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Introduction to Health Assessment Flashcards

1
Q

In Nursing: Scope and Standards of Practices, What Standard is this?

“The registered nurse collects comprehensive data pertinent to the patient’s health or situation.”

A

Standard I

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2
Q

In Nursing: Scope and Standards of Practices, What Standard is this?

“The registered nurse analyzes the assessment data to determine the diagnoses or issues.”

A

Standard II

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3
Q

IN EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT

  • Nurses relied on their natural senses, client’s face and body would be observed.

What year is this?

A

Late 1800s to Early 1900s

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4
Q

IN EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT

  • The role of case finding, prevention of communicable diseases, and routine use of assessment skills as PHN.

What year is this?

A

1930 to 1949

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5
Q

IN EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT

  • Hired to conduct pre-employment stories & physical examinations for major companies.

What year is this?

A

1950 to 1969

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6
Q

IN EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT

  • Prompted to develop an active role in the provision of primary health services and expanded role in conducting health histories & physical & psychological assessments.

What year is this?

A

1970 to 1989

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7
Q

IN EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT

  • Advanced practice nurses have been increasingly used.

What year is this?

A

1990 to Present

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8
Q

This is the first phase of the nursing process.

A

Assessment

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9
Q

Assessment is the most irrelevant phase of the nursing process.

TRUE OR FALSE

A

FALSE

Note:

  • Assessment is the most critical phase of the nursing process.
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10
Q

Assessment is the deliberate and systematic collection of data to determine the client’s current and past health and functional status.

TRUE OR FALSE

A

TRUE

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11
Q

Assessment determines the client’s current and past coping patterns.

TRUE OR FALSE

A

TRUE

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12
Q

Assessment is ended and intermittent throughout all the phases of the nursing process.

TRUE OR FALSE

A

FALSE

Note:

  • Assessment is an ongoing and continuous throughout all the phases of the nursing process.
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13
Q

What are the 4 Basic Types of Assessment?

A
  • Initial comprehensive assessment
  • Ongoing or partial assessment
  • Focused or problem-oriented assessment
  • Emergency assessment
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14
Q

What are the (4) Steps of Health Assessment?

A
  • Collection of Subjective data
  • Collection of Objective data
  • Validation of Data
  • Documentation of data
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15
Q

What are the (2) Types of Data?

A
  • Subjective Data
  • Objective Data
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16
Q

Data are elicited and verified by the client.

Examples:

  • “I can’t see clearly.”
  • “My backache is worsening each day.”
  • “I give up.”
  • “I know God is with me in all of these.”
A

Subjective Data

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17
Q

What are the Skills needed to obtain Subjective Data?

A
  • Interview and therapeutic communication skills.
  • Caring ability
  • Empathy
  • Listening skills

REMEMBER THE ACRONYM ICEL

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18
Q

Data are directly or indirectly observed or measured.

Examples:

  • Reddened patches all over posterior chest
  • Bipedal edema
  • BP: 90/60 mmHg
  • Weight: 55 kg
  • Height: 185 cms
A

Objective Data

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19
Q

What are the Skills needed to obtain Objective Data?

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

REMEMBER THE ACRONYM IPPA

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20
Q

A planned communication or a conversation with a purpose.

A

Interview

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21
Q

FAMILIARIZE ONLY!

The nursing interview is a communication process that has (2) two focuses:

A
  • Establish rapport and a trusting relationship with a client.
  • Gathering information on the client’s developmental, psychological, physiologic, sociocultural, and spiritual status.
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22
Q

What are the 8 Sections of Health History?

A
  • Biographical Data
  • Reasons for seeking health care
  • History of present health concern
  • Personal health history
  • Family health history
  • ROS for current health problems
  • Lifestyle and health practice profile
  • Developmental level
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23
Q

What part of assessment tool is this?

  • Name
  • Address
  • Phone
  • Gender
  • Provider of history (Patient or other)
  • Birthdate
  • Place of birth
  • Race or ethnic background
  • Primary and secondary languages (spoken and read)
  • Marital status
  • Religious or spiritual practices
  • Educational level
  • Occupation
  • Significant others or support persons (availability)
A

Biographical Data

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24
Q

What part of assessment tool is this?

