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N1I02 > Week 5 - Intro to Health Assessment > Flashcards

Week 5 - Intro to Health Assessment Flashcards

1
Q

Link to Therapeutic Communication

A

Throughout assessments, nurses observe behavior, ask questions and listen

Assessments require integration of therapeutic communication principles throughout the interaction

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2
Q

Medical assessment

A
  • aims to identify the causative factor of the disease/injury
  • identifies any pre-existing medical conditions that may pose risks for the conventional/surgical intervention offered
  • used to develop a medical treatment plan for the disease/injury
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3
Q

Nursing assessment

A
  • focuses on the patient’s response to disease/injury
  • ascertain the impact of the disease/injury on the patient’s ability to perform ADL’s
  • Helps identify facilitators/barriers to patients achieving the optimal level of health
  • identifies supports that may need to be put in place for successful discharge
  • develop a care plan
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4
Q

Difference b/w nursing and medical assessment

A
  • medical assessment: trying to find the disease
  • nursing assessment: looking at the patient’s response and the impact of the possible diease
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5
Q

Health assessment

A

Health assessment = health history + physical exam + (behavioural and cultural assessment)

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6
Q

What is the purpose of health assessment?

A

to “establish an individualized data-base about the client’s health status to include perceived needs, health challenges, and problems and to respond to these challenges or problems”

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7
Q

Nurse must collect and verify ____, then analyze to develop an ___________ ______ of care

A

Nurse must collect and verify data, then analyze to develop an individualized plan of care

  • data can be subjective or objective
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8
Q

Objective data definition

A

Data that is measurable, directly observable, or verifiable by the nurse

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9
Q

What is objective data?

A

Observations or measurements of a client’s health status
- (i.e. a wound, vital signs, lab results, auscultating lung sounds)

  • Value free observation of client behavior based on an accepted standard (i.e. cm, mmHg)
  • Can be normal or abnormal
  • Use of the senses

Examples:
Cultures positive for strep in the throat
3 day food record shows insufficient caloric intake

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10
Q

What do nurses need to know to collect objective data?

A
  • Requires sound knowledge of the physical & social sciences
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11
Q

Subjective data definition

A

The client’s verbal description of their health concerns

  • what the patients tells you
  • can’t be measured (eg. pain)
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12
Q

What do subjective data reflect?

A

Can reflect physiological changes that the nurse can further assess through objective data

Examples:
My throat is sore
I am eating well

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13
Q

What does a complete health assessment include?

A

Includes a nursing health history, behavioural and physical examination, and cultural assessment

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14
Q

Nursing Health Assessment

Health history

A
  • Person centered
    - i.e. “a person with diabetes”, not “a diabetic”
  • Determine client concerns and identify possible solutions
  • Focus on the client’s strengths and available supports
  • Highlight priority or potential health challenges
  • Questions are asked in an interview that allow nurses to collect data, categorize cues, make inferences, and identify emerging patterns, potential problems, and solutions
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15
Q

Nursing Health Assessment

Physical examination

A
  • A complete physical exam is done for routine screening/health promotion/prevention
  • An acutely ill patient will have a focused assessment based on the body systems involved
    - ie. Asthma attach = respiratory assessment
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16
Q

What are the 5 skills required for physical examination?

A

Inspection, Palpation, Percussion, Ausculation, Olfaction

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17
Q

What info does nursing health history gather?

A

Gathered by client interview by exploring client’s current illness or state of health, health history, and expectations of care

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18
Q

What is the aim of nursing health history?

A

To identify patterns of health and illness, risk factors for physical and behavioural problems, changes to normal function, and available resources for adaptation health practices, patterns of health/illness

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19
Q

Where is the data collected from for nursing health history?

A

Data primarily obtained from the patient

  • Other data sources: family, health care team, medical chart/records, lab & diagnostic tests
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20
Q

What are complete physical examinations done for?

