Exam# 1 Study Guide-Assessment
also known as postural hypotension, occurs when a person's blood pressure falls when suddenly standing up from a lying or sitting position.
- This position assists in detecting murmurs.
- This position is poorly tolerated in patients with respiratory difficulties.
- Head and neck, anterior thorax and lungs, breasts, axilla, heart, abdomen
- This position is used for abdominal assessment because it promotes relaxation of abdominal muscles.
- Patients with painful disorders are more comfortable with knees flexed.
- Rectum and vagina
- Flexion of hip and knee improves exposure of rectal area.
- Joint deformities may hinder patient’s ability to bend hip and knee.
- Head and neck, anterior thorax and lungs, breasts, axilla, heart, abdomen, extremities
- pulses This is the most normally relaxed position. It provides easy access to pulse sites.
- If patient becomes short of breath easily, nurse may need to raise head of bed.
- Musculoskeletal system
- This position is used only to assess the extension of the hip joint. This position is poorly tolerated in patients with respiratory difficulties.
hearing loss due to age
blood flow sounds heard when taking a blood pressure
trouble seeing things far away (nearsightedness)
trouble seeing things close up ( farsightedness)
eye sight that gets worse due to age.
high pitch, large side of the stethoscope (flat)
- sounds such as extra heart or vascular sounds (bruit).
- hear soft low pitch, the small side of the stethoscope (curve side)
focused assessment questions
What are your symptoms?
When did they start?
What activity were you doing ?
What makes it better or worse?
What are you doing to relieve the symptom?
often used to describe the presenting signs and symptoms experienced by a patient.
Characteristics of Sounds Heard by Auscultation
Intensity is the loudness of the sound, described as soft, medium, or loud.
Pitch is the frequency or number of sound waves generated per second. High-pitched sounds have high frequencies. Expected high-pitched sounds are breath sounds, whereas cardiac sounds are low pitched.
Duration of sound vibrations is short, medium, or long. Layers of soft tissue dampen the duration of sound from deep organs.
Quality refers to the description of the sounds (e.g., hollow, dull, crackle).
Standards Nursing Practice Nursing Process
ADPIE A=assessment D=diagnosis P=planning I=implementation(Outcome Identification) E=evaluation
Episodic/follow-up assessment (Types of Health Assessment)
- (assessment history) Assesses for changes since last visit Focuses on specific problems for which client is already receiving treatment.
- This type of assessment is usually done when a patient is following up with a health care provider for a previously identified problem.
- For example patient treated by health care provider for pneumonia might be asked to return for a follow-up visit after completing a prescription of antibiotics.
- An individual treated for an ongoing condition such as diabetes is asked to make regular visits to the clinic for episodic assessment
Comprehensive assessment (Types of Health Assessment)
- detailed history/physical examination performed at onset of care primary care setting or on admission to a hospital or long-term care facility.
- encompasses health problems experienced by the patient
- health promotion, disease prevention, & assessment for problems associated with known risk factors or assessment for age- & gender-specific health problems.
Problem-based/focused assessment (Types of Health Assessment)
- history & examination that are limited to a specific problem or complaint (e.g., a sprained ankle).
- most commonly used in a walk-in clinic or emergency department but it may also be applied in other outpatient settings. Focus data collection on specific problem, potential impact patient’s underlying health status also must be considered.
- Use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas
- Using palmar surfaces of fingers may be light or deep and controlled by amount of pressure.
- Light palpation accomplished by pressing to a depth of approximately 1 cm, used to assess skin, pulsations, and tenderness.
- Deep palpation accomplished by pressing to a depth of 4 cm with one or two hands used to determine organ size and contour.
Types of Health Assessment
- Comprehensive assessment
- Problem-based/focused assessment
- Episodic/follow-up assessment
- Shift assessment
- Screening assessment/examination
Shift assessment (Types of Health Assessment)
- When individuals are hospitalized, nurses conduct assessments each shift.
- purpose of the shift assessment is to identify changes to a patient’s condition from the baseline
- focus of the assessment is largely based condition or problem patient experiencing.
- Adapting an assessment to the hospitalized patient is discussed in
Screening assessment/examination (Types of Health Assessment)
- short examination focused on disease detection.
- performed health care provider’s office (as part of a comprehensive examination) or at a health fair.
- Examples blood pressure screening, glucose screening, cholesterol screening, and colorectal screening.
Clarification Signs and Symptoms
Signs are objective data observed, felt, heard, or measured. Ex. signs include rash, enlarged lymph nodes, and swelling of an extremity.
Symptoms are subjective data perceived and reported by the patient. Ex.. symptoms include pain, itching, and nausea. Occasionally data may fall into both categories. Ex.. patient may tell the nurse that he “feels sweaty”—a symptom. At the same time the nurse may observe excessive sweating, or diaphoresis—a sign.
Types of Health Assessment
- context of care
- patient needs
- nurse’s experience
Five core competencies
- (quality improve competencies)
1. provide patient-centered care
2. work in interdisciplinary teams
3. use evidenced-based practice
4. apply quality improvements
5. use informatics
- collection of objective data -signs
- objective data are collected using the techniques of inspection, palpation, percussion, and auscultation for each body system
Components of health assessment
data analysis & interpretation
standardized pain scales
wound assessment scales
risk for fall assessment scales
(Comprehensive) subjective data collected during an interview.
history includes info about the current state of health of patients, the medications they take, any previous illnesses and surgeries, & a family history and review of systems.
Patients may report feelings or experiences associated with health problems.
These patient reports are called symptoms & are considered subjective data Subjective data acquired directly from a patient are considered primary source data.
If data are acquired from another individual (such as a family member), they are referred to as secondary source data.
Describe 5 steps of nursing process:
Assessment The registered nurse collects comprehensive data pertinent to the health care consumer’s health and/or the situation. Standard
Diagnosis The registered nurse analyzes the assessment data to determine the diagnoses or issues. Standard
Outcome Identification The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation. Standard
Planning The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. Standard
Implementation The registered nurse implements the identified plan. 5A: Coordination of Care—The registered nurse coordinates care delivery. 5B: Health Teaching and Health Promotion—The registered nurse uses strategies to promote health and a safe environment. 5C: Consultation—The graduate level–prepared specialty nurse or APRN provides consultation to influence the identified plan, enhance the ability of others, and effect change. 5D: Prescriptive Authority and Treatment—The APRN uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations. Standard 6: Evaluation
3 levels of health promotion
- Primary prevention
- Secondary prevention
- Tertiary prevention
- Focus: Protection to prevent occurrence of disease
- is to prevent a disease from developing through the promotion of healthy lifestyles
- Examples: Immunizations, pollution control, nutrition, exercise
- Focus: Early identification of disease before it becomes symptomatic to halt the progression of the pathologic process
- consists of screening efforts to promote the early detection of disease
- Examples: Screening examinations and self-examination practices (e.g., colorectal screening, mammography, blood pressure screening).
- Focus: Minimize severity and disability from disease through appropriate therapy for chronic disease
- is directed toward minimizing the disability from acute or chronic disease or injury and helping the patient to maximize his or her health.
- Examples: Diabetes mellitus management Cardiac rehabilitation Hypertension management
Health Promotion and Health Protection
- process of health assessment, nurses assess patients’ current health status, health practices, & risk factors.
- Interpretation data allows nurses to target appropriate health promotion needs for patients.
- Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential.
- Health protection is behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within its constraints.
Sometimes referred to as “fifth vital sign
Highly accurate noninvasive measurement estimates arterial oxygen saturation in blood
Light waves reflect off oxygenated and deoxygenated hemoglobin circulating in blood
Used to estimate % of oxygen saturation in arterial blood and pulse rate
Sensor taped to ear, finger, or toe
>95% good reading, <90% abnormal
Visual Acuity and Screening
Snellen chart is wall chart 20 feet from client.