  • Major health problem or concern
  • Feelings about seeking health care (fears and past experiences)
A

Reasons for seeking health care

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25
Q

What part of assessment tool is this?

  • Character (How does it feel, look, smell, sound, etc.?)
  • Onset (When did it begin; is it better, worse, or the same since it began?)
  • Location (Where is it? Does it radiate?)
  • Duration (How long does it last? Does it recur?)
  • Severity (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever experienced]?)
  • Pattern (What makes it better? What makes it worse?)
  • Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities [leisure or exercise]?)
A

History of Present Health Concern using COLDSPA

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26
Q

COLDSPA stands for what?

A

Character, Onset, Location, Duration, Severity, Pattern, Associated factors

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27
Q

What part of assessment tool is this?

  • Problems at birth
  • Childhood illnesses
  • Immunizations to date
  • Adult illnesses (physical, emotional, mental)
  • Surgeries
  • Accidents
  • Prolonged pain or pain patterns
  • Allergies
  • Physical, emotional, social, or spiritual weaknesses
  • Physical, emotional, social, or spiritual strengths
A

Past Health History

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28
Q

What Assessment tool is this?

  • Age of parents (Living? Date of death?)
  • Parents’ illnesses and longevity.
  • Grandparents’ illnesses and longevity.
  • Aunts’ and uncles’ ages and illnesses and longevity.
  • Children’s ages and illnesses or handicaps and longevity.
A

Family Health History

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29
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff.
A

Integumentary (Skin, hair, and nails)

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30
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat.
A

Head and neck

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31
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, ringing, buzzing, drainage, difficulty hearing, exposure to loud noises, dizziness.
A

Ears

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32
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double vision.
A

Eyes

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33
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Mouth pain, sore throat, lesions, hoarseness, nasal obstruction, sneezing, coughing, snoring, nosebleeds.
A

Mouth, throat, nose, and sinuses

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34
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, difficulty breathing, shortness of breath with activities, orthopnea, cough, sputum, hemoptysis, respiratory infections.
A

Thorax and lungs

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35
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, lumps, discharge from nipples, dimpling or changes in breast size, swollen and tender lymph nodes in axilla.
A

Breasts and regional lymphatics

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36
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Chest pain or pressure, palpitations, edema, last blood pressure, last ECG.
A

Heart and neck vessels

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37
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Leg or feet pain, swelling of feet or legs, sores in feet or legs, color of feet and legs.
A

Peripheral vascular

38
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, indigestion, difficulty swallowing, nausea and vomiting, gas, jaundice, hernias.
39
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Painful urination, frequency or difficulty starting or maintaining urinary system, blood in urine, sexual problems, penile lesions, penile pain, scrotal swelling, difficulty with erection or ejaculation, exposure to STIs.
A

Male genitalia

40
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pelvic pain, voiding pain, sexual pain, voiding problems (dribbling, incontinence), age of menarche or menopause (date of last menstrual period), pregnancies and types of problems, abortions, STIs, HRT, birth control methods.
A

Female genitalia

41
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, with defacation, hemorrhoids, bowel habits, constipation, diarrhea, blood in stool.
A

Anus, rectum, and prostate

42
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Pain, swelling, redness, stiff joints, strength of extremities, abilities to care for self and work.
A

Musculoskeletal

43
Q

What REVIEW OF SYSTEMS for current health problems is this?

  • Mood, behavior, depression, anger, headaches, concussions, loss of strength or sensation, coordination, difficulty with speech, memory problems, strange thoughts or actions, difficulty reading or learning.
A

Neurologic

44
Q

What Assessment tool is this?

