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health assessment 1 ABSN Summer23 > Lecture 1: Introduction to Health Assessment > Flashcards

Lecture 1: Introduction to Health Assessment Flashcards

1
Q

Learning Objectives

A

*Discuss the characteristics of evidence-based practice, diagnostic reasoning, the nursing process, and critical thinking
*List the steps to cultural competency
*List elements of a complete health history
*Interview a client to gather data for a complete health history
*Analyze the client data, and record the history accurately
*Learn the assessment techniques of inspection, palpation, percussion, and auscultation
*Identify equipment needed for a complete physical examination
*Learn the method of gathering data for a general survey

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2
Q

What is Nursing (according to the ANA)

A

“the protection, promotion, and optimization of health and abilities, prevention all illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in care of individuals, families, communities, and populations”

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3
Q

What is Assessment

A

The Collection of data about an individual’s health state

Includes
- subjective data
- objective data
- patient’s record

Assessments are the starting point to making diagnoses

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4
Q

What are the Phases of the Nursing Process

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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5
Q

What is Assessment

A

The first phase of the Nursing Process where subjective and objective data is collected

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6
Q

What is Diagnosis

A

The second phase of the Nursing Process that includes the analysis of the subjective/objective data to make professional nursing judgments (diagnosis, collaboration, or referral)

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7
Q

What is Planning

A

The third phase of the nursing process where outcome criteria are defined and a plan is developed

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8
Q

What is Implementation

A

The fourth phase of the nursing process where the plan is carried out

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9
Q

What is Evaluation

A

The fifth and final step of the Nursing process where the outcome criteria are assessed and the plan is revised as necessary

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10
Q

What is clinical judgment

A

The observed outcome of critical thinking and decision making that is an iterative process that uses nursing knowledge to observe and assess presenting situation, ID client concern, and generate the best possible evidence-based solutions to deliver safe client care

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11
Q

Nursing model diagram

A
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12
Q

What is Diagnostic Reasoning

A

the analysis of health data to draw conclusions and identify diagnosis

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13
Q

Comparison of Health Promotion, Risk, and Actual Nursing Diagnoses (table)

A
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14
Q

Types of Assessments

A

Complete: includes complete health history and full physical exam

Focused (problem centered): For limited or short term problems

Follow Up: evaluate problems at regular intervals

Emergency: rapid collection of data w/ concurrent lifesaving measures

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15
Q

Assessment Process

A

Start with building rapport and trust

Use effective communication techniques: reflection (repeating what you’ve heard to encourage more detail), empathy, facilitation (encouraging patient to say more)

Spend more time listening vs talking

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16
Q

N.U.R.S.E. Empathy Skills

A

Name emotion: ( Ex: “I’m hearing that you are frustrated”
“I’m seeing that this is really upsetting you”
“If I went through that, I may feel sad. How are feeling?”)

Understand & legitimate: “Anyone in your shoes might feel the same way”
“I’m sorry you have been waiting so long” (the blameless apology)

Respect: (Ex: “You are showing tremendous courage in sharing this”
“I give you a lot of credit in getting through this”)

Support: (“I will be here with you each step of the way”
“We will work together on this”)

Explore: (“How has the impacted your life”
“What ideas might you have about what is causing this?”
“What are your hopes for this visit?”)

17
Q

Open Ended v. Closed Questions

A

open ended: asking for a narrative response
- use more at the beginning of an interview

closed: asking specific info, yes/no questions, fills in details or moves the interview alone

18
Q

Skills to Assist the Narrative

A
  1. silent attentiveness (give the pt time to think and organize what they want to say without interruption)
  2. reflection (echo the pt’s words, repeat & reframe what they say, focusing attention on specific phrases)
  3. empathy (recognize pt’s feelings and name them)
  4. clarification (use when pt’s words are ambiguous/confusing, asking pt to confirm or deny something)
  5. confrontation (if there’s discrepancy or inconsistency in the person’s narrative, give honest non-judgmental feedback)
  6. explanation (informative statements, factual and objective info, giving reasons for requirements or actions)
  7. interpretation (based on your conclusions, linking events/making associations, implies cause)
19
Q

interacting with patients in emotional states (table)

A
20
Q

Health Equity

A

the attainment of the highest level of health for all people

considering social determinants of health: (conditions of life that affect one’s health. age, sex, location, food insecurities, housing, habits, etc)

21
Q

Cultural Competence

A

cultural sensitivity: possessing basic knowledge of and constructive attitudes toward diverse cultural populations

cultural competence: understanding and attending to total context of patient’s situation including beliefs about health and illness, cultural similarities and differences

22
Q

Signs v. Symptoms

A

Sign: OBJECTIVE information
- physical examination or lab reports
- measured/observed by a healthcare provider (ie: BP, wound drainage, heart sounds, K+ level)

Symptom: subjective informations
- can only be validated by patient
- what the patient states/feels (ie: pain, anxiety, fatigue, dizziness)

23
Q

Health History

A

provides a database of SUBjective information consisting of a patient’s past and present health

biographical data: name, address, phone, age, DOB, race, ethnicity, occupation, marital status, gender

chief complaint

hx of present illness (use COLDSPA/ OLD CARTS for symptom analysis)

past medical hx
- childhood, accidents, serious/chronic illness, hospitalizations, OB hx, immunizations, allergies, current meds

family hx
- age health COD of relatives , genetic predisposition

ROS

Functional Assessment
-ADLs

who is giving the history? is the source reliable (consistent)

24
Q

Chief Complaint (CC)

A

part of one’s health history

a brief statement in the person’s own words that describes the reason for the visit

25
Q

COLDSPA

A

Character
Onset
Location
Duration
Severity
Pattern
Associated factors

26
Q

OLD CARTS

A

Onset
Location
Duration

Characteristics
Associated Symptoms
Relieving or Aggravating factors
Temporal factors
Severity (intensity)

27
Q

Review of Systems (ROS)

A

Subjective data. This is not the physical exam

-Evaluate the past and present health state of each body system
-Evaluate health promotion practices
-Order of systems is roughly head-to-toe

28
Q

Functional Assessment for Health History

A

gathering information on self-care ability

Activities of Daily Living (ADLs)
Self-esteem/self-concept
Sleep/rest
Nutrition/elimination
Interpersonal relationships
Spiritual resources
Coping/stress management
Personal habits
Tobacco, alcohol, caffeine, street drugs

29
Q

Physical Exam

A

purpose: to gather OBJECTIVE data about the patient

common equipment: Thermometer
Stethoscope
Sphygmomanometer
Scale
Visual acuity charts
Penlight
Measuring Tape

advanced equipment: Ophthalmoscope
Otoscope on model of ear
Tuning fork
Reflex hammer

30
Q

Assessment Techniques (IPPA)

A

Inspection (vision)
Palpation (touch)
Percussion (tapping)
Auscultation (hearing)

31
Q

Inspection

A

“careful scrutiny”

  • inspect as a whole and then each body system
  • Compare right and left sides of body for symmetry
    -Focus on color, shape, size and movement
    -Requires good lighting and adequate exposure
    -Categories
    *Indirect-assisted by equipment
    *Direct-sight, hearing, smell
32
Q

Palpation
(touch)

A

calm gentle approach, warm hands

assess:
-texture
-temp
-moisture
-swelling (edema), spasticity, crepitation, vibration, pulsation
-organ location and size
-presence of -lumps/masses
-presence of pain/tenderness

-Fingertips-tactile discrimination
*Skin texture, swelling, pulsation, determining presence of lumps

-Fingers and thumb
*detect position, shape, and consistency of an organ or mass

-Dorsa (backs) of hands
*used for determining temperature

-Base of fingers (metacarpophalangeal
joints) or ulnar surface of the hand-detects
*vibration

Light palpation: (one hand, dominant 1-2cm deep )
Pulse
Skin temp
Texture
Consistency
Warmth
Mobility
Tenderness

Deep palpation:
organ shape and size, rebound tenderness, abnormalities

33
Q

Percussion

A

“to strike”- tapping
- relaxed, limp wrist to assess the location, size, and density of underlying structures and to detect tenderness (deep tension uses percussion hammer)

direct (immediate): hand or fingertip
directly on surface

indirect (mediate): used more often

blunt: reflex hammer

34
Q

percussion note characteristics

A

*Resonance (lungs):
Clear, hollow, low-pitched sounds

*Hyperresonance (lungs):
Low, booming, longer sound than resonance

*Tympany (abdomen):
Loud, high pitched, musical or “drum like”

*Dullness (dense organs):
soft, high pitched, muffled

Flatness (muscle, bone, solid mass):
very soft, high pitched; dead stop of sound

35
Q

Auscultation

A

“Listen to sounds produced through stethoscope”

Determines intensity, pitch, duration, recurring sounds

Warm, quiet room
Avoid artifact

Warm stethoscope end-piece
rub in palm

Never listen through a gown/over clothing!

36
Q

Parts of the stethoscope

A

Diaphragm
- used for high pitched sounds (breath, bowel, normal heart sounds)

Bell (small side)
- used for low pitched sounds (extra heart sounds and murmurs)

37
Q

Order of Physical Assessment (normal v. abnormal)

A

Usual: IPPA

Abdominal and Infant: IAPP
(inspection, auscultation, percussion, palpation)

38
Q

Notes on charting

A

Assessment is on of the first things you should do after receiving report

Immediately following your assessment, start documenting your findings.

Start at the beginning of the page with date and time (military)

Use abbreviations approved by the facility, there is a list of generally medical abbreviations in syllabus.

Do not write in complete sentences, avoid slang terms unless they are direct quotes

End the paragraph with your first initial, last name and UANS.
Paper charting, when EHR down, chart in black pen ONLY!

Falsification of documentation can result in dismissal

When in doubt, ask faculty

If error is made:
One line through error and initial
Some facilities require “mistaken entry” or “error”

health assessment 1 ABSN Summer23 (7 decks)

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