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Health Assessment Exam #1

Terms in this set (133)

Communication
Relay of patient information other health care members.
Confidentiality
Protection of private patient information once it is disclosed in health care settings.
Documentation
Institutional standards may dictate how often this should occur.
Employee
HIPAA provides protection to these people when they change jobs.
HIPAA
Health Insurance Probability and Accountability Act
Obligation
Nurse have this with regard to keeping information about patients confidential.
Patients
HIPAA provides rights to these people
PHI
Protected Health Information
Privacy
Right of patients to keep personal information from being disclosed.
Protection
HIPAA was enacted to provide this for certain health information.
Define Asses
Gather information about the patient's condition.
Define Diagnose
Identify the patient's problem.
Define Plan
Set goals of care and desired outcomes and identify appropriate nursing actions.
Define Implement
Perform the nursing actions identified in planning.
Define Evaluate
Determine if goals and expected outcomes are achieved.
What is critical thinking?
The ability to think in a systematic and logical matter with openness to questions and reflect on the reasoning process.
What does the code of ethics serve for?
A statement of the ethical obligations and duties of every person who choose to enter the profession of nursing.
What is Standardized Format?
Framework of obtaining information about a client's physical, developmental, emotional, intellectual, social, and spiritual dimensions.
What is therapeutic technique?
For health assessment foster communication and create an environment that promotes an optimal health assessment/data collection.
What does Therapeutic Communication do?
The techniques encourage a trusting relationship, whereby clients feel comfortable telling their story.
Define Opened-Ended questions
Use initially to encourage clients to tell their story in their own way. Use terminology clients can understand. "Tell me more"
Define Active Listening
Show clients that they have your undivided attention.
"Listening with your whole body"
Define Back Channeling
Use active listening phrases such as "Go on" and "Tell me more" to convey interest and to prompt disclosure of the entire story.
Define Close-Ended questions
ask questions that require a yes or no answer to clarify information, such as "Do you have any pain when you cannot sleep?"
1.1
Respect for Human Dignity- this is a fundamental principal that underlies all nursing practice is respect for the inherent dignity, worth, unique attributes, and human rights for all individuals.
1.2
Relationship with Patients- we must choose to establish relationships of trust provide nursing services according to need, setting aside any bias or prejudice.
1.3
The Nature of Health- nurses respect the dignity and tights of all human beings regardless of the factors contributing to the person's health status.
1.4
The Right to Self Determination- patients have the moral and legal right to determine what will be done with and to them.
The significance of the Nurse-Patient relationship during a health assessment:
Establishing a nurse-patient therapeutic relationship allows you to know a patient as a person.

Brings hope for a patient and nurse.

When you choose to connect with your patient and their family it will help you collect a database.
Hourly Rounding is a great way to build ________.
TRUST
________________ are the most trusted profession of all professions.
Nurses
How do nurses use critical thinking?
They use critical thinking to analyze, problem-solve, and make clinical judgments and decisions.
What are the two stages of assessment?
Collection and Verification of Data
Analysis of Data
What are the types of data?
Subjective and Objective.
Define Subjective Data
Patients verbal descriptions of their health problems.
Patient- "I threw up last night."
Define Objective Data
Observations or measurements of a patient's health status.
EX: Sees patient actually throw up.
What is the patient-centered interview when conducting a Health Assessment?
Motivational Interviewing
Effective Communication
Interview Preparation
Phases of an Interview
What are the three phases of the patient-centered care interview when conducting a health assessment?
Orientation and setting an agenda.
Working Phase
Termination
Leading Question
"You said you vomited..."
Probing
"Tell me anything else..."
Observation
Look head to toe
Diagnostic and Lab Data
Results provide further explanation of alterations or problems identified during the health history and physical examination.
Interpreting and Validating Assessment Data
Ensures collection of complete database.
Leads to second step of nursing process.
Data Documentation
Use clear, concise appropriate terminology
Becomes baseline for care.
Concept Mapping
Visual representation that allow you to graphically show the connections among a patient's health problems.
Regular Body Temp.
98.6-100.4 F
OR
36-38 C
Assessment of Temperature
Oral, rectal, axillary, tympanic membrane, temporal artery, & esophageal pulmonary artery.
Factors Affecting Body Temp.
Age, exercise, hormone level, stress, circadian rhythm.
Fever (Pyrexia)
Heat-loss mechanisms are unable to keep pace with excessive heat production.
Febrile
Has fever
Afebrile
No fever
How to document temp:
98.7 F, O
Pulse
Palpable bounding of blood flow notes as various points on the body
Pulse Rate
Number of pulsing sensations in 1 minute
Assessment of Pulse
Temporal, carotid, apical, radial , ulnar, femoral, popliteal, posterior, tibial, and dorsalis pedis.
Characters of the Pulse
Rate, Rhythm, Strength, & Quality
Rhythm= regular or irregular
Volume= strong or weak
How to document pulse:
78/min, regular, strong
Normal Repiration
12-20 for adult
Normal Pulse Rate
60-100 beats per minute
How to document respirations:
20/min, deep, regular, non labored
What is repiration?
Ventilation- movement of gases into and out of the lung.
Diffusion- movement of oxygen & carbon
Perfusion- Distribution of red blood cells to and from the pulmonary capillaries.
Physiological control; hypoxemia.
What is systolic?
maximun peak pressure during ventricular contraction.
What is diastolic?
minimal pressure during ventricular relaxation.
Normal blood pressure
120/80
Factors affecting arterial BP
Cardiac output, peripheral resistance, blood volume, viscosity, & elasticity.
Factors influencing BP
Age, Stress, Ethnicity, Gender, daily variations, medications, activity, weight and smoking.
Hypertension is:
More common than hypotension, thickening of walls, loss of elasticity, family history,
Hypo tension is:
systolic <90 mm Hg, dilation of arteries, loss of blood volume, decrease of blood flow to vital organs, orthostatic/postural.
How to document bp
BP 120-80, R upper arm
LOC
Level of Consciousness
Hyperthermia
Too hot
Heat Stroke
More severe, stop sweating
Heat Exhaustion
Can lead to heat stroke
Hypothermia
Too cold
Who is the best source of information?
the Patient
Define Growth
Physical change, increase in size, and can be measured quantitatively.
Define Development
Increase in complexity of function/skill, capacity and skill to adapt to environment.
Define Biophysical Development
How our physical bodies grow and change.
What was Gesell's Developmental Theory?
Each child's pattern of growth is unique.
Pattern is directed by gene activity.
Pattern follows fixed developmental sequence.
Developmental influenced by environmental factors.
Psychoanalytical/Psychosocial Theories
Describe human development from perspectives of
Personality
Thinking
Behavior

Development is
Primarily unconscious
Influenced by emotion
Feud's Psychoanalytical Model of Personality Development
Individuals go through stage 5 of psychosexual development.
Each stage characterized by sexual pleasure in parts of the body.
Adult Personality is result of how one resolves conflicts.
Oral
Birth to 12-18 Months "Sucking"
Anal
12-18 Months to 3 years "toilet training"
Phallic or Oedipal
3 to 6 years "genital"
Latency
6 to 12 years
Genital
Puberty to Adulthood "Sexual urge is awaken"
Id
basic instinctual impulses driven to achieve pleasure. Most primitive part of personality; originates in infant.
"I want it now"
Ego
reality component (one's sense of self) Mediates conflicts between environment and forces of id.
Superego
regulates, restrains, prohibits actions (conscience). Influenced by standard of outside forces.
Erikson's Theory of Psychosocial Development
Emphasized relationship to family and culture rather than sexual urges.
Individuals need to accomplish particular task before progressing.
Each task framed with opposing conflicts.
Stage 1 Trust vs. Mistrust
Birth to 1 year "basic trust to take care of one"
Stage 2 Autonomy vs. Sense of Shame and Doubt
1-3 years "self activities things on own"
Stage 3 Initiative vs. Guilt
3-6 year "superego"
Stage 4 Industry vs. Inferiority
6-11 years"eager to apply themselves and thrive on pleasure"
Stage 5 Identity vs. Role Confusion
Puberty "How they look and Who am I?"
Stage 6 Intimacy vs. Isolation
Young Adults "Deeper relationships or no relationships"
Stage 7 Generality vs. Self Absorption and Stagnation
Middle Age "Contributing to younger generations"
Stage 8 Integrity vs Despair
Olg age "Meaningful or regrets (goals haven't been achieved"
What are the three basic classes of temperaments?
Easy Child, Difficult Child, Slow to Warm up Child
Define Easy Child
Easy going, even tempered, predictable
Define Difficult Child
Highly active, irritable, irregular habits
Define Slow to Warm up Child
Reacts negatively, adapts slowly
Piaget Theory of Cognitive Development
Includes four periods related to age.
Demonstrates specific categories of knowing and understanding.
Period I Sensorimotor
Birth to 2 year "hitting and kicking"
Period II Preoperational 2 to 7 years
2-7 years "symbols and mental images"
Period III Concrete Operations
7-11 years "Mental operations; difference between friends."
Period IV Formal Operations
11 years to adulthood "Abstract, reasoning"
Who conducted study on childhood temperament?
Stella Chess & Alexander Thomas
Kohl berg's Theory of Moral Development
Expands on Piaget's cognitive theory.
Moral reasoning develops in stages.
Six stages of developmental under the three levels.
Stage 1 Punishment and Obedience Orientation
"I must follow the rules or I will be punished"
Stage 2 Instrumental Relativist Orientation
Recognizes that their is more than one right view
Stage 3 Good Boy- Nice Girl Orientation
Being good is important and defined as having good motives.
Stage 4 Society Maintain Orientation
Expand their focus from a relationship with others to societal concerns
Stage 5 Social Contract Orientation
Follows the societal law but recognizes the possibility of changing the law to improve society.
Stage 6 Universal Ethical Principal Orientation
defines "right" by the decision of conscience in accord with self-chosen ethical principals.
Nurses need to
Identify their own moral reasoning
Recognize level of moral reasoning used by other health care team members.
Separate own beliefs when helping patients with moral decision making process.
Integrating developmental theories into practice:
Helps nurses use critical thinking skills
Helps nurses explain/ predict human behavior
Provides important guidelines for understanding human process
Allows nurses to recognize deviations from the norm.
Watson's 10 Carative Factors
Forming a human-altruistic value system
Instilling faith-hope
Cultivating a sensitivity to one's self and to others
Developing a helping, trusting, human caring relationship
Promoting and expressing position and negative feelings
Using creative problem-solving, caring processes
Promoting transpersonal teaching-learning
Providing for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment
Meeting human needs
Allowing for existential-phenomenological-spiritual forces
Which of the following examples are steps of nursing assessment? (Select all that apply.)

