M1_HA Flashcards
According to _____, Date? , a nurse’s scope of practice puts emphasis on diagnosis and treatment of human responses based on ______________________
ANA, 2010, ACCURATE CLIENT ASSESSMENTS
Role in health assessment: the standards
STANDARD 1: COLLECTS COMPREHENSIVE DATA PERTINENT TO THE PATIENT’S HEALTH OR SITUATION
STANDARD 2: Analyzes the assessment data to determine diagnoses or issues:
T or F
The most marketable nurses will continue to
be those with STRONG ASSESSMENT and
CLIENT TEACHING ABILITIES as well as those
who are TECHNOLOGICALLY SAVVY.
T
What trends should be keep in mind?
- Increased focus on primary care
- Increasing complexity of acute care
- Growing aging population
- Intensifying mental health issues
- Expanding service networks
The purpose of _______________ differs greatly from that of a medical or other type of health care assessment.
nursing assessment
PURPOSE: collect HOLISTIC. Subjective and
objective data to determine OVERALL LEVEL
OF FUNCTIONING in order to make a
PROFESSIONAL CLINICAL JUDGMENT
nursing assessment
In nursing assessment, the nurse collects these types of data about the clients
physiologic, psychological, sociocultural, developmental and spiritual
used to organize
information and promote the
collection of holistic data
Nursing Framework
Generic and basic Sections include in nursing framework for HA are:
History of Present Health Concern
Personal Health History
Family History
Lifestyle and Health Practices
PHYSICAL ASSESSMENT
Types of Health Assessment
- INITIAL COMPREHENSIVE ASSESSMENT
- ONGOING/ PARTIAL ASSESSMENT
- FOCUSED/ PROBLEM-ORIENTED ASSESSMENT
- EMERGENCY ASSESSMENT
A type of HA INCLUDES:
Subjective data about client’s perception of health
Initial Comprehensive Assessment
A type of HA INCLUDES:
Past health history
Initial Comprehensive Assessment
A type of HA INCLUDES:
Objective data gathered from Physical Examination
Initial Comprehensive Assessment
A type of HA INCLUDES:
Family history, lifestyle and health practices
Initial Comprehensive Assessment
A TOTAL health assessment is needed when the
client FIRST enters a health care system and
periodically thereafter
Initial Comprehensive Assessment
Depends on age, risk factors, health status , health
promotion and lifestyle
Initial Comprehensive Assessment
Consists of data collection that occurs after
the comprehensive database is established
ONGOING / PARTIAL ASSESSMENT
Mini-overview of the client’s body systems and
holistic patterns as a follow-up on health status
ONGOING / PARTIAL ASSESSMENT
Reassessment of health problems detected to
determine changes and detect any new
problems
ONGOING / PARTIAL ASSESSMENT
Performed whenever the nurse encounters a
client
ONGOING / PARTIAL ASSESSMENT
Determined by acuity of the client
ONGOING / PARTIAL ASSESSMENT
Performed when a comprehensive
database exists for a client who
comes to a healthcare facility with a
specific health concern
FOCUSED / PROBLEM-ORIENTED ASSESSMENT
Consists of thorough assessment of a
particular client problem and does not
address areas not related to the
problem
FOCUSED / PROBLEM-ORIENTED ASSESSMENT
Very rapid assessment performed
in life-threatening situations to
provide prompt treatment
EMERGENCY ASSESSMENT
Used to determine the status of
the client’s life-sustaining physical
functions
EMERGENCY ASSESSMENT
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted to the medical surgical ward for the first time in preparation for an abdominal surgery
Initial Comprehensive Assessment
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted due to gunshot wound and bleeding
profusely
EMERGENCY ASSESSMENT
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted 3 days ago for evaluation of anti-cancer medication side effects
ONGOING / PARTIAL ASSESSMENT
WHAT ASSESSMENT SHOULD BE DONE AT THIS TIME?
Patient was admitted to the medical surgical ward for monitoring of respiratory status
FOCUSED / PROBLEM-ORIENTED ASSESSMENT
the first and most critical phase of
the nursing process.
Assessment
If _________________ is inadequate
or inaccurate, incorrect nursing judgments may be
made that adversely affect the remaining phases of
the process
data collection
Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
The steps of a nursing process are interrelated, forming a continuous circle of thought and action that is both dynamic and cyclic, according to?