- 11 lines of letters decreasing in size
- Letter size indicates visual acuity from 20 feet
- Tests one eye at a time
- Provides visual acuity number (distance vision)
- Top number = distance from chart
- Bottom number = distance person with normal vision should be able to read line
is repeating what client said and encourages elaboration or more information.
is used when inconsistencies are noted between client report and nurse’s observations.
- Use tone of voice to convey confusion or possible misunderstanding.
concentrates on client responses and subtleties.
- Avoid formulating next question during responses.
- Avoid assuming how client will respond.
is repeating in different words what client says to confirm interpretation.
uses phrases to encourage clients to continue talking further.
- Verbal: “Go on,” “Uh-huh,” “Then…?”
- Nonverbal: head nodding or shifting forward to listen more intently
is used to gather more information. “What do you mean by…?”,
- When Did the Symptoms Begin?
- When did the symptom(s) begin?
- Did they develop suddenly or over a period of time? (Ask for the specific date, time, day of week if appropriate.)
- Where were you or what were you doing when the symptoms began?
- Does anyone else with whom you have been in contact have a similar symptom?
Where Are the Symptoms? • Are they in a specific area?• Are they vague and generalized?• Do the symptoms radiate to another area?
How Long Do the Symptoms Last?
• Since they began, have the symptoms become worse? About the same?
• Are the symptoms constant or intermittent (do they come and go)? • If they are constant, does the severity of symptoms fluctuate?
• If they are intermittent, how many times a day, week, or month do the symptoms occur? How do you feel between episodes of the symptoms?
Describe the Characteristics of the Symptoms
• Describe how the symptoms feel or look.
• Describe the sensation: stabbing, dull, aching, throbbing, nagging, sharp, squeezing, itching.
• If applicable, describe the appearance: color, texture, composition, and odor.
Aggravating and Alleviating Factors
What Affects the Symptoms?
• What makes the symptoms worse? Are the symptoms aggravated by an activity (e.g., walking, climbing stairs, eating, a particular body position)? Are there psychological or physical factors in the environment that may be causing them (e.g., stress, smoke, chemicals)?
• What makes the symptoms better? Do certain body positions relieve them?
Are Other Symptoms Present?
• Have you noticed that other symptoms have occurred at the same time (e.g., fever, nausea, pain)?
Describe Self-Treatment Before Seeking Care
• Which methods of self-treatment have you tried? Medication? (If so, ask for the name of the medication, dosage, and time of last dose.) Heat applications? Cold applications?
• Have any of these methods been effective?
• Have you seen another health care provider for this same problem?
Describe the Severity of the Symptom
• Describe the size, extent, number, or amount.
• On a scale of 0 to 10, with 10 being most severe, how would you rate your symptoms?
• Are the symptoms so severe that they interrupt your activities (e.g., work, school, eating, sleeping)?
placed over a joint; as the patient extends or flexes the joint, the nurse measures the degree of flexion and extension on the protractor.
- are collected from the patient before specific body systems are examined.
- These initial or baseline data are often referred general inspection. Other terms include general survey, general observations, and initial observations.
- general inspection, other baseline data collected include the vital signs, height, and weight.
Components of the Comprehensive Health History
- Biographic data
- Reason for seeking care
- Present health status
- Past medical history
- Family history
- Personal and psychosocial history
- Review of all body systems
- Tympany: loud, high pitched sound heard over the abdomen
- Resonance: heard over normal lung tissue
- Hyper resonance: heard over abnormal lung as in emphysema
- Dullness: heard over liver
- Flatness: heard over bone and muscle
- Ascites: condition where fluid builds up in the abdomen
is used to differentiate the characteristics of tissue, fluid, and air within a specific body cavity
- produces a black-light effect and is used to detect fungal infections of the skin or corneal abrasions of the eye.
- The examination room should be darkened to enhance the determination of the lesion color.
- Skin lesions caused by a fungal infection exhibit a fluorescent yellow-green or blue-green color when examined with a Wood’s lamp.
- When fluorescein dye is placed in the eye, the Wood’s lamp can also detect scratches or abrasions of the cornea.
Enlargement or overgrowth of an organ or part of the body due to the increased size of the constituent cells.