Health Assessment - 1st Class to Midterm Questions and Answers

Health Assessment - 1st Class to Midterm Questions and Answers Diagnosis Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral) Planning Determining outcome criteria and developing a plan Implementation Carrying out the plan Evaluation Assessing whether outcome criteria have been met and revising the plan as necessary Purpose of Nursing Assessment to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. The four basic types of assessment are: -Initial comprehensive assessment -Ongoing or partial assessment -Focused or problem-oriented assessment -Emergency assessment -Each assessment type varies according to the amount and type of data collected. Initial Comprehensive Assessment An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client's overall functioning) as well as objective data gathered during a step-by-step physical examination. Ongoing or Partial Assessment An ongoing or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. This consists of a minioverview of the client's body systems and holistic health patterns as a follow up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data Focused or Problem-Oriented Assessment A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not address areas not related to the problem. Emergency Assessment An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment. Steps of Health Assessment -Collection of subjective data -Collection of objective data -Validation of data -Documentation of data Preparing for the Assessment Knowing the client's basic biographical data (age, sex, religion, educational level, and occupation). Framework for Health Assessment in Nursing The questions asked in each physical system's chapter focus on that particular body system and are broken down into four sections: -History of present health concern -Personal health history -Family history -Lifestyle and health practices Subjective Data Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client The major areas of subjective data include: -Biographical information (name, age, religion, occupation) -History of present health concern: physical symptoms related to each body part or system (e.g., eyes and ears, abdomen) -Personal health history -Family history -Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment) -Review of systems The examiner directly observes objective data. These data include: -Physical characteristics (e.g., skin color, posture) -Body functions (e.g., heart rate, respiratory rate) -Appearance (e.g., dress and hygiene) -Behavior (e.g., mood, affect) -Measurements (e.g., blood pressure, temperature, height, weight) -Results of laboratory testing (e.g., platelet count, x-ray findings) Collective data is obtained by: Using the four physical examination techniques: inspection, palpation, percussion, and auscultation. Another source of objective data is The client's medical/health record, which is the document that contains information about what other health care professionals (i.e., nurses, physicians, physical therapists, dietitians, social workers) observed about the client. Validating Assessment Data Validation of assessment data is a crucial part of assessment that often occurs along with collection of subjective and objective data. It serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data. Documenting Data Documentation of assessment data is an important step of assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team. Thorough and accurate documentation is vital to ensure that valid conclusions are made when the data are analyzed in the second step of the nursing process. A nursing diagnosis is defined as: "a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable" Collaborative problems Defined as certain "physiological complications that nurses monitor to detect their onset or changes in status" Process of Data Analysis -Identify abnormal data and strengths. -Cluster the data. -Draw inferences and identify problems. -Propose possible nursing diagnoses. -Check for defining characteristics of those diagnoses. -Confirm or rule out nursing diagnoses. -Document conclusions. Subjective data consist of: -Sensations or symptoms -Feelings -Perceptions -Desires -Preferences -Beliefs -Ideas -Values -Personal information The nursing interview is a communication process that has two focuses: -Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information. -Gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual status to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse-client collaboration. Phases of the Interview Four basic phases: preintroductory, introductory, working, and summary/closing phases. Preintroductory Phase The nurse reviews the medