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Heath Assessment
| Question | Answer |
|---|---|
| What is an assessment? | A collection of subjective and objective data |
| What is subjective data? | What a person is saying about their health |
| What is the objective data? | What you assess through four assessment techniques |
| What are the four assessment techniques for objective data? | Inspecting, Percussion, Palpating, Auscultating |
| What is included in health history? | Biographic, chief complaint, history of present illness, past medical history, family history, |
| Why is a health history important? | Provides baseline of care, helps identify risk factors for disease, builds trust w/pt |
| What body fluids can we test? | Blood, urine, saliva, CSF, stool, vaginal, sputum |
| What are the types of blood labs? | Venous, atrial, capillary |
| What is the database? | The totality of information available about the patient |
| What is a judgement? | Nurses' interpretation of al the assessment data |
| What is the diagnosis? | A statement that identifies a pt's actual or potential health problem |
| How do we make a clinical judgement or diagnosis? | Collect data, cluster data, interpret meaning, make judgement, diagnosis |
| What is diagnosistic reasoning? | Process of analyzing health data and drawing conclusions to identify diagnoses |
| What are the four major diagnostic reasoning? | Attending to cues, formulating diagnostic hypotheses, gathering data, and evaluating each hypothesis |
| What is a novice nurse? | Clear cut rules to guide thinking |
| What is an experienced nurse? | Uses rules and adapting as the patient situation warrants |
| What is a first level priority patient? | Life threatening |
| What is a second level priority patient? | Medication |
| What is a third level priority patient? | Education |
| What is evidence-based practice? | A systematic approach to practice that uses the best evidence, the clinician's experience, and the patients' preferences and values to make decisions about care and treatment |
| What is a complete assessment? | A complete health history and a full physical exam |
| What is a focus ed assessment? | Focuses on one problem, cue complex, or body system |
| What is a follow up database? | Evaluates the status of any identified problem at regular intervals to follow up on short term or chronic health problems |
| What is an emergency database? | An urgent and rapid collection of data |
| What commonly occurs during an emergency database collection? | Patient is usually unresponsive and must rely on family for answers |
| What does the concept of health include? | Health promotion and disease prevention |
| What should a health assessment consider? | Developmental task for each age group and cultural beliefs/practice of different people |
| Why is collecting a heritage assessment beneficial? | Can help gather accurate and meaningful data while guiding culturally sensitive and appropriate care |
| What is heritage consistency? | The degree to which a person's lifestyle reflects his or her traditional heritage |
| What can occur if patient and nurse are different? | Cultural conflicts |
| What is a health disparity? | Health difference that is linked with social, economic, and /or environmental disadvantage |
| What is the purpose of a health interview? | To collect subjective data |
| How is a health interview different than a social interaction? | Thought to be like a contract where client discusses what they need and expect from healthcare and what the clinician has to occur |
| What are internal factors of a health interview? | Factors that are specific to the examiner such as liking others, empathy, ability to listen, and self-awareness |
| What are external factors of a health interview? | physical environment, dress, note taking, electronic health record, and privacy |
| What are the three phases of an interview? | Introduction, a working phase, and a closing |
| What type of data is gathered in the working phase of an interview? | Open-ended and closed |
| What verbal responses focuses on the patient's frame of reference? | Facilitation, silence, reflection, empathy, and clarification |
| What verbal responses focuses on the providers frame of reference? | Confrontation, interpretation, explanation, and summary |
| What are the ten traps of interviewing? | providing false assurance or reassurance, giving unwanted advice, using authority, using avoidance language, distancing, using professional jargon, using leading or biased questions, talking too much, interrupting, using why questions |
| What are nonverbal modes of communication? | Physical appearance, posture, gestures, facial expression, eye contact, voice, and touch |
| What are four assessment techniques? | inspection, palpation, percussion, and auscultation |
| When does the inspection begin? | As soon as you meet someone |
| What does inspection require? | Good lighting, adequate exposure, and use of instruments |
| Should you inspect body system or individual first? | Individual then the body system |
| What is the fingertips best for during palpation? | Fine tactile discrimination |
| What should you use to detect position, shape, and consistency of an organ or mass? | Fingers and thumb |
| What is using the backs of the hands or fingers best for? | Determining temperature |
| What is best for assessing vibration? | Base of fingers or ulnar surface of hands |
| What does light palpation evaluate? | Surface characteristics and identifies areas of tenderness |
| What does deep palpation assess? | Organ or mass deeper in the body cavity |
| What is bimanual palpation? | Use of both hands to envelop or capture certain body parts or organs |
| What is percussion? | Tapping of the skin w/short, sharp strokes to create an audible vibration |
| What does percussion detect? | Location, size, density of an organ |
| Where should you avoid percussing? | Over bone |
| How do you know you're percussing over bone? | Sound will be flat |
| What finger is the "striking finger" | Middle |
| How many times do you percuss in each location? | Twice |
| On what type of patients would you need to use harder strokes during percussion? | Obese or muscular |
| What does a thud sound indicates during percussion? | Fluid or tumor |
| What is a normal abdominal sound? | Timpany |
| What is a normal lung sound? | Residence |
| What is auscultation? | Listening to sounds produced by the body |
| What tool do you use for auscultation? | Stethoscope |
| What part of the stethoscope is used for high pitch sounds? | Diaphragm |
| What part of the stethoscope is used for low pitch sounds? | Bell |
| What is a brewie? | Plaque buildup in arteries |
| What is most important step to infection control? | Hand washing |
| When do you preform hand hygeine? | Before and after physical contact with a patient, after contact with body fluids or contaminated equipment, and after removing gloves |
| When do you use soap and water over hand sanitizer? | When hands are spoiled or when person is infected with spore forming organism |
| What is a common example of a spore forming organism? | CDIFF |
| When do you use standard precaution? | For all patients |
| What is standard precaution? | Hand hygiene and gloves when needed |
| When is transmission-based precautions used? | Patients with documented or suspected transmissible infections |
| What are the three types of transmission-based precautions? | Contact, droplet, and airborne |
| What is used in contact precaution? | Hand hygiene, gown, gloves |
| What is droplet precaution? | hand hygiene and mask |
| What is airborne precaution? | Hand hygiene, gown, respiration, gloves, and eyewear |
| What is neutropenic precaution? | Low WBC so no sick people in the room |
| What is chemo precaution? | Chemo is toxic so protect them and you with gown, double gloves, and double flush urine |
| How do you reduce patient anxiety? | Maintain confident, consideration, and unhurried manner |
| What actions should a nurse begin with? | Measuring height, weight, and vital signs |
| Why should a nurse preform hand hygiene in a patients room? | Indicates being protective of them and starting fresh |
| How should an examination be conducted? | Systematically and brief teachings when appropriate |
| What should be considered during examination of a child? | Position, preparation, and developmental stage |
| What can be beneficial to be less threatening when examining a child? | Utilizing parent help or maintaining privacy for an older child |
| What should be adjusted for examining an aging adult? | Position, preparedness, and pace |
| What is a mini database? | Only examine body area in regard of problem |
| How does pain develop? | Nociceptive and neuropathic processing |
| What is nociceptive pain? | Protective, warning signal that injury is about to or has occurred |
| What is neuropathic pain? | Caused by lesion or disease |
| What type of pain is time limited? | Nociceptive pain |
| What are four types of neuropathic pain? | Visceral, deep somatic, cutaneous, and referred |
| Where is visceral pain? | Large internal organs |
| Where is deep somatic pain? | Deep vessels, joints, tendons, muscles, and bone |
| Where is cutaneous pain? | Skin surface and subcutaneous tissue |
| What does neuropathic pain cause? | Increased vital signs |
| What is the most common type of neuropathic pain? | Sciatic |
| What is referred pain? | Pain felt at one location but originates elsewhere |
| What is acute pain? | Short term and self-limiting |
| What is chronic pain? | 6 mo or longer |
| How is pain felt in infants? | Same capacity as adults |
| How is pain perceived in older adults? | No evidence that they perceive pain to lesser degree or sensitive is diminished |
| Is pain expected in aging? | No |
| What genetic difference are there? | Black patients report worse pain intensity than white but are prescribed less |
| What is the most reliable indicator of pain? | Subjective |
| What questions can be used on an initial pain assessment? | PQRST and COLDSPA |
| What does PQRST stand for? | Provocation, quality/quantity, region/radiation, severity scale, and timing |
| What does COLDSPA stand for? | Character, onset, location, duration, severity, pattern, and associated factors |
| What is the brief pain inventory? | Rate pain within past 24 hours |
| What is the numeric pain assessment? | 0-10 rating |
| What is visual analogue pain assessment tool? | Pictures |
| What is faces pain assessment tool? | Happy, neutral, sad, angry |
| What is a PAINAD assessment tool? | Used for dementia patients |
| Where is it important to access a patient? | Where patient can't see |
| What does pruritus mean? | Itching |
| What should be the first question before beginning any assessment? | Any past history or family history |
| What additional questions should be asked during a skin, hair, and nails of an infant? | Any birth marks, changes in skin color, and diaper rash |
| Where should color changes be looked for on patients of darker complexion? | Mucous membranes, lips, nail beds, and sclera |
| What should the nurse do if she notices a lesion? | ABCDE it |
| What should be assessed on the skin? | Temperature, moisture, texture, thickness, edema, mobility, turgor, vascularity, bruising, or lesions |
| What should be assessed in the hair? | Color, texture, distribution, scalp lesions, and infestations |
| What should be assessed on the nails? | Shape, contour, consistency, color, and capillary refill |
| What should you educate patient on during the skin, hair, and nails assessment? | Importance of skin self examination, avoidance of ultraviolet light For infants teach parents about newborn skin variations such as Mongolian spots and jaundice |
| What is the braden scale? | Used to determine risk of developing a pressure ulcer |
| What is on the Braden scale? | Sensory perception, moisture, activity, mobility, nutrition, and friction/shear |
| Does a high or low score on the braden scale indicate a risk for a pressure ulcer? | Lower the score higher the risk |
| What is the highest score on the braden scale? | 23 |
| What demographic is FLACC used for? | Babies |
| What does FLACC stand for? | Face, legs, activity, cry, consolability |
| Does more or less movement from a baby indicate pain? | More |
| How many stages are there for pressure ulcers? | 4 |
| What is a first stage pressure ulcer? | Non blanchable skin |
| What is a second stage pressure ulcer? | Broken skin |
| What is a third stage pressure ulcer? | Subcutaneous layer is broken |
| What is a fourth stage pressure ulcer? | Down to the muscle or bone |
| What stages of pressure ulcers are hard to recover from? | 3rd and 4th |
| What is important to do when noticing a pressure ulcer? | Document |
| What is level of consciousness? | Being aware of one's own experience, feelings, thoughts, and of the environment |
| What is orientation? | Orientated to self, place, and time |
| What is the purpose of full mental status examination? | Determine health strengths and coping skills to screen for dysfunction |
| What are the four main components of examination? | Appearance, behavior, cognition, and thought process |
| What is assessed with behavior? | Level of consciousness |
| What is the mini mental state examination? | Test of cognitive function |
| What demographic should you use caution with for the mini mental state exam? | Low educated |
| What is a normal score on the mini mental examination? | 24-30 |
| What may be normal for older adults during a mental status exam? | Slower response time, vision, or hearing deficits |
| What is the mini-cog | 3-word recall |
| What is a lower or higher score more impaired? | 0 |
| What memory goes first in aging? | Short term |
| What is GAD? | General anxiety disorder |
| What is PHQ9 screening? | For depression and suicide |
| When do you give a screening examination? | For seemingly well people who have no significate findings from the history |
| When you give a complete examination? | On people who have neurologic concerns or show signs of neurologic dysfunction |
| When you give a neurologic recheck? | When someone with a neurological deficit is hospitalized or in extended care |
| What reflexes are seen in infants? | Rooting, sucking, palmer, planter, Bobinski, tonic neck, and moro |
| What is the rooting reflex and when is it present? | Turn head toward side being touched with the mouth open birth-4mo |
| What is the sucking reflex and when it is present? | Touch lips and should start sucking, birth-12 mo |
| What is the palmer reflex and when is it present? | Grip fingers, birth-4mo |
| What is the plantar reflex and when is it present? | Touch bottom of foot and toes should curl down, birth-10 mo |
| What is the Bobinski reflex and when is it present? | Stroke finger up lateral edge to the ball of foot and toes should fan, birth- 24 mo |
| What is the tonic neck reflex and when is it present? | Turn head laying down will change position, birth-6 mo |
| What is the moro and when is it present? | Startled will look like hugging tree, birth-4mo |
| What should be accessed on muscle groups? | Size, strength, and tone |
| What is cerebellar function? | Complex motor system that coordinates movement, maintains equilibrium, and maintains posture |
| What is the Romberg test beneficial for? | Test optic nerve VIII, acoustic |
| What is the romberg test? | Stand up with feet together arms @ side, close eyes and hold position for 20 secs |
| What is the finger-to-finger test? | Touch finger to pen then finger to finger |
| What is the finger to nose test? | Touch finger to nose then to pen |
| What are the levels of eye-opening response on the GCS? | 4-1 |
| What are the levels of motor response on the GCS? | 6-1 |
| What are the levels of verbal response on the GCS? | 5-1 |
| What is the normal GCS score? | 15 |
| What is FAST? | Face, arms/legs, speech, and time |
| What is the NIH used for? | To determine severity of an experienced stroke |
| What are the three types of strokes? | TIA, Ischemic, hemographic |
| What is a TIA stroke? | A mini stroke where symptoms come and go |
| What is an Ishemic stroke? | Plaque formation creates a blockage |
| How can an ischemic stroke be reverside? | TPA given max 3 hours after strok e |
| What is cranial nerve I? | Olfactory |
| What is cranial nerve II? | Optic |
| What is cranial nerve III? | Oculomotor |
| What is the cranial nerve IV? | Trochlear |
| What is the cranial nerve V? | Trigeminal |
| What is the cranial nerve VI? | Abducens |
| What is cranial nerve VII? | Facial |
| What is cranial nerve VIII? | Accoustic |
| What is cranial nerve IX? | Glossopharngeal |
| What is cranial nerve X? | Vagus |
| What is cranial nerve XI? | Spinal accessory |
| What is cranial nerve XII? | Hypoglossal |
| How is olfactory nerve examined? | Closing one nostril and using small scent |
| How is optic nerve examined? | Snellen chart |
| How are cranial nerves III, IV, VI? | Eye movements |
| How is trigeminal nerve examined? | Clenching of the jaw |
| How is facial nerve examined? | Making faces such as smile, frown, raise eyebrows |
| How is acoustic nerve examined? | If pt can hear you |
| How is vagus nerve examined? | Gag reflect |
| How is glossopharyngeal nerve examined? | Wiggle tongue |
| How is spinal accessory nerve examined? | Lifting shoulders |
| What are the 6 cardinal fields of gaze? | Following pen without moving head |
| What nerves is the 6 cardinal fields of gaze used for? | III, IV, and VI |
| What is PERRLA? | Pupils, equal, round, reactive, light, and accommodation |
Created by:
emilychaltraw