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Nursing J1 Health Assessment
QUESTIONS AND ANSWERS. NEW
UPDATE!!
Assessment - CORRECT ANSWER -is the collection of data about the
individual's health state. (composed of objective and subjective data)
subjective data - CORRECT ANSWER -what the person says about himself or
herself during history taking
objective data - CORRECT ANSWER -what you as the health professional
observe by inspecting, percussing, palpating, and auscultating during the physical examination
data base - CORRECT ANSWER -Together with the patient's record and
laboratory studies, these elements form the
Cluster or group together - CORRECT ANSWER -the assessment data that
appear to be causal or associated. For example, with a person in acute pain, associated data are rapid heart rate, increased BP, and anxiety. Organizing the data into meaningful clusters -may indicate specific diagnosis/situation
Validate the data - CORRECT ANSWER -you collect to make sure they are
accurate. As you validate your information, look for gaps in data collection. Be sure to find the missing pieces, because identifying missing information is an essential critical- thinking skill. -making sure DATA is CORRECT
nursing process - CORRECT ANSWER -you collect to make sure they are
accurate. As you validate your information, look for gaps in data collection. Be sure to find the missing pieces, because identifying missing information is an essential critical- thinking skill.
Figure 1.2 Patient going through nursing process: - CORRECT ANSWER --
review of the clinical record (we read the patient's record, which either is electronically or on paper copy);
health history - we get this by doing an interview; physical examination - where we looking for signs, using objective techniques including blood pressure monitor, thermometer; functional assessment - also refer to Activities of daily living - we assess if patient can do things like dress themselves, go to work, make meals, move around; risk assessment - in nursing this include like assessing patient's risk for falls and pressure ulcers (thus we do a skin assessment). Identifying Immediate Priorities:
Including Allergies - CORRECT ANSWER -It is always important to ask about
allergies - a allergies can be for food, medication (like penicillin or other antibiotics), environmental (like cats, dogs, bees). If a patient expresses an allergy, ask the patient... "what happened when you were giving the medication..., or when you ate seafood)
Collecting Four (4) Types of patient data: - CORRECT ANSWER -Every
examiner needs to establish four different types of databases, depending on the clinical situation: complete, focused or problem-centered, follow-up, and emergency. Complete (Total Health) Database Collecting Four (4) Types of patient data:
#1 Complete - CORRECT ANSWER -This includes a complete health history and
a full physical examination. -It describes the current and past health state -forms a baseline against which all future changes can be measured. -It yields the first diagnoses. The complete database often is collected in a primary care setting (pediatric or family practice clinic) Collecting Four (4) Types of patient data:
#2 Focused or Problem Centered - CORRECT ANSWER -This is for a limited or
short-term problem. Here you collect a "mini" database, smaller in scope and more targeted than the complete database. -It concerns mainly one problem, one cue complex, or one body system. -It is used in all settings—hospital, primary care, or long-term care.
- example, 2 days after surgery a hospitalized person suddenly has a congested cough, shortness of breath, and fatigue. The history and examination focus primarily on the respiratory and cardiovascular systems. Collecting Four (4) Types of patient data:
-Disease causation may be viewed in three major ways: from a biomedical or scientific perspective, a naturalistic or holistic perspective, or a magicoreligious perspective
biomedical or scientific theory - CORRECT ANSWER -illness causation assumes
that all events in life have a cause and effect. -Among the biomedical explanations for disease is the germ theory, -germ theory: which holds that microorganisms such as bacteria and viruses cause specific disease conditions. -Most educational programs for physicians, nurses, and other health care providers embrace the biomedical or scientific theories that explain the causes of both physical and psychological illnesses.
Naturalistic/ Holistic perspectives - CORRECT ANSWER -found most frequently
among American Indians, Asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. -These people believe that the forces of nature must be kept in natural balance or harmony. Naturalistic/ Holistic perspectives (examples of theories);
- Ying/Yang Theory-
2. Hot and Cold Theory- - CORRECT ANSWER -1. Some Asians believe, in
which health exists when all aspects of the person are in perfect balance.
- Many Hispanic, Arab, and Asian groups, -an explanatory model with origins in the ancient Greek humoral theory. -The four humors of the body—blood, phlegm, black bile, and yellow bile—regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. -The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. -Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not on their physical characteristics.
Culturally sensitive - CORRECT ANSWER -implies that caregivers possess
some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing.
Culturally appropriate - CORRECT ANSWER -implies that the caregivers apply
the underlying background knowledge that must be possessed to provide a given person with the best possible health care.
Culturally competent - CORRECT ANSWER -implies that the caregivers
understand and attend to the total context of the individual's situation, including
awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. -example all three: female/ male patient wanting the same sex nurse for treatment like inserting urinanary catheter Sending:
Nonverbal Communications - CORRECT ANSWER -is as important as verbal
communication. -This is your body language—posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair. -Because nonverbal communication is under less conscious control than verbal communication, it may be more reflective of true feelings. Communication, non-verbal
-Body language - CORRECT ANSWER --Communication can be VERBAL (talk,
what we say) or NON-VERBAL (our body language)
- important things to remember is our facial expression, our posture (like folding your arms), not facing the person at his/her level, putting the computer between you and the patient!
Empathy - CORRECT ANSWER -means viewing the world from the other
person's inner frame of reference while remaining you. -It is a recognition and acceptance of the other person's feelings without criticism. -described as the ability to understand and be sensitive to the feelings of someone else. -Empathy is the ability to recognize how someone perceives his or her world.
Ensuring Privacy - CORRECT ANSWER -Aim for geographic privacy—a private
room in the hospital, clinic, office, or home. -If geographic privacy is unavailable, create "psychological privacy," using curtained partitions
- make sure that the person feels comfortable with the privacy provided. -Privacy extends to ensuring that the client is comfortable with the people in the room. Refuse Interruptions:
Establish Rapport - CORRECT ANSWER -Most people resent interruptions
except in cases of an emergency. -You need to concentrate and establish rapport. -An interruption can destroy in seconds what you have spent many minutes building up. -If you anticipate an interruption, let the person know ahead of time. -Inform colleagues of the interview and the need to minimize interruptions.
Taking- Notes - CORRECT ANSWER --While note-taking is needed to make
sure you document everything correctly
- When you sit down later to record the interview, cannot rely completely on memory
2. Last four responses: - CORRECT ANSWER -look at chart print out
Therapeutic vs non-therapeutic response: - CORRECT ANSWER --therapeutic
refers to 'good', promoting a patient's health and well-being. -non-therapeutic response would be giving unwanted advice, giving false reassurance and others
The Older Adult - CORRECT ANSWER -The aging adult has the developmental
task of finding the purpose of his or her own existence and adjusting to the inevitability of death. -Some people have developed comfortable and satisfying answers and greet you with a calm demeanor and self-assurance, but be alert for the person who sounds hopeless and despairing about life and his or her future.
Addressing The Older Adult? Interviewing - CORRECT ANSWER -Always
address the person by his or her proper surname, and avoid using the first name. -Some older adults resent being called by their first name by younger people and think that it demonstrates a lack of respect. -Older adults have a longer story to tell; therefore plan accordingly. Interview will take longer Interviewing special needs:
Impaired hearing - CORRECT ANSWER --may feel isolated and anxious
because they cannot understand everything that is happening. -Ask the person his or her preferred way to communicate—by signing, lipreading, or writing. -If the person has hearing aids, make sure that he or she is using them properly.
Acutely III People - CORRECT ANSWER --Emergent situations require
combining the interview with the physical examination. -In this case focus the interview on pertinent information only, including history of present illness, medications, allergies, last meal, and basic health state. -Subjective information is a crucial component of providing care; therefore, it is important that you try to interview as much as possible while performing lifesaving actions.
Standardized Communication - CORRECT ANSWER --The SBAR is used in may
hospitals when nurses communicate with physicians
- it helps us to use a standardized format and ensure continuity in patient treatment
- we sometimes also use this format when we do shift handover from nurse to nurse like at the end of night shift or day shifts.
SBAR stands for: - CORRECT ANSWER -Situation, Background, Assessment,
Recommendation
table in separate document, go look
chronologic record - CORRECT ANSWER -according to what happens first,
dates, when it started
The Health History Sequence: - CORRECT ANSWER -1. Biographic data
- Reason for seeking care
- Present health or history of present illness
- Past history
- Medication reconciliation
- Family history
- Review of systems
- Functional assessment or activities of daily living (ADLs)
5. Medication reconciliation - CORRECT ANSWER -For example - pt. says
taking St Worth herbal meds every evening - may impact on Hypertension (high blood pressure) A term used to describe the process when asking about all the medication a patient is taking, thus prescribed medication, OTC (over the counter drugs... think of common medication people buy?), herbal medication - herbal preparations can interfere with the medication prescribed for a patient
1. Biological data- - CORRECT ANSWER -Biographic data include name,
address, and phone number; age and birth date; birthplace; gender; relationship status; race; ethnic origin; and occupation. If illness has caused a change in occupation, include both the usual occupation and the present occupation. Record the person's primary language.
Source of History- - CORRECT ANSWER -1. Record who furnishes the
information—usually the person himself or herself, although the source may be an interpreter or caseworker. Less reliable is a relative or friend.
- Judge how reliable the informant seems and how willing he or she is to communicate. A reliable person always gives the same answers, even when questions are rephrased or repeated later in the interview.
- Note whether the person appears well or ill; a sick patient may communicate poorly.
2. Reason for seeking care - CORRECT ANSWER -This is a brief, spontaneous
statement in the person's own words that describes the reason for the visit. Think of it as the "title" for the story to follow. It states one (possibly two) symptoms or signs and their duration.
A symptom - CORRECT ANSWER -is a subjective sensation that the person
feels from the disorder
3 quantity over severity - CORRECT ANSWER -Attempt to quantify the sign or
symptom, such as "profuse menstrual flow soaking five pads per hour." -Quantify the symptom of pain using the scale shown on the right. With pain, avoid adjectives, and ask how it affects daily activities. Then record if the person says, "I was so sick I was doubled over and couldn't move" or "I was able to go to work, but then I came home and went to bed." The eight critical characteristics
4 timing (onset, duration, frequency) - CORRECT ANSWER -When did the
symptom first appear? -Give the specific date and time or state specifically how long ago the symptom started prior to arrival (PTA). -"The pain started yesterday" will not mean much when you return to read the record in the future. The report must include answers to questions such as the following: "How long did the symptom last (duration)?" "Was it steady (constant) or did it come and go (intermittent)?" "Did it resolve completely and reappear days or weeks later (cycle of remission and exacerbation)?" The eight critical characteristics
5 setting - CORRECT ANSWER -Where was the person or what was the person
doing when the symptom started? What brings it on? -For example, "Did you notice the chest pain after shoveling snow, or did the pain start by itself?" The eight critical characteristics
6 aggravating or reliving factors - CORRECT ANSWER -What makes the pain
worse? Is it aggravated by weather, activity, food, medication, standing, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? What is the effect of any treatment? Ask, "What have you tried?" or "What seems to help?" The eight critical characteristics
7 Associated Factors - CORRECT ANSWER -Is this primary symptom
associated with any others (e.g., urinary frequency and burning associated with fever and chills)? -Review the body system related to this symptom now rather than waiting for the Review of Systems section later. -Many clinicians review the person's medication regimen now (including alcohol and tobacco use) because the presenting symptom may be a side effect or toxic effect of a chemical. The eight critical characteristics
8 patients perception - CORRECT ANSWER -Find out the meaning of the
symptom by asking how it affects daily activities
(Fig. 4.3). "How has this affected you? Is there anything you can't do now that you could do before?" Also ask directly, "What do you think it means?" This is crucial because it alerts you to potential anxiety if the person thinks the symptom may be ominous.
pain scale - CORRECT ANSWER -Quantify the symptom of pain by asking:
"On a 10-point scale, with 10 being the most pain you can possibly imagine and 0 being no pain, tell me how your pain feels right now." question sequence into the mnemonic PQRSTU to help remember all the points. -
CORRECT ANSWER -P: Provocative or Palliative. What brings it on? What were
you doing when you first noticed it? What makes it better? Worse? Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it? R: Region or Radiation. Where is it? Does it spread anywhere? S: Severity Scale. How bad is it (on a scale of 0 to 10)? Is it getting better, worse, staying the same? T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur? U: Understand Patient's Perception of the Problem. What do you think it means?
past health, ask relative questions: - CORRECT ANSWER -ex: patient 90,
childhood disease may not be important Past health events are important because they may have residual effects on the current health state. The previous experience with illness may also give clues about how the person responds to illness and the significance of illness for him or her.
serious or chronic illness - CORRECT ANSWER -we ask: do u have anything
bothering you for a long time, or are you suffering from a chronic illness ex: Asthma, depression, diabetes, hypertension, heart disease, human immunodeficiency virus (HIV) infection, hepatitis, sickle cell anemia, cancer, and seizure disorder.
Obstetric History, age appropriate questions - CORRECT ANSWER -Number of
pregnancies (gravidity), number of deliveries in which the fetus reached full term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). For each complete pregnancy, note the course of pregnancy; labor and delivery; sex, weight, and condition of each infant; and postpartum course.
Allergies - CORRECT ANSWER -Note both the allergen (medication, food, or
contact agent such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing).
- Attention: The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli.
- Memory: The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years' worth of experiences.
- Abstract reasoning: Pondering a deeper meaning beyond the concrete and literal.
- Thought process: The way a person thinks; the logical train of thought.
the aging adult - CORRECT ANSWER -The aging process leaves the
parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth; it takes a bit longer for the brain to process information and to react to it.
the aging adult - CORRECT ANSWER -Age-related hearing loss involves
-high-frequency sounds. -Consonants are high-frequency sounds; therefore, older people who have difficulty hearing them have problems with normal conversation. -This problem produces frustration, suspicion, and social isolation and may make the person look confused. -Recent memory, which requires some processing (e.g., medication instructions, 24- hour diet recall, names of new acquaintances), is somewhat decreased with aging. Remote memory is not affected.
A, B, C, T - CORRECT ANSWER -Appearance, Behavior, Cognition,
and Thought processes Integrating the mental status examination into the health history interview is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction. It is necessary to perform a full mental status examination when you discover any abnormality in affect or behavior
Normal Range of Findings/Abnormal Findings - CORRECT ANSWER -on table
separate sheet