A
  • Routine screening/preventive health
  • Routine yearly medical exam
  • Insurance eligibility
  • Pre-employment for new job
  • Admission to hospital or long-term care
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21
Q

Physical examination:

For _____ illness, nurse assesses only involved body systems

A

For acute illness, nurse assesses only involved body systems

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22
Q

Physical exam techniques

A
  • Skill of using senses of sight, smell, touch, and hearing to gather data
  • Develops over time with practice
  • Technical skills plus knowledge base
  • Skills of physical examination are inspection, palpation, percussion, and auscultation
  • Performed one at time, in above order
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23
Q

Physical examination

Inspection

A
  • Concentrated watching, close/careful scrutiny
  • Starts with general survey, then start assessment of each body system with inspection
  • Compare patient’s right and left sides (symmetrical)
  • Use good lighting
  • Ensure adequate patient exposure (do it respectfully)
24
Q

What can inspection detect in physical examination?

A

Inspection can detect: size, shape/contour, colour, symmetry, position, drainage, abnormalities

25
Q

Physical examination

Palpation

A
  • Using sense of touch can confirm points noted during inspection
  • Need warm hands, short nails, gentle approach
  • Palpate tender areas LAST
  • Use light, intermittent pressure
  • Temperature best with dorsal side of hand
  • Ulnar surface for vibration
26
Q

______ _______ & ______ _____ best to assess position, texture, size, mass, consistency, fluid

A

Palmar surface & finger pads best to assess position, texture, size, mass, consistency, fluid

27
Q

Physical examination

Percussion

A
  • Tapping skin with short, sharp strokes to assess underlying structures
  • Yields palpable vibration and characteristic sounds
    • Location, size, density of underlying organ
28
Q

Physical examination

Auscultation

A
  • Uses sense of hearing for sounds produced by heart, blood vessels, lungs, and abdomen channeled through a stethoscope
  • Fit and quality of stethoscope
    - Diaphragm (high pitch) and bell (low pitch) endpieces
  • Eliminate confusing artifacts
  • Learning begins with comfort in identifying normal sounds (vs. abnormal and extra sounds)
  • Listen selectively to one sound at a time
    NEVER listen through clothing/gown
29
Q

What is the interview b/w nurse to a patient?

A

An organized conversation to gather information on client’s health history and current illness

30
Q

Interview stage:

Orientation

A

Introduce self, name & title, interview purpose, time frame, confidentiality

31
Q

Interview stage:

Working

A

Be focused

Organized, orderly, use open ended questions when possible, use variety of communication strategies (active listening, clarification, summarizing, paraphrasing)

32
Q

Interview stage:

Termination

A

Summarize key points, give client chance to ask questions/clarify, offer follow up

33
Q

What are the 7 steps in health history?

  • Jarvis
A
  1. Biographical Data
  2. Reason for Seeking Care
  3. Current Health or History of Current Illness
  4. Past Health
  5. Family History
  6. Review of Systems
  7. Functional Assessment
34
Q

Health history

  1. Biographical data
A

Name, contact information, age, DOB, relationship status, gender, cultural background, occupation or daily activity pattern, primary/preferred language

35
Q

Health history

  1. Reason for seeking care
A

Brief statement in patient’s own words

Symptoms and signs
- We are looking for more symptoms, not signs

Careful not to use a medical diagnosis

If many reasons given, try to focus on most pressing

36
Q

Health history

  1. Current health or history of current illness
A

If well, short statement about general health
- Tell me how you are feeling OR Tell me about how your health has been

If ill, ask patient to provide chronological history
- Assess symptoms using: PQRSTU
O-onset
P-provocative and palliative
Q-quality and quantity
R- region and radiation
S-severity
T-timing (duration, frequency)
U-understand patient’s perception, impact on daily life
V-patient values (goals, expectations)

37
Q

Health history

  1. Past Health
A

Childhood illnesses-especially with ongoing health impacts

Accidents or injuries: MVA, head injuries, fractures, etc

Serious or chronic illnesses

Hospitalizations: reason, duration, outcome

Operations/Surgeries: type, recovery

Obstetrical history: GTPAL

Immunizations: MMR, DPTP, HPV, influenza, TB, tetanus, COVID

Most recent exams: physical, eye, ear, dental, vision, ECG, chest Xray

Allergies-note allergen and reaction, use of EpiPen

Current medications: include OTC, vitamins, supplements, birth control pills, ASA, antacids. Include reason, dose, schedule

38
Q

Health history

  1. Family History
A

Age and health (or age at death and cause)

Parents, grandparents, siblings, spouse, children
- ask about them, look for if the have any possible genetic disease

Often drawn and presented as a genogram

Ask specifically for: heart disease, cancer, diabetes, high BP, stroke, blood disorders, sickle cell disease, arthritis, obesity, allergies, mental health, alcoholism, seizure disorders, kidney disease
- genetic diseases –> possible in the patient

Look at the sample genogram

How would this guide your health assessment?