Doenges and Moorhouse, 2008
In the nursing process, it’s the information collection or gathering data
assessment
In the nursing process, it’s the information interpretation or stating problems or strengths
diagnosis
In the nursing process, it’s settling nursing goals, desired outcomes and planning interventions
planning
In the nursing process, it’s the patient’s status and effectiveness of nursing interventions
evaluation
In the nursing process, it’s performing nursing interventions
Implementation
THE NURSE’S ROLE IN ASSESSMENT: Based on the __________, the nurse ___________________?
Nursing Scope of Practice, “collects comprehensive data
pertinent to the patient’s health or situation”
T or F
The nurse focuses on how the client’s health status
affects activities of daily living and how clients interact
within their family and community
T
proponents of HEALTH BELIEF MODEL
Becker & Rosenstock, 1987
Based on 3 concepts which is existence
of sufficient motivation, belief that one is
susceptible/ vulnerable to a serious
problem and the belief to change
following a health recommendation
HEALTH BELIEF MODEL
in HEALTH BELIEF MODEL these are the gender, class, age, etc.
demographic variables
in HEALTH BELIEF MODEL these are the personality, peer group pressure, etc.
Psychological characteristics
the 5 variables in HEALTH BELIEF MODEL
perceived susceptibility
perceived severity
health motivation
perceived benefits
perceived barriers
proponents of HEALTH PROMOTION MODEL
Pender, 1996
in HEALTH PROMOTION MODEL these are the individual characteristics and experiences
- prior related behavior
- personal factors: biological, psychological, sociocultural
in HEALTH PROMOTION MODEL these are the behavior-specific cognitions and affect
- perceived benefits of action
- perceived barriers to action
- perceived self-efficacy
- activity-related affect
interpersonal influences (family, peers, providers), norms, supports, models - situational influences: options, demand characteristics, aesthetics
STEPS OF HEALTH ASSESSMENT
- COLLECTION OF SUBJECTIVE DATA
2.COLLECTION OF OBJECTIVE DATA
3.VALIDATION OF DATA
4.DOCUMENTATION OF DATA
provides basic biographical data, chronic illness and clues on how present illness affects patient’s ADL.
medical record and other members of the health team
sensations/ symptoms, perceptions, desires, preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the client
SUBJECTIVE DATA
considered a primary source and all others are secondary sources
Patient
provides a focus for the physical exam and identify potential
nursing diagnoses
Health History
It should begin with an explanation to
the client of why the information is
being requested
COMPLETE HEALTH HISTORY
When students are collecting information and sharing in a form of academic discussion, ___________ must be deleted, and ______ are used to protect the client’s privacy
identifiable information, initials
REASONS FOR SEEKING HEALTH CARE May be termed as this during initial physician interview
chief complaint
Question that Assists the client in focusing on the most significant health concern
WHAT IS YOUR MAJOR HEALTH PROBLEM OR CONCERNS AT THIS TIME?
question that Encourages the client to discuss fears or other feelings about having to see a health care
provider
HOW DO YOU FEEL ABOUT HAVING TO SEEK HEALTH CARE?
Encourage the client to explain the health problem or symptom in as much
detail as possible and what the client perceives as causing the problem
HISTORY OF PRESENT HEALTH
CONCERN
he information gathered here will help the nurse evaluate the client’s insight
into the problem and the client’s plans for managing it
HISTORY OF PRESENT HEALTH
CONCERN
In HISTORY OF PRESENT HEALTH CONCERN Ask the client to?
- Evaluate what makes the problem worse
- what makes it better
- previous management/treatment done
- what effect the problem has had with daily life and ability to provide self-care
MNEMONICS FOR SYMPTOM ANALYSIS
C - character
O - onset
L - location
D - duration
S - severity
P - pattern
A - associated factors / how it affects the client
In symptom analysis, it gives the time or it questions when did it begin?
onset
In symptom analysis, it describes the sign or symptom
character
In symptom analysis, it questions, where is it? Does it radiate? Does it occur anywhere else?
location with radiation
In symptom analysis, it questions, how long does it last? Does it recur?
duration
In symptom analysis, it questions, how bad is it? How much does it bother you?
severity
In symptom analysis, it questions, what makes it better or worse?
pattern
In symptom analysis, it questions, what other symptoms occur with it? How does it affect you?
associated factor / how it affects the client
example of characteristics in symptom analysis
feeling
appearance
sound
smell
taste
Other MNEMONICS FOR SYMPTOM ANALYSIS
L - location
O - onset
C - character
S - severity
T - timing
A - associated symptoms
A - aggravating / alleviating factors
M - meaning
&
P - provoking / relieving
Q - quality
R - region and radiation
S - severity
T - time
on the PQRST, it questions,
1. what brings the pain on?
2. what makes it better?
3. what makes it worse?
4. what medications are you using at the moment?
5. how often are you taking them?
6. do they help?
7. do they cause any side effects?
8. have you taken anything else in the past for this pain?
9. what was the effect of that?
provoking / relieving
on the PQRST, it questions,
1. Describe the pain.
2. what does it feel like (stabbing, burning, sharp, aching)?
quality
on the PQRST, it questions,
1. where is the pain?
2. does it spread anywhere else?
region and radiation
on the PQRST, it questions,
1. how severe is the pain? Now? at its worst? at its least? most of the time?
2. how does the pain affects your daily activities?
severity
on the PQRST, it questions,
1. when did the pain start?
2. is it constant or intermittent?
3. how often does it occur?
4. how long does it last?
time
This portion focuses on questions related to:
* Childhood illnesses and immunizations
* Adult co-morbidities
* Past surgeries/ accidents
* Prolonged episodes of pain, allergies and prescription medications
PERSONAL HEALTH HISTORY
T or F
in PERSONAL HEALTH HISTORY, you should Note client’s perception about themselves during discussion.
T
T or F
in PERSONAL HEALTH HISTORY, you should Use open-ended questions as much as possible.
T
what basic or general section of NURSING FRAMEWORK FOR HEALTH ASSESSMENT include maternal and paternal grandparents, aunts and uncles, parents, siblings and children?
FAMILY HISTORY
what basic or general section of NURSING FRAMEWORK FOR HEALTH ASSESSMENT you Should include many genetic relatives as the client can recall?
FAMILY HISTORY
Organize FAMILY HISTORY using a ________?
genogram
in genogram, Females are indicated by a ______ while males are a _______.
circle, square
in genogram, If the relatives has no problems, write ____________, if deceased, they are
noted by an _____.
“A/W” (alive and well), X
in genogram, _________ show genetic relationships otherwise _______ for spouse or adopted
member
Straight lines, dotted lines
T or F
in REVIEW OF SYSTEMS, Care must be taken to include only the client’s subjective information and not the nurse’s observations.
T
T or F
in REVIEW OF SYSTEMS, Document the client’s descriptions of her health status and note denial of signs, symptoms, diseases or problems.
T
T or F
in REVIEW OF SYSTEMS, Phrase questions in such a way that elicits answers and provoke verbalization of the client.
T
what basic or general section of NURSING FRAMEWORK FOR HEALTH ASSESSMENT Deals with human responses, which includes nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept and self-care activities, social and community activities, relationships, values and
beliefs system, education and work, stress level and coping style and environment?
LIFESTYLE AND HEALTH
PRACTICES PROFILE
T or F
in LIFESTYLE AND HEALTH PRACTICES PROFILE, Use open-ended questions to promote a dialogue with the client.
Follow up on specific questions to guide discussion and clarify data as necessary.
T
Enumerate the LIFESTYLE AND HEALTH PRACTICES PROFILE
- Description of typical day
- Nutrition and Weight Management
- Activity Level and Exercise
- Sleep and Rest
- Self-Concept and Self-Care Responsibilities
- Social Activities
- Relationships
- Values and Belief System
- Education and Work
- Stress Levels and Coping Styles
- Environment
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it’s the overview of the client’s usual daily activity.
Description of typical day
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it recalls 24-hour intake with emphasis of what foods are eaten and in what amounts. This also considers how much fluid intake is consumed (caffeinated/ uncaffeinated).
Nutrition and Weight Management
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it assess how active the client is during an average week.
Activity Level and Exercise
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it’s Compare with recommended 5-8 hours a night for adults but may vary depending on need and it Focus on specific sleep patterns (hours of sleep, interruptions, whether the
client feels rested, problems, rituals and concerns. whether the client is getting enough quality of these.
Sleep and Rest
under LIFESTYLE AND HEALTH PRACTICES PROFILE, an assessment of how the
client view herself including sexual responsibility, basic hygiene practices,
regularity of health care checkups, breast/testicular self-exam, and
accident and hazard protection
Self-Concept and Self-Care Responsibilities
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it helps the nurse discover outlets the client has for
support and relaxation and if the client in involved in the community
beyond the family and work
Social Activities
under LIFESTYLE AND HEALTH PRACTICES PROFILE, the client describes the composition of the family into
which they were born and about past and current relationships with
these family members
Relationships
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it assesses the client’s values, philosophical,
religious and spiritual belief
Values and Belief System
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it identify areas of stress and satisfaction in the
client’s life, should bring about kind and amount of education the client
has, did the client enjoyed school or what he/she perceives his/her
education
Education and work
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it investigate amount of stress the
clients perceive they are under and how they cope, how they address
events and how they usually respond
Stress levels and coping styles
under LIFESTYLE AND HEALTH PRACTICES PROFILE, it assess health hazards unique to the
client’s living situation and lifestyle.
