NSG121 Health Assessment Exam 1 Study Guide

CULTIVATE A SPIRIT OF INQUIRY

The Nurse’s Role in Health Assessment

To Promote health, to prevent illness, to treat human responses to health or illness, to
advocate for individual, families, communities, and populations

Types of Assessments

Emergent assessment: Life Threatening, Unstable, ABCs compromised

General Survey: Begins immediately upon meeting the patient and continues throughout the
assessment. No measurements are done

Focused: Patient is Stable- Based on patient’s health issues (what they are in for)

Comprehensive: Assess everything, admission, all body systems, Complete health history and
physical assessment
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Levels of Intervention to Promote Healthy Change

Primary: Preventing Problems, Vaccines, Health Teaching, Safety Precautions
Secondary: Screening to Promote the early diagnosis of health problems
Mammogram, eye exams, smoking cessation, Vision Screenings, Paps

Tertiary: Focuses on preventing complications of an existing disease and promoting health to

the highest level
Medication, Surgical Treatment, Physical Therapy

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Assessment Frameworks

Functional- Focuses on the functional patterns that all humans share

-Health Perception, activity and exercise, nutrition and metabolism, sleep and rest, cognition and
perception, self-perception, self-perception and self-concept, roles and relationships, stress
tolerance, values and beliefs, sexuality, and reproduction

Head-to-Toe- Most organized system for gathering comprehensive physical data

Body Systems Approach- Tool for organizing data when documenting and communicating
findings
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Communication Process
Verbal- Exchange of information using spoken or written word
Nonverbal- Transmission of information without the use of words
Electronic- Electronic medical record, email

Components of Communication
o Sender- Person or group who initiates or begins the communication
o Receiver- Must translate and interpret the message sent
o Understanding- Was the message understood
o Perception
o Culture

Therapeutic Communication
Caring- Encompasses your empathy for and connection with the patient
o Listening, nodding, touch, following-up
Empathy- Being able to see and feel the situation from the patient’s perspective rather than your
own
Self-Concept- Need to be aware of your own biases, values, personality, cultural background,
and communication style
o Don’t let these form developing a therapeutic relationship with patient
Verbal and Non-Verbal Communication Skills
Active Listening- Ability to focus on patients and their perspectives
Reflection- Summarize the main themes of communication
Elaboration- Encourages the patient to keep talking and completely describe difficulties
Focusing- Use when patients are straying from a topic and need redirection
Clarification- Important when the patient’s word choice or idea isn’t clear
Summarizing- Review and condense most important information
Therapeutic Responses
False reassurance- Giving false hope of a positive outcome when the chances are not good
Sympathy- When being sympathetic, you are not being therapeutic because you are interpreting
the situation as you perceive it
Unwanted Advice
Biased Questions
Change of Subject
Distractions
Technical or Overwhelming Language
Interrupting

Phases of interview Process

Pre-interaction- Before meeting with the patient, collect data from the medical record
Beginning- Introduce yourself by name, and state the purpose of the interview
o Explain reason for asking questions
Working- Collect data by asking specific question of client or family member
o Closed or open-ended questions
Closing- Summarize and state what the two or three most important patterns or problems might
be

Data Sources for the Health History

 Health History Sources-

Primary: Directly from the patient Secondary: Chart, family members

Reliable Historian- Provides information consisted with record

Inaccurate Historian- Information differs from record

Psychosocial Factors
Involves asking personal questions Ask at the end since a relationship has been established
o Social, Cultural, and Spiritual Assessment
o Mental Health Assessment
o Human Violence Assessment
o Sexual History and Orientation

Lifestyle Factors
o Hearing Impairment
o Decreased Level of Consciousness
o Cognitive Impairment
o Mental Illness
o Anxiety

Safety Precautions to Prevent Infection

o Handy Hygiene
o Gloves
o Standard Precautions
o Latex Allergy
o Skin Reactions

The Physical Examination

o Non-abdomen
 Inspect
 Palpate
 Percuss
 Auscultate
o Abdomen
 Inspect
 Auscultate
 Percussion
 Palpation (Palpating can increase bowel sounds so it is done after auscultating

Hyper resonant Tone: Intensity… Very Loud, Pitch ..Low, Duration...Long, Quality…
Booming, Location…Emphysematous Lungs
Resonant Tone: Intensity…Loud, Pitch…Low, Duration…Long, Quality…Hollow, Location…
Healthy Lungs

Tympanic Tone: Intensity…Loud, Pitch…High, Duration…Moderate, Quality…Drum Like,

Location…Stomach

Dull Tone: Intensity…Moderate, Pitch…High, Duration…Moderate, Quality…Thud,

Location…Liver

Flat Tone: Intensity…Soft, Pitch…High, Duration…Short, Quality…Dull, Location…Bone

Purpose of Documentation
o To keep record of all patient assessment data and interventions
o “If it’s not documented, it’s not done”

Principles of Documentation
o Accuracy & Completeness- Descriptions should be as clear and precise as possible
o Confidentiality- Keeping private any information pertaining to health status or care
received
o Organization- Entries are made chronologically
o Timeliness- Point of care documentation (in room) reduces errors that can occur with
batch charting
o Conciseness- Be complete with documentation, but avoid unnecessary words

Documentation Formats
o Narrative- Unstructured Paragraphs
o SOAP(IE)
o Subjective
o Objective
o Analysis
o Plan
o Intervention
o Evaluation
o PIE
o Problem
o Intervention
o Evaluation
o DAR
o Data
o Action
o Response
o Charting by Exception- Abnormal assessments require a note
o SBAR
 o Situation
 Identify Patient
 Summary of primary problem
o Background
 Date of admission
 Reason for admission
 Recent set of vital signs
 Current Medications
 Lab Work
 Plan of Care
o Assessment
 Current Nursing Assessment
 Most Recent Set of Vital Signs
 Relevant Lab Values
o Recommendation
 What do you need from this individual
 Suggestions to advance the plan of care
 Any new/urgent needs that need follow-up
 Any orders need to be changed or reviewed
Unit 3
Assessment for Violence & Abuse
o Put patient’s safety first
o Do not question in front of friends and family (abuser could be there)
o Establish rapport and ask questions simply and directly
o “Do you feel safe at home?”
o Do not assume who abuser is
o Do not ask about police or pressing charges. This decision is up to the prosecutor

Objective Data for Social Assessment

o Identifying the social factors influencing the patterns of health and illness for individual
patients, communities, and societies

Lifespan Considerations
o Pregnant Women- Require additional 300-500 calories/day
o Infants/Young Toddlers- Fat intake is crucial for brain development
o Children and Adolescents- Extra protein during growth spurts
o Older Adults- Diminished taste of sweet and salty. Lower metabolic rate, reduced
physical activity

Nutritional Assessment
o Past Medical History- Medical Conditions, food allergies or intolerance
o Lifestyle and Personal Habits- Eating patterns, fluid intake, cooking ability
o Medications and Supplements- Medication Schedule, Alcohol and Drug Use
o Family History- GI or other diseases that influence nutrition
 Objective Mental Health Assessment
o A- Appearance
o Posture, Movement, Activity, Hygiene, and grooming, dress
o B- Behavior
o Level of Consciousness, Eye Contact and Facial Expressions, Speech
o C- Cognitive Function
o Orientation, Attention Span, Memory, Judgement
o T- Thought Process
o Logical, Relevant, Coherent, Consistent
Unit 4

General Survey
o Begin immediately upon meeting the patient and continues throughout the assessment
o Overall Appearance
o Hygiene and Dress
o Skin Color
o Body Structure and Development
o Behavior
o Facial Expressions
o Posture
o Range of Motion
o Gait
o Speech
o Level of Consciousness
Objective versus. Subjective Data
o Objective data is observable and measurable
o Subjective data is gathered from what the chart says and is based on the patient’s
experience and perception
Basic Theories of Pain (Gate Control Theory of Pain)
o Depolarization of the nerve fiber causes gate to open
o The pain stimulus passes from the peripheral to central nervous system up the afferent
nerve pathway
o The pain stimulus passes up the spine
o The stimulus is identified as pain in the cerebral cortex
o The response passes down the efferent pathways and a reaction is created

Pain Assessment (OPQRST)

o Onset
o Proactive/Palliative
o Quality
o Region/Radiation
o Visceral- Abdominal Organs --> Crampy
o Somatic- Muscle, Bones, Joints --> Sharp
o Cutaneous- Skin
 o Referred- Originates from a specific site but the person experiencing it feels the
pain at another site along the intervening spinal nerve
o Phantom Pain-Pain in an extremity or body part that is no longer there
o Severity
o Numeric Pain Scale
o Wong-Baker FACES Pain Scale
o Timing
Considerations and Barriers to Pain Assessment
o Pain-Facilitating Substances
o Substance Pulse- Quickens pain substance
o Bradykinin- Release at site of injury
o Glutamate- Neurotransmitter
o Pain Blocking Substances
o Serotonin- Neurotransmitter
o Opioids
o Gamma- aminobutyric acid, gabapentin, pregabalin

Documenting and Reporting Pain

Vital Signs
o Oral- 97.7-98.6
o Axillary- 96.7- 98.5
o Rectal- 98.7-100.5
o Tympanic- 98.2-100.0
o Temporal- 98.7-100.5
Pulse Sites
o Temporal
o Carotid
o Apical
o Brachial
o Radial
o Ulnar
o Femoral
o Popliteal
o Posterior tibial
o Dorsalis pedis