  • Description of a typical day (AM to PM)
  • Nutrition and weight management
  • 24-hour dietary intake (foods and fluids)
  • Who purchases and prepares meals
  • Activities on a typical day
  • Exercise habits and patterns
  • Sleep and rest habits and patterns
  • Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs)
  • Self-concept
  • Self-care responsibilities
  • Social activities for fun and relaxation
  • Social activities contributing to society
  • Relationships with family, significant others, and pets
  • Values, religious affiliation, spirituality
  • Past, current, and future plans for education
  • Type of work, level of job satisfaction, work stressors
  • Finances
  • Stressors in life, coping strategies used
  • Residency, type of environment, neighborhood, environmental risks
A

Lifestyle and Health Practices

45
Q

IN DEVELOPMENTAL LEVEL, what corresponds to the given?

  • Intimacy versus Isolation.
A

Young adult

46
Q

IN DEVELOPMENTAL LEVEL, what corresponds to the given?

  • Generativity versus stagnation.
A

Middlescent

47
Q

IN DEVELOPMENTAL LEVEL, what corresponds to the given?

  • Ego integrity versus despair.
A

Older adult

48
Q

What are the 4 Phases of the Interview?

A
  • Pre-introductory
  • Introductory
  • Working
  • Summary and Closing

Note:
The pre-introductory part may be removed. Pag 3 Ang tinanong then Hindi Kasama Yung pre-introductory.

49
Q

What phase of the interview is this?

  • Reviews the medical record before meeting with the client.
  • Knowing some of the client’s already documented biographical information may assist the nurse when conducting the interview.
A

Pre-introductory

50
Q

What phase of the interview is this?

  • Introduce yourself
  • Explain the purpose of the interview
  • Discuss the type of questions that will be asked, explain the reasons of taking notes.
  • Assures the client that confidential information remains confidential
  • Conduct an interview at eye level
  • Develop trust and rapport
A

Introductory

51
Q

What phase of the interview is this?

  • Elicits the client’s comments about major biographical data, reasons for seeking care, history of Present Health Concern, past health history, family history, review of system (ROS) for current health problems, lifestyle and health practices, developmental level.
52
Q

What phase of the interview is this?

  • Summarizes obtained information
  • Validate problems and goals with the client
  • Identifies and discusses possible plans to resolve the problem with the client.
A

Summary and Closing

53
Q

What are the 2 Approaches to Interviewing?

A
  • Directive Interview
  • Non-directive interview
54
Q

What Approaches to Interview is this?

  • Highly structured, elicits specific information.
  • Nurse establishes purpose of and controls the interview.
  • Used to gather and get information when time is limited.
A

Directive Interview

A directive interview is a structured interview where the interviewer controls the conversation by asking specific, pre-determined questions. It follows a fixed format, ensuring that all interviewees are asked the same questions. This method is commonly used in job interviews, research, and surveys because it allows for easier comparison of responses.

55
Q

What Approaches to Interview is this?

  • Rapport building
  • Nurse allows client to control the purpose, subject matter, and pacing.
A

Non-directive Interview

A non-directive interview, on the other hand, is more open-ended and flexible. The interviewer encourages the interviewee to express their thoughts freely, guiding the discussion with minimal intervention. This method is often used in counseling, therapy, and qualitative research to gain deeper insights into a person’s feelings, opinions, or experiences.

56
Q

What are the 7 Types of Verbal Communication?

A
  • Closed-ended questions
  • Open-ended questions / Neutral
  • Laundry List
  • Rephrasing
  • Well-Placed Phrases
  • Inferring
  • Providing Information
57
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Used in directive interview
  • Restrictive, generally requires a “yes” or “no” or short factual answers giving specific information.
  • Often begin with “when”, “where”, “who”, “what”, “do (did, does)”, “is (are, was)”.
A

Closed-ended questions

Note:

  • Questions that require short, specific answers, usually “yes” or “no” (e.g., “Do you feel pain?”).
58
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Used in non-directive interview
  • Invite clients to discover and explore, elaborate, clarify, and illustrate their thoughts or feelings
  • Answers are longer than two words
  • Gives clients the freedom to divulge information that they are ready to disclose
  • Useful at the beginning of an interview or to change topics and to elicit attitudes
  • May begin with “what” or “how”
A

Open-ended questions / Neutral

Note:

  • Questions that encourage detailed responses and deeper discussions (e.g., “Can you describe how you’re feeling?”).
59
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Provide a client with a list of words to choose from a describe symptoms, conditions, or feelings.
  • It helps to obtain specific answers and reduces the likelihood of the client perceiving or providing specific answers.
A

Laundry List

Note:

  • Providing a set of choices to help the person respond more easily (e.g., “Is your pain sharp, dull, or throbbing?”).
60
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Helps to clarify information on the client has stated.
  • Enables the client to reflect on what he/she said.
A

Rephrasing

Note:

  • Restating what the person said to ensure understanding (e.g., “So, you’re saying the pain worsens at night?”).
61
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Use phrases like “uh-huh”, “yes”, or “I agree” to encourage cline to continue.
A

Well-Placed Phrases

Note:

  • Short verbal cues to show attentiveness and encourage conversation (e.g., “I see,” “Go on.”).
62
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Information of what the client tells you and what you observe in the client’s behavior may elicit more data or verify existing data.
A

Inferring

Note:

  • Making logical conclusions based on what the person says or how they act (e.g., If a patient winces, you might infer they’re in pain).
63
Q

What TYPE of VERBAL COMMUNICATION is this?

  • Answers all questions and concerns the client has.
  • If you do not know the answer, explain that you will find out.
A

Providing Information

Note:

  • Explaining or educating to help the person understand better (e.g., “This medication will help reduce inflammation.”).
64
Q

What are the 2 Types of Communication?

A
  • Verbal
  • Non-Verbal
65
Q

What are the 6 under the Nonverbal communication?

A
  • Appearance
  • Demeanor
  • Facial Expression
  • Attitude
  • Silence
  • Listening

REMEMBER THE ACRONYM AD-FASL

66
Q

This is under the Nonverbal Communication. What is this?

  • Wear comfortable, neat clothes/uniform with name tags.
  • Hair should be neat and pulled back if long.
  • Fingernails should be short and neat.
  • Jewelry should be minimal.
A

Appearance

67
Q

This is under the Nonverbal Communication. What is this?

  • Be professional
  • Display poise
  • Do not enter the rooms laughing loudly, yelling to a co-worker
  • Greet the client calmly by name not by references.
  • Focus your full attention to the client.
  • Do not be overwhelmingly friendly or “touchy”
68
Q

This is under the Nonverbal Communication. What is this?

  • Keep your expression neutral and friendly.
A

Facial Expression

69
Q

This is under the Nonverbal Communication. What is this?

  • A healthcare professional has a non-judgemental attitude.
  • Do not act as though you feel superior to the client or appear shocked, disgusted, or surprised at what you are told.
70
Q

This is under the Nonverbal Communication. What is this?

  • Allows the nurse and client to reflect and organize thoughts, which facilitates more accurate reporting and data collection.
71
Q

This is under the Nonverbal Communication. What is this?

  • An important skill to learn and develop fully in order to collect complete and valid data from the client.
  • Maintain good eye contact
  • Smile or display an open, appropriate facial expression
  • Maintain an open body position
  • Avoid preconceived ideas or biases
  • Be open-minded
  • Concentrate to the client, do not engage with an electronic devices.
72
Q

FAMILIARIZED ONLY!

What are the Communication to AVOID?

A

Nonverbal Communication

  • Excessive or insufficient eye contact
  • Distractions and Distance
  • Standing

Verbal Communication

  • Biased or Leading Questions
  • Rushing through the Interview
  • Reading the questions
73
Q

FAMILIARIZE ONLY!

Structure of an Interview – Closing Techniques

A
  • Offer to answer questions – Before ending, allow the interviewee to ask any questions or clarify concerns. This ensures they feel heard and valued.
  • Conclude by saying, “Well, that’s all I need to know for now.” Preceding a remark with the word “well” generally signals that the end of the interaction is near.
  • Thank the client. You may also shake the client’s hand.
  • Express concern for the person’s welfare and future. – Expressing care for their situation (e.g., “Take care, and I hope you feel better soon”) reassures the person and fosters trust.
  • Plan for the next meeting, if there is to be one, or state when it will happen next. Include the day, time, place, topic, and purpose.
  • Provide summary to verify accuracy & agreement. Summarizing not only terminates the interview but also reassures the client that the nurse has listened.
74
Q

In Planning the Interview and Setting,

  • Nurse should review unavailable information.

