genitourinary System
Normal:
- Clear, pale yellow color
- No discomfort during urination
- Little Sediment
Abnormal:
- Unusual color (red, brown, green)
- Dysuria (pain with urination)
- Significant sediment (cloudiness, crystals)
What questions should you ask a patient to gain data about their urine?
- How often do you pee/urinate normally?
- Do you feel any paint/discomfort when you pee/urinate?
- What color is your pee/urine?
Compare normal and abnormal findings for the following:
Gastrointestinal System
Normal:
- Soft, non-tender abdomen, audible bowel sounds.
- Active: irregular gurgling (every 5-20 sec)
Abnormal:
- Hard, tender abdomen
- Hyperactive: high pitched, loud sound every 3 secs
- Hypoactive: soft, infrequent sound per minute
- Absent: no sounds heard after 1 min in all quadrants
What questions should you ask to gain data about your patients excrement?
- when was your last bowel movement
-> ask abt. constipation, diarrhea, consistencyc and color - do you have hemorrhoids?
- do you have any special dietary needs?
- are you passing gas?
-> Important question to ask if someone had abdominal surgery
Compare normal and abnormal findings for the following:
Neurological Status
Normal:
- Alert, oriented, PERRLA reactive.
Abnormal:
- Slurred speech, confusion, unequal pupils, tremors, weakness.
Describe what PERLA stands for.
- Pupils
- Equals
- Round
- Reactive
- Light
- Accommodation
-> Further distance: dilating
-> Closer: constricting
Compare normal and abnormal findings for the following:
Musculoskeletal System
Normal:
- Normal gait, posture, ROM, no tenderness/swelling.
Abnormal:
- Joint swelling, pain, deformities, muscle atrophy, tremors.
Compare normal and abnormal findings for the following:
Integumentary (Skin)
Normal:
- Warm, dry, intact, even tone, no lesions.
Abnormal:
- Pallor
- Cyanosis
- Jaundice
- Erythema
- Ulcers
- Rashes.
Describe the following skin problem:
Cyanosis
- Blue discolloration
-> lips & fingers - Caused by lack of oxygenation: <80% 02 sat
Describe the following skin problem:
Pallor
- Paleness
- Seen in anemic patients:
-> ↓ hemoglobin circulation
Describe the following skin problem:
Jaundice
- Yellow discoloration of the skin, eyes, and mucous membranes
- Seen in patients with liver & gallbadder problems:
-> ↑ bilirubin levels
Describe the following skin problem:
Erythema/Flushing
- Redness
- Caused by dilation of blood vessles at surface of skin
- Seen in patietns with a fever or sunburn
Compare normal and abnormal findings for the following:
Peripheral Vascular
Normal:
- Strong, symmetrical pulses, no swelling.
Abnormal:
- Weak/absent pulses, edema, varicose veins, temp differences.
What are the five steps of the nursing process?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Compare the following health assessment date:
Subjective data
Objective data
Holistic focus
- Subjective Data: Patient-reported (pain, nausea, fatigue).
- Objective Data: Measurable (vital signs, exam findings, labs).
- Holistic Focus: Assess impact on daily life & well-being.
What is the importance of documentation in health assessment?
- Ensure accurate, concise, systematic recording
- Differentiate between objective & subjective data
- Ensure legal compliance & future reference
What is the importance of trending in health assessment?
- compare current and past assessments
-> detect changes in a patients conditions - monitor vital signs & symptoms for deviations
- use EHRs for early detection of deterioration
What is the importance of communication & teamwork in health assessment?
- Collaborate with healthcare professionals.
- Use ISBAR for structured reporting.
- Educate patients & families on conditions & treatments.
What is the importance of safety in health assessment?
- Follow infection control (hand hygiene, PPE, sterile technique).
- Ensure proper positioning & comfort during assessments.
- Identify abnormal findings & respond to emergencies immediately.
What position is used to take vital signs?
Sitting
Sitting position allows easy access for measuring vital signs.
What is the purpose of the supine position?
Allows for relaxation of abdominal muscles
Which position is used for patients having difficulty maintaining the supine position?
Dorsal recumbent
What is the Sims position primarily used for?
Assessment of rectum or vagina
This position facilitates examination of the rectal area.
What is the prone position used for?
Assessment of rectum or vagina
What is the lithotomy position used for?
Assessment of female rectum and vagina; used for brief period only
This position is commonly used in gynecological exams.
What is the purpose of the knee-chest position?
Assessment of the rectal area; used for brief period only
This position is often used for rectal examinations.
What does the standing position assess?
Posture, gait, and balance
This position is important for evaluating a patient’s overall stability and mobility.
What instrument is used to visualize the interior structure of the eye?
Ophalmoscope
What instrument is used to examine the external ear canal and tympanic membrane?
Otoscope
What chart is used to test for distant vision?
Snellen Chart
What instrument is used to visualize the lower and middle turbinates of the nose?
Nasal Speculum
What instrument is used to examine the vaginal canal and cervix?
Vaginal speculum
What instrument is used to test for auditory function and vibration perception?
Tuning fork
What instrument is used to test deep tendon reflexes and determines tissue density?
Percussion hammer
What should you do when assessing a patient with potential Deep Vein Thrombosis (DVT)?
- Ask about the pain
- Inspect for Edema
- Inspect for redness
- Use the back of hand as a “blade” to assess for heat
A patient is admitted into the hosiptal with a pain level of 7/10 in the right leg. When the nurses assesses their leg, they notice that the leg is noticibly swollen and red. When the nurse touches the patients leg, they notice that the leg is hot to the touch. What is the patients diagnosis?
The patient has Deep Vein Thrombosis (DVT).
Describe the different types of health care assessment.
- Comprehensive (admission): conducted upon admission
- Ongoing partial (shift): conducted at regular intervals (2-4 hours)
- Focused: conducted to assess specific problem (usually occurring in the ER)
- Emergency (Triage): conductor when addressing a life-threatening or unstable situation → major system problems