1. Collection of information from patient's family members
2. Recognition that further observations are needed to clarify information
3. Comparison of data with another source to determine data accuracy
4. Complete documentation of observational information
5. Determining which medications to administer based on a patient's assessment data
1. Collection of information from patient's family members
2. Recognition that further observations are needed to clarify information
3. Comparison of data with another source to determine data accuracy
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?

1. Value-belief pattern
2. Cognitive-perceptual pattern
3. Coping-stress-tolerance pattern
4. Health perception-health management pattern
4. Health perception-health management pattern
When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)

1. An observation of how a patient turns and moves in bed
2. The unit policy and procedure manual
3.The care recommendations of a physical therapist
4. The results of a diagnostic x-ray film
5. Your experiences in caring for other patients with similar problems
1. An observation of how a patient turns and moves in bed
3. The care recommendations of a physical therapist
4. The results of a diagnostic x-ray film
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:

1. Cue.
2. Reflection.
3. Clinical inference.
4. Probing.
3. Clinical inference
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe?

1. Review of systems approach
2. Use of a structured database format
3. Back channeling
4. A problem-oriented approach
A problem-oriented approach
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?

1. Orientation
2. Working phase
3. Data validation
4. Termination
2. Working phase
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems?

1. "I can tell that your eating habits have led to your diabetes. Is that right?"
2. "It's been difficult for people to find jobs. Is that why you work part time?"
3. "You have four children; do you have any concerns about going home and caring for them?"
4. "I wish patients understood how overeating affects their health."
3. You have four children; do you have any concerns about going home and caring for them?"
Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?

1. Probing
2. Open-ended
3. Problem-oriented
4. Confirmation
2. Open ended
A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.)

1. The skin around the wound is tender to touch.
2. Fluid intake for 8 hours is 800 mL.
3. Patient has a heart rate of 78 beats/min and regular.
4. Patient has drainage from surgical wound.
5 Body temperature is 38.3° C (101° F).
6. Patient states, "I'm worried that I won't be able to return to work when I planned."
1. The skin around the wound is tender to touch.
4. Patient has drainage from surgical wound.
5 Body temperature is 38.3° C (101° F).
A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:

1. Patient's level of function.
2. Patient's willingness to perform self-care.
3. Patient's level of consciousness.
4. Patient's health management values.
1. Patient's level of function
A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? (Select all that apply.)

1. The nurse asks the patient to rate his pain on a scale of 0 to 10.
2. The nurse asks the patient what caused his fall.
3. The nurse asks the patient if he has had pain in his back in the past.
4. The nurse assesses the patient's lower-limb strength.
5. The nurse asks the patient what pain medication is most effective in managing his pain.
1. The nurse asks the patient to rate his pain on a scale of 0 to 10.
4. The nurse assesses the patient's lower-limb strength
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess?

1. Health perception-health management pattern
2. Value-belief pattern
3. Cognitive-perceptual pattern
4. Self-perception-self-concept pattern
4. Self-perception-self-concept pattern
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.

1. "You say you've lost weight. Tell me how much weight you've lost in the last month."
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history."
3. "I have no further questions. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history."
4. "Tell me what brought you to the hospital."
1. "You say you've lost weight. Tell me how much weight you've lost in the last month."
5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"
3. "I have no further questions. Thank you for your patience."
During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing?

1. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct?
2. Have you taken anything for your headaches?
3. Tell me what makes your headaches begin.
4. Uh huh, tell me more.
3. Tell me what makes your headaches begin
The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.)

1. Listen attentively to the patient's story.
2. Use gestures that reinforce your questions or comments.
3. Stand back away from the bedside.
4. Maintain direct eye contact.
5. Ask questions quickly to reduce the patient's fatigue
1. Listen attentively to the patient's story.
2. Use gestures that reinforce your questions or comments.
4. Maintain direct eye contact
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