TRUE OR FALSE

A

FALSE

Nurse should review available information.

75
Q

In Planning the Interview and Setting,

  • Nurse reviews the institution’s data collection form if there’s any, otherwise, the nurse may prepare an interview guide.

TRUE OR FALSE

76
Q

What are the 5 Things we need to consider during an Interview?

A
  • Time
  • Place
  • Seating Arrangement
  • Distance
  • Language
77
Q

GUIDELINES DURING AN INTERVIEW

  • Listen attentively, using all your senses, and speak fast and gibberish.

TRUE OR FALSE

A

FALSE

Listen attentively, using all your senses, and speak slowly and clearly.

78
Q

GUIDELINES DURING AN INTERVIEW

  • Clarify points that are not understood.

TRUE OR FALSE

79
Q

GUIDELINES DURING AN INTERVIEW

  • Plan questions to follow an incoherent sequence.

TRUE OR FALSE

A

FALSE

Plan questions to follow a logical sequence.

80
Q

GUIDELINES DURING AN INTERVIEW

  • Ask only one question at a time. Multiple questions limit the client to one choice and may confuse the client.

TRUE OR FALSE

81
Q

GUIDELINES DURING AN INTERVIEW

  • Acknowledge the client’s right to look at things the way they appear to him and not the way they appear to the nurse or someone else.

TRUE OR FALSE

82
Q

GUIDELINES DURING AN INTERVIEW

  • Impose your own values on the client.

TRUE OR FALSE

A

FALSE

Do not impose your own values on the client.

83
Q

GUIDELINES DURING AN INTERVIEW

  • Use personal examples, such as saying, “If I were you,…”.

TRUE OR FALSE

A

FALSE

Avoid using personal examples, such as saying, “If I were you,…”

84
Q

GUIDELINES DURING AN INTERVIEW

  • Nonverbally convey respect, concern, interest, and acceptance.

TRUE OR FALSE

85
Q

GUIDELINES DURING AN INTERVIEW

  • Be aware of the client’s and your body language.

TRUE OR FALSE

86
Q

GUIDELINES DURING AN INTERVIEW

  • Be unconscious of the client’s and your voice inflection, tone, and affect.

TRUE OR FALSE

A

FALSE

Be conscious of the client’s and your voice inflection, tone, and affect

87
Q

GUIDELINES DURING AN INTERVIEW

  • Sit down to talk with the client (be at an even level).

TRUE OR FALSE

88
Q

GUIDELINES DURING AN INTERVIEW

  • Avoid & reject silence to help the client search for more thoughts or to organize them.

TRUE OR FALSE

A

FALSE

Use & accept silence to help the client search for more thoughts or to organize them.

89
Q

GUIDELINES DURING AN INTERVIEW

  • Use eye contact to be anxious, rushed, and indifferent.

TRUE OR FALSE

A

FALSE

Use eye contact to be calm, unhurried, and sympathetic.

90
Q

In interview guidelines, the ff is for?

ASSESS:

  • Hearing (speak slowly, face the client, position on the best hearing side)
  • Establish Trust, privacy & partnership
  • Speak clear and straightforward language
  • Ask questions in simple terms (avoid jargons & modern slang)
A

GERONTOLOGIC (Old people) VARIATIONS IN COMMUNICATION,

91
Q

In interview guidelines, the ff is for?

  • Ethnic/cultural variations in communication and self-disclosure may affect the information obtained.
  • Language barrier – ask for help (culture broker)
  • Communication through pictures
A

Cultural Variations

92
Q

In interview guidelines, the ff is for?

  • Not every client you encounter will be calm, friendly & eager to participate in the interview process (scared or anxious).
A

Emotional Variations

Health Assessment Lec [Prelims] (4 decks)

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