W1: Health Assessment Flashcards

1
Q

What is Health assessment?

A
  • 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.
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2
Q

ADPIE

A

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

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3
Q

What is the nurses role in assesment?

A

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.

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4
Q

Essential Parts to Assessment

A
  • Therapuetic communication, open ended questions and buidling up that rapport. Find the underlying issues, access risk factors and create health promotion.
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5
Q

Health Promotion

A

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

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6
Q

what is evidence based assessment?

A
  • 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.
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7
Q

ADPIE Assessment

A

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

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8
Q

When to document?

A

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

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9
Q

Assessment IPPA

A

Inspection
Palpation
Percussion
Auscultation

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10
Q

Inspection

A

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.

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11
Q

Palpation

A

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.

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12
Q

Palptation Techniques

A

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

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13
Q

Percussion

A

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

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14
Q

Auscualtion

A
  • 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
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15
Q

First Level

A

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

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16
Q

Second level

A

Urgent , necessitating prompt intervention (acute)

17
Q

Third

A

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

18
Q

Emergency Assessment

A

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!”

19
Q

Problem Centered

A

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.

20
Q

Comprehensive

A

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.

21
Q

Parts to Health Assessment

A

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

22
Q

Objective data

A

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

23
Q

Subjective data

A

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

24
Q

Body position

A

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

25
Terms
26
What is health history?
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.
27
What are the sources of data used?
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
28
Signs and symptoms
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
29
Health History Components
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
31
Asking Questions methods
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
32
Subjective Questions
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…
33
Open ended techniques vs closed
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
34
Instances to use closed ended
During emergency situations and create yes or no answer Do you feel dizzy etc