Unit I - Introduction to Health Assessment Flashcards
When was the nursing process introduced?
The nursing process was first introduced in 1958 and has been integrated with the nursing care plan since the early 1960s.
What is health?
Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, according to WHO.
WHO Definition of health:
Health is a quality of life, involving social, emotional, mental, spiritual, and biological fitness on the part of the individual which results from adaptations to the environment.
___ refers to the achievement of the highest level of health in each of several key dimensions
Wellness
___ is to gather information about the patient’s condition
Assess
___ is to identify the patient’s problem
Diagnose
___ is to set goals of care and desired outcomes and identify appropriate nursing actions
Plan
___ is to perform the nursing actions identified in the planning
Implement
___ is to determine if goals and expected outcomes are achieved
Evaluate
it is the Deliberate & systematic collection of data to determine clients’ current/past health status, and present & coping patterns.
Nursing Assessment
What is happening?
(actual problem),
What could happen?
(potential problem)
Importance of nursing health assessment:
Establish a database (medical information) for the client’s normal abilities, risk factors, and any alterations.
Plan strategies to encourage the continuation of healthy patterns, prevent potential health problems, and alleviate or manage existing health problems.
Provide a holistic view of the client.
Provide an essential foundation for the care of the client.
1 day to 28 days
Neonates
Cuddling facilitates the development of trust and bonding with the parents, especially the mother.
Neonates
Protect the ___ from stressors such as lights and excessive handling.
neonates
developmental stage for neonates
Trust vs. Mistrust
Recognize that the neonate’s behavior is largely ___ in nature.
reflexive
29 days to 2 years
Infant
stressors for this age group are: strangers, loud noises, bright lights, and sudden environmental changes.
Infant
1 year to 3 years
Toddler
Expect exaggerated responses to pain, frustration, and changes in the environment.
Toddler
___ are ritualistic (exact time to follow in performing hygiene, putting off lights, waking up on their chosen side of the bed, etc).
Toddlers
This age group also are impulsive and their moods change quickly.
As a result, they often do things like take unnecessary risks, blurt things out, don’t wait their turn, and interrupt conversations.
Toddlers
Parents and nurses should use the firm, direct approach. ___ test limits and may have temper tantrums.
Use play to prepare for and explain procedures.
Toddlers
developmental stage for toddlers
Autonomy vs. Shame and Doubt
3 years to 5 years
Preschool Age
___ engage in magical thinking and may become fearful based upon imagined threats.
Preschoolers
Support them when fearful. Fear of the unknown, the dark, mutilation, bodily injury, and being left alone are common.
Preschoolers
developmental stage for preschoolers
Initiative vs. Guilt
6 years to 12 years
School-Aged Child
Allow to participate in his care cause they resent forced dependence.
School-Aged Child
developmental stage for School-Aged Child
Industry vs. Inferiority
13 years to 18 years
Adolescent
subgroup of adolescents aged 13 years to 15 years
Young adolescents
subgroup of adolescents aged 16 years to 18 years
Older adolescents
Encourage peer visitation if possible. Peers are important to ___.
adolescents
developmental stage for adolescents
Identity vs. Confusion
Provide support & information related to threats to body image.
adolescents
19 years and older
Adult
subgroup of adults aged 20 years to 40 years
Young adults
subgroup of adults aged 40 years to 65 years
Older adults
Assess physical and cognitive ability to work and communicate with co-workers, family, and friends.
Adult
Assess the impact of hospitalization on family, work, and body image.
Adult
developmental stage for young adults
Intimacy vs. Isolation
developmental stage for middle-aged adults
Generativity vs. Stagnation
developmental stage for older adults
Integrity vs. Despair
A Complete Health Assessment consists of:
Physical
Emotional
Mental
Social
Spiritual
Approach to Identifying Priorities
Immediate priorities
Second-level Priorities
Third-level priorities
The ABCs of immediate priorities
Airway
Breathing
Circulation
Vital Signs
Second-level Priorities
Mental status change
Acute pain
Urinary elimination problem
Untreated medical problem (diabetic without insulin)
Abnormal lab values
Risk of infection, safety, security
Third-level priorities
Lack of sleep
Activity, rest, sleep
Types of Assessment
Initial nursing assessment
Focus or Ongoing assessment
Emergency assessment
Time-Lapsed assessment
It is performed within a specified time after admission to a health care agency.
Initial nursing assessment
Purpose of Initial Nursing Assessment
To establish a complete database for problem identification, reference, and future comparison.
Ongoing process integrated with nursing care.
Focus or Ongoing assessment
Purpose of the focus or ongoing assessment:
To determine the status of a specific problem identified in an earlier assessment and to identify a new or overlooked problem.
During any psychologic or physiologic crisis of the client
Emergency assessment
Purpose of the emergency assessment:
To identify life-threatening problems.
Several months after the initial assessment.
Time-Lapsed assessment
Purpose of the time-lapsed assessment:
To compare the client’s current status to baseline data previously obtained
Approaches/skills in Assessment
- Cognitive skills
- Problem–solving skills
- Psychomotor skills
- Affective and interpersonal skills
- Ethical skills
the skill where the Assessment is a “thinking” process.
The why, how, and what in the nurse assessment findings. Clinical decision making. The use of knowledge plus experience.
Cognitive skills
a skill that is performed with experience and scientific methods.
Problem–solving skills
the skill where the Assessment is “doing”.
Psychomotor skills
the skill where the Assessment is “feeling” trust and mutual respect.
Affective and interpersonal skills
the skill where the Assessment is “being responsible and accountable “
Ethical skills
The assessment process means:
collecting data
organizing data
validating data
documenting data
reporting data.
Types of Data
Subjective data
Objective data
also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person.
Subjective data
also referred to as signs or overt data, they are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.
Objective data
Sources of Data
Primary source
Secondary source
what type of source is the patient?
Primary source
what type of source is data collection, family members, health professionals, diagnostic results, records, and reports
Secondary source
Methods of Data Collection
- Observation
- Interview
- Examination
It gathers data by using the senses of sight, smell, and hearing.
Observation
This is a planned communication or a conversation with the purpose of identifying more cues about the patient’s problems.
Interview
Forms/Types of Interview
directive interview
non-directive interview
The ___ interview is highly structured and directly asks questions. The nurse controls the interview.
directive
A ___ interview, or rapport-building interview, allows the client to control the interview.
non-directive
Nurses can ease clients’ apprehensions by being prepared for client’s clarifications about their health.
Facilitating interventions
Occurs when a reward is given to strengthen a desired behavior.
Reinforcement
Using the patient’s words, the nurse indicates that he/she heard the client.
Reflection
This is to clarify things or modify the client’s level of understanding.
Ending the summary by “Does that sound okay for you?’
Summarizing
Acknowledge what clients say.
can be done by saying “Yes, I understand”
Accepting
Acknowledge the patient’s behavior.
“I noticed you took all your meds”
Giving recognition
A comment to remove fears and doubts but false ___ should never be given
reassurance
This shows that the nurse values the client and is willing to give the latter time.
Offering to stay for lunch
Watch TV with client
Sitting with the client
Offering self
Allowing the client to direct the conversation and allow him to talk on the topic.
“What’s on your mind today?”
“What would you like to talk about?”
Giving broad opening
Observe the client’s appearance, demeanor or behavior
The nurse observes the client’s eyebags, fatigue or not eating.
Making observations
Patients do not always have a specific topic or question relevant to their illness.
The nurse can open or pick out topics or possible questions for the client to initiate the conversation.
Focusing
Being attentive to what the client is saying by facing the client, eye contact, and attentiveness.
Active listening
To check whether the client is able to understand what the nurse is conveying.
Seeking clarification
As the patient manifests s/s, these areas may have other related symptoms and should be explored.
Associations
Very helpful if the interviewer smiles, laughs, or even when appropriate, adds another punchline.
Sharing of ___ can decrease tension and anxiety and reinforce the interviewer’s genuineness.
Use of humor
Often, encouraging the patient to continue their story can be facilitated by asking who, what, where, when questions.
“Why” questions are generally not helpful early in an interview.
Leading
Gently encouraging the patient to talk more about the issue may be quite productive.
Tell me more. How did that affect you?
Probing
___ can be used when the patient changes topics too quickly or persists in offering information about non-productive or already crossed areas.
Redirection
Interrupting the patient finishes off what they are saying.
Premature Interpretation
If introduced in an unclear manner, unconnected to content, or poorly timed, they may be experienced as unresponsive to the patient’s concerns or feelings.
Obstructive interventions
- Even though it may be accurate, it may be counter-productive, as the patient may respond defensively and feel misunderstood.
Premature advice
___ gives an opportunity to think through and process what comes next in the conversation.
It may give patients the time and space they need to broach a new topic.
Using silence
Three Stages of Interviewing
Introduction
Body
Close
- Generally a professional non-confrontational tone
- Greet interviewee and state reason for interview
- Sets the tone for all interview types
- Establish rapport with interviewee
- Assess witness’ spirit of cooperation
- Provides the beginnings of the baseline for assessment of misdirection and deceit
Introduction
- Facts and evidence of the case are reviewed withinterviewee
- Generally open-ended questions
- Allow interviewee to completely answer question
- Completely understand answers before moving on
- Demonstrate patience and don’t interrupt interviewee
- Focus on listening, gathering information, and watching for misdirection and deceit
- Issues with checklists and pre-written questionnaires
Body
- Review and summarize important aspects of the interview
- Clarify any questions regarding the interviewee’s responses
- Attempt to end the interview on a positive note
- Interviewer should leave the door open for future discussion
Close
The physical ___ is a systemic data collection method to detect health problems.
examination
Four primary techniques used in the physical assessment
Inspection
Palpation
Percussion
Ausculatation
type of inspection that relies on sight and smell.
Direct inspection
type of inspection that uses of equipment to expose internal tissues or to enhance view of a specific body area
Indirect inspection
___ is the examination of the body using the sense of touch. The pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination.
Palpation
these sense vibrations
Metacarpophalangeal joints
these assess Fine tactile discrimination, Moisture, Texture, Masses, Pulsations, Edema, Crepitation, Organ size, shape, position, mobility, and consistency
Finger pads
this is the secondary part of the hand that senses vibration
Ball of hand
The ___ is used to assess surface temperature.
dorsum, or back of the hand,
- It is used to feel the abnormalities that are on the surface.
- Use the front of your fingers, and gently press down into the area of the body about 1-2 cm.
- Then lift your fingers off the body and move to the next nearby area.
- It helps to identify the texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
- All areas must be palpated systemically.
- Use nine quadrants as a guide
Light palpation
light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm). Use it to check muscle tone and to assess for tenderness.
Light palpation
- is used to feel internal organs and masses.
- Use the front of your fingers to firmly press down into the area of the body about 4-5 cm, then lift your fingers off the body and move to the next area nearby.
- It helps to identify the size, shape, tenderness, symmetry, and motility.
- can be painful and uncomfortable for patients while examining the abdomen.
- Another way to palpate is to put one hand on top of another when pressing down it is called the bimanual technique.
Deep palpation
___ is used with caution because pressure can damage internal organs. The skin and underlying structures about 1 inch (2 cm) are depressed.
To identify abdominal organs and abdominal masses.
Deep palpation
___ palpation places the fingers of one hand on top of those of the other.
The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation.
Two-handed deep
The tapping of fingers quickly and sharply against body surfaces to produce sounds, to detect tenderness, or to assess reflexes.
This helps locate organ borders, identify shape and position determine if the organ is solid or filled with fluid or gas.
Percussion
Methods of percussion
Direct percussion
Indirect percussion
using one hand to strike the surface of the body
Tapping the patient’s body directly with the distal end of a finger.
Direct percussion
using the finger of one hand to tap the finger of the other hand.
Indirect percussion
the middle finger of the nondominant hand
Pleximeter
Percussion elicits five types of sound.
Flatness
Dullness
Resonance
Hyperresonance
Tympany
___ is an extremely dull sound produced by very dense tissue such as muscle or bone.
Flatness
___ is a thudlike sound produced by dense tissue such as the liver, spleen, or heart.
Dullness
___ is a hollow sound such as that produced by lungs filled with air.
Resonance
___ is not produced in the normal body. It is described as booming and can be heard over an emphysematous lung.
Hyperresonance
___ is a musical or drumlike sound produced from an air-filled stomach.
Tympany
It is the process of listening to sounds produced within the body using a stethoscope
Auscultation
Parts of the stethoscope:
Eartips
Binaural
Binaural spring
Tubing
Bell
Diaphragm
Types of Auscultation
Direct or immediate auscultation
Mediate/Indirect auscultation
Application of the ear directly to the body surface where the sound is most prominent.
Direct or immediate auscultation
The use of sound augmentation devices such as stethoscopes in the detection of body sounds.
Mediate/Indirect auscultation
Auscultation can be performed in the following activities:
- Listening to body sounds
- Movement of air in the lungs
- Blood flow like taking the HR and BP
- Fluid and gas movement (bowels)
Technique order used in the physical assessment ->
IPPA
Technique order For Abdominal assessment ->
IAPP (percussion then palpation)
Nursing models or framework
➤ Gordon’s functional health pattern
> Orem’s self-care model
> Roy’s adaptation model
➤ Wellness model
Nonnursing models
➤ Body system model
➤ Maslow’s hierarchy of needs
➤ Developmental theories
___ is the act of “double checking “or verifying the data to confirm that it is accurate and factual.
Validation
Takes place when two or more people share information about client care, either face-to-face or by telephone.
REPORTING
Three general types of assessment:
Functional assessment
Descriptive assessment
Indirect assessment
A method used to determine the function of problem behavior.
Functional assessment
type of assessment Intended to help us determine why a behavior occurs rather than how often a behavior occurs.
Descriptive assessment
It is gathering information through means other than looking at actual samples of student work.
These include surveys, exit interviews, and focus groups.
Indirect assessment
Types of Clients to be Assessed
- Silent Client
- An Overly Talkative Client
- The anxious frightened patient
- The angry client
- The intoxicated client
- Depressed client
Short periods of silence may be normal.
Allow them time to collect their thoughts.
The patient may be frightened, or perhaps you frightened them
Are you dominating the discussion?
Have you offended the client?
Is there a physical or mental disorder? Or a lack of understanding?
Silent Client
Allow the client to talk.
Don’t display your impatience
If necessary, politely interrupt and focus the discussion
An Overly Talkative Client
Try to understand the pts. Feelings – “I don’t know why you are so anxious, would you like to talk about it?”
Identify the source of anxiety/fear
The anxious frightened patient
Understand the source of these feelings
Be firm but let your verbal and body language show that you care
The angry client
These patients may manifest being irrational, at times violent and abusive, shouting
Do not respond back with shouting
The intoxicated client
Call for assistance
Depressed client