Environment
T or F
In Activity Level and Exercise, it’s Recommended to exercise regimen of aerobic exercise for 20-30mins
3x/week
T
T or F
Distinguish heavy physical work which is stressful and fatiguing and exercise which is designed to reduce stress and strengthen individual.
T
Quick way to assess how alert you are feeling.
Stanford sleepiness scale
State the degree of sleepiness according to stanford sleepiness scale.
Feeling active, vital, alert, or wide awake.
1
State the degree of sleepiness according to stanford sleepiness scale.
Functioning at high levels, but not at peak; able to concentrate.
2
State the degree of sleepiness according to stanford sleepiness scale.
Awake, but relaxed; responsive but not fully alert.
3
State the degree of sleepiness according to stanford sleepiness scale.
Somewhat foggy, let down.
4
State the degree of sleepiness according to stanford sleepiness scale.
Foggy; Losing interest in remaining awake; slowed down.
5
State the degree of sleepiness according to stanford sleepiness scale.
Sleepy, woozy, fighting sleep; prefer to lie down.
6
State the degree of sleepiness according to stanford sleepiness scale.
No longer fighting sleep, sleep onset soon; having dream like thoughts.
7
State the degree of sleepiness according to stanford sleepiness scale.
Asleep.
X
SLEEP AND REST SCREENING TOOLS
- The Sleep Disorders Screening Survey (Division of Sleep Medicine, Harvard
Medical School, 2007). - Sleep Disorder Screening Tests (Getbettersleep.com, 2009)
- The Insomnia Screening Questionnaire (Clinical Practice Guideline, 2007)
A SLEEP AND REST SCREENING TOOL, that has Ten True/False questions
The Sleep Disorders Screening Survey (Division of Sleep Medicine, Harvard
Medical School, 2007).
A SLEEP AND REST SCREENING TOOL that has A several-page list
of symptoms partitioned to address the following sleep disorders: insomnia;
exces- sive daytime sleepiness; depression; hypothyroidism; obstructive sleep
apnea; heartburn or reflux disease (GERD); nocturnal myoclonus (limb and leg
symptoms); nasal or sinus issues, allergies, asthma, or lung disease; circadian
rhythm disorder; hypersomnia; narcolepsy; and parasomnias.
* The Insomnia Screening Questionnaire (Clinical Practice Guideline, 2007). A
Sleep Disorder Screening Tests (Getbettersleep.com, 2009)
A SLEEP AND REST SCREENING TOOL that has
17- item Likert-like scale with interpretation of results.
The Insomnia Screening Questionnaire (Clinical Practice Guideline, 2007)
T or F
On the LIFESTYLE AND HEALTH PRACTICES PROFILE (values and belief system), all clients are comfortable
discussing their feelings and should be respected
T
~ The physical examination
Collecting Objective data
information about the client
that the nurse directly
observes during interaction
and elicited through physical
examination techniques
Objective data
To become proficient with physical assessment, the
nurse should know 3 things:
- Types and operation of equipment needed for the particular
examination - Preparation of the setting, oneself and the client for the
physical assessment - Performance of the four assessment techniques: Inspection, Palpation, Percussion and Auscultation
assessment techniques:
I - inspection
P - palpation
P - percussion
A - auscultation
Equipment for PE: these must be used for all examinations to protect examiner in any part in any part of the examination when the examiner may have contact w/ blood, body fluid, secretion, excretion, and contaminated items or when disease causing agengs cauld be transmitted to or from the client.
Gloves and gowns
use to measure diastolic systolic blood pressure.
sphygmomanometer
use to auscultate blood sounds when measuring blood pressure.
stethoscope
use to measure body temperature
thermometer (oral, rectal, tympanic)
Pain rating scale that is good to use for children
wong-baker faces
enumerate wong-baker faces Pain rating scale
0 - no hurt
2 - hurts little bit
4 - hurts little more
6 - hurts even more
8 - hurts whole lot
10 - hurts worst
use to rate pain behavior
behavioral pain scale (BPS)
used to measure height and weight also for nutritional status examination
platform scale w/ height attachment
use to measure skinfold thickness of subcutaneous tissue
skinfold calipers
use to measure mid-arm circumference
flexible tape measure
use to mark measurements
skin marking pen
Tools for nutritional status examination
- platform scale w/ height attachment
- skinfold calipers
- flexible tape measure
- skin marking pen
tools for skin, hair and nail examination
- examination light
- penlight
- wood’s light
- metric ruler
- magnifying glass
- mirror
use to measure size of sin lesions
metric ruler
use for clients’ self-examination of skin
mirror
use to enlarge visibility of lesion
magnifying glass
use to test for fungus
wood’s light
tools for eye examination
- penlight
- snellen E chart
- newspaper
- opaque card
- ophthalmoscope
use to test pupillary constriction
penlight
use to test distant vision
snellen E chart
use to test near vision
newspaper
use to test for strabismus
opaque card
use to view the red reflex and to examine the retsina of the eye
ophthalmoscope
tools for ear examination
- tuning fork
- otoscope
use to test for bone and air conduction of sound
tuning fork
use to view the ear canal and tympanic membrane
otoscope
tools for mouth, throat, nose and sinus examination
- penlight
- 4x4 inch small gauze pad
- tongue depressor
- otoscope
use to provide light to view the moth and throat and to transilluminate the sinuses
penlight
use to grasp tongue to examine mouth
4x4 inch small gauze pad
use to depress tongue to view throat, check looseness of teeth, view cheeks, and check strength of tongue
tongue depressor
use to measure diaphragmatic excursion
metric ruler and skin marking pen
tools for thoracic and lung examination
- steth
- metric ruler
- skin marking pen
use in diaphragm to auscultate breath sounds
steth
tools for heart and neck vessel examination
- steth
- 2 metric rulers
use in bell and diaphragm to auscultate breath sounds
steth
use to measure jugular venous pressure
metric ruler
use to measure blood pressure and auscultate vascular sounds
sphygmo and steth
tools for peripheral vascular examination
- sphygmo
- flexible metric measuring tape
- tuning fork
- doppler ultrasound device and conductivity gel
- steth
use to measure size of extremities for edema
flexible metric measuring tape
use to detect vibratory sensation
tuning fork
use to detect pressure and weak pulses not easily heard with a steth
doppler ultrasound device and conductivity gel
tools for abdominal examination
- steth
- flexible metric measuring tape
- skin marking pen
- two small pillows
use to place under knees and head to promote relaxation of abdomen
small pillows
use to measure size and mark the area of percussion of organs
flexible metric measuring tape and skin marking pen
use to detect bowel sounds
steth
use to measure size of extremities
flexible metric measuring tape
tools for muscoskeletal examination
- flexible metric measuring tape
- goniometer
use to test for stereognosis (ability to recognize objects by touch)
objects to feel
use to measure degree of flexion and extension of joints
goniometer
tools for neurologic examination
- cotton-tipped applicators
- newspaper
- ophthalmoscope
- flexible metric measuring tape
- objects to feel (coin, key, etc.)
- reflex (percussion) hammer
- cotton ball
- paper clip
- substances to smell and taste
- snellen E chart
- penlight
- tongue depressor
- tuning fork
use to put salt or sugar on tongue to test taste
cotton-tipped applicators
use to test deep tendon reflexes
reflex (percussion) hammer
use to test for light, sharp, and dull touch and 2 point discrimination
cotton ball and paper clip
use to test for smell and taste perception
substances to smell and taste
use to test for rise of uvula and gag reflex
tongue depressor
use to test for vibratory sensation
tuning fork
tools for male genitalia and rectum examination
- gloves
- water-soluble lubricant
- penlight
- specimen card
use to promote comfort for client
gloves and water-soluble lubricant
use for scrotal illumination
penlight
use for occult blood
specimen card
tools for female genitalia and rectum examination
- vaginal speculum
- water-soluble lubricant
- bifid spatula
- endocervical broom
- large swabs
- Liquid pap medium
- Ph paper
- Feminine napkin
Use to obtain endocervical swab and cervical scrape and vaginal pool sample
bifid spatula and endocervical broom
use to inspect cervix through dilation of the vignal
Vaginal speculum and water-soluble lubricant
For vaginal examination
Large swabs
Preparing for the examination
- Preparing the physical setting
- Preparing oneself
- Approaching and preparing the client
