W1: Health Assessment

Question 1

What is Health assessment?

Answer 1

• Refered to as a collection of subjective data ( how the pt is feeling) and objective data ( physcial assesssment, general survey, head to toe assessment, vitals) involved in a paitents heath history.
• Aim to create personalized paitent centere careing plans done from a intradisiplinary approach and make clinical judgements.

Question 2

ADPIE

Answer 2

Foundational aspect to nursing pratice and client assessments. Conducts interaction and maximizes an ogranized approach to care plans.
Composed of Assessment Nursing Diagnosis Implementation Evaluation

Question 3

What is the nurses role in assesment?

Answer 3

Nurses role is to be a communicator and document our findings. Using evidence based assessments and find the baseline levels, how are a clients ADL’s being effected and idenifty coping skills.

Question 4

Essential Parts to Assessment

Answer 4

• Therapuetic communication, open ended questions and buidling up that rapport. Find the underlying issues, access risk factors and create health promotion.

Question 5

Health Promotion

Answer 5

Empowering to take control over health
- Screening for history ( focused questions)
- Primary- secondary, teritary prevention
Compare current with past medical status, what can they no longer do and how can we help assess.
Primary Prevention: Aims at health promotion and empowering to take control, ex( exceirse, diet)
Secondary: Diease prevention so vaccines or screening
Teriatry: rehabiliation limit symptoms

Question 6

what is evidence based assessment?

Answer 6

• Should inform clinical descions regarding health and guide nursing descions. Best pratice techniques, examination. CNA is defined as information acquired through research and scientific evaluation of practice. Assessment skills are foundational
  Importance of questioning tradition in assessment when no evidence exists to support.

Question 7

ADPIE Assessment

Answer 7

Gathering objective and subective data
- ADPIE assessment
- evidenced based plan, diagnosis,
- Analyze the alternatives and how to communiate
Document findings

Question 8

When to document?

Answer 8

Always document the needs, change in clients condition, reassess after interventions , side effects.

Question 9

Assessment IPPA

Answer 9

Inspection
Palpation
Percussion
Auscultation

Question 10

Inspection

Answer 10

Use eyes to view expressions, behavior, what you obsereve. Visual, auditory, olfactory sense
1. General Inspection ( general survey) obervable cues for assessment.
2. Location Inspection ( body systems): color, lesions, movement, contour, symmetry, accessing subjective data and verbal/nonverbal Assess if subjective (verbal , nonverbal data) agrees with the inspection.

Question 11

Palpation

Answer 11

Gentle poking, use of touch, temperature, sensations, kineesthetic
1. Light: skin is depressed to depth of 1 cm
2. Deep: Skin is depressed to a 3-4 cm in circualr motions, dripping motions, direct pressure, gliding motions, grasping.

Question 12

Palptation Techniques

Answer 12

Finger pads–> texture, moistures, conttour, consitency, vibrations
Fingerprints / Pads–> Fluid content of tissues , elastic pulses, thickness, vasucularity, swelling, lumps, palptate tender last
Dorsum and ulnear edge: temp.
Ulnear edge: vibrations

Question 13

Percussion

Answer 13

Tapping of surface
- Tympany, ressonace, hyperresonace , dullness
- Tapping by nurse produces sound to be interpreted
1. Direct: tapping body surface , direct to examine sinuses
2. Indirect: storking exmainer hand or finger on surface

Question 14

Auscualtion

Answer 14

• Various body sounds: cardiac, respiratory, abdomen
  Stethoscope: best quality bell low pitch, diaphram high pitched sounds.
• Hold still, quite area
• Bell: low frequrncy sounds
• Diaphram: higher sounds

Question 15

First Level

Answer 15

First level or emergent probelms are life-threatning and are Airway breathing circulation, vitals.

Question 16

Second level

Answer 16

Urgent , necessitating prompt intervention (acute)

Question 17

Third

Answer 17

Stable, important addressed are more urgent issues emergent, urgent, stable

Question 18

Emergency Assessment

Answer 18

Urgent situations needing life saving measures to occur. Unstable airway, breathing, circulation, Asssess and intervene together . Open airway, arit resp, CPR, pain, protect.
Overdose ‘what did you take!”

Question 19

Problem Centered

Answer 19

Focused on client’s issues and the main complaint. One issue or body system in detail and includes general survey, vitals, assessment of one system.

Question 20

Comprehensive

Answer 20

Completes health history of past and current
Strength, risks, function abilities, health education, physical exam, all body systems. Annually for primary care setting outpaietnts, following admission to facility.

Question 21

Parts to Health Assessment

Answer 21

1) General Survey: nurses observations
2) Subjective Data History
3) Objective Data ( vitals, assessment)

Question 22

Objective data

Answer 22

Data gathered from pure oberavations and documentation from the nurse ( temperature, MP, signs)

Question 23

Subjective data

Answer 23

Stated, what the client says “ i can’t breath or my head hurts” symptoms that the client feels. Focused questions used to determine IPPA required.

Onset of problem/symptom
• P: Provoking/Palliating
• Q: Quality
• R: Region/Radiation
• S: Severity
• T: Timing
• U: Understanding
V: value

Question 24

Body position

Answer 24

anatomical, facing erect, straight
Whether prone or supine imagien paitent in this position

Question 25

Terms

Answer 25

Question 26

What is health history?

Answer 26

We ask questions to form accurate info about client and their full physical / mental heath to develop comprehensive care HH also provides full pt heath database. - proper documentation and wrist band for allergy, ask family but never assume.

Question 27

What are the sources of data used?

Answer 27

1) primary- client always should first be considered 2)secondary -family members, health team, medical records, nurse experience ( The client may not want the family involved Each level provides info regarding the clients strengths, wellness, risks, goals, and patterns of illness. They should both be considered when gathering data

Question 28

Signs and symptoms

Answer 28

When documenting patients words use quotations including health needs and some promotion Symptoms is defined as a subjective experience that the client reports while sign shows up through objective data via lab data or results gathered from the nurse

Question 29

Health History Components

Answer 29

1. Reasons for seeking care 2. Biological data and demographics 3. Current health and history 4. Past health and medications 5. Family history 6. Systems and Gordon’s Assessments

Question 31

Asking Questions methods

Answer 31

Refrain from why type questions Active listening: SOLAR S SIT FACING PATIENT O open posture L lean A eye contact R relax Prior to speaking think how will this info I am seeking benefit my client. If any hesitation justify after Questions should show respect, maintain privacy, why, what, where, how, silence, no jargon

Question 32

Subjective Questions

Answer 32

Closed : gathering console info such as are you on medications Open: gather clients view such as what brings you to hospital Focused: clients perception so what has been most challenging…

Question 33

Open ended techniques vs closed

Answer 33

Open ended questions typically are focused around what, when, where, how while focused questions seek specific answers and less detail Closed questions are less broad and require yes and no answers often make client feel threatened and uncomfortable

Question 34

Instances to use closed ended

Answer 34

During emergency situations and create yes or no answer Do you feel dizzy etc