39
Q

Genogram symbols

A

Square - male

Circle - female

Clear/white-coloured - alive

Filled in/black-coloured - deceased

40
Q

Health history

  1. Review of Systems
A

Evaluates past and current health for each body system, and health promotion practices

Follows approximately head to toe

Only include data given by client, not physical assessment data

Need to think critically about which sections and questions need to be included

Begin with overall health-weight, fatigue, fever, weakness, malaise

41
Q

Health history

  1. Functional assessment (how the patient is impacted by the disease)
A
  • Assesses client self-care abilities, lifestyle, living environment
  • ADLs: bathing, dressing, eating, toileting, walking
  • IADLs: housekeeping, cooking, shopping, laundry, managing finances, using the phone
  • Self-concept & Self-esteem
  • Activity & Mobility
  • Sleep & Rest
  • Nutrition & Elimination
  • Interpersonal Relationships & Resources
  • Spiritual Resources
  • Coping & Stress Management
  • Smoking history, Alcohol & Substance use
  • Environmental hazards
  • Intimate partner violence
  • Occupational health
  • Perceptions of health
42
Q

How many Gordon’s functional health patterns are there?

A

11 functional health patterns

  • By examining these patterns and interactions among the patterns, nurses can assess (notice), diagnose (interpret) and intervene (respond) effectively towards health and well-being
43
Q

The 11 Gordon’s functional health patterns is an effective to collect _________ information and _________ findings

A

The 11 functional health patterns is an effective way to collect holistic information and organize findings.

44
Q

What are the 11 Gordon’s functional health patterns?

A
  • Health Perception & Health
  • Management
  • Nutrition & Metabolic
  • Elimination
  • Activity & Exercise
  • Sleep & Rest
  • Cognitive & Perceptual
  • Self-perception & Self-concept
  • Roles & Relationships
  • Sexuality & Reproduction
  • Coping & Stress Tolerance
  • Values & Beliefs
45
Q

Gordon’s functional health patterns

Health perception/management

A

Overall health status, health and safety practices, current level of health or wellness, health promoting activities

46
Q

Gordon’s functional health patterns

Nutrition/metabolic

A

Nutrient & food intake, fluid intake, eating & drinking patterns, 24-hr diet recall, food restrictions/allergies, changes in weight

47
Q

Gordon’s functional health patterns

Activity & exercise

A

Activity level, exercise program, leisure activities, mobility limitations
- Type, frequency, duration, intensity of physical activity

48
Q

Gordon’s functional health patterns

Elimination

A

Bowel, bladder, skin (excessive sweating)
- Regularity, quantity, quality, use of laxatives

49
Q

Gordon’s functional health patterns

Sleep & rest

A

Assess perception of adequacy of sleep
- Assess sleep quality & quantity
- Issues with onset, interruptions, awakening

50
Q

Gordon’s functional health patterns

Cognitive & perceptual

A

Ability to understand, follow directions, retain information, make decisions, use language appropriately
- 5 senses, pain assessed
- Educational level, recent memory changes, thought processes

51
Q

Gordon’s functional health patterns

Self perception/self concept

A

Personal identity, goals, emotional patterns, feelings about self

52
Q

Gordon’s functional health patterns

Roles & relationships

A

Roles assumed, perception of/satisfaction with roles, family structure, support, decision making, family communication

53
Q

Gordon’s functional health patterns

Sexuality & reproduction

A

Sexual functioning, reproduction, health promotion

54
Q

Gordon’s functional health patterns

Coping & stress tolerance

A

Coping behaviours, response to stress, past coping patterns

55
Q

Gordon’s functional health patterns

Values & beliefs

A

Values & beliefs that guide goals & decisions
- Goals and expectations concerning health

N1I02 (7 decks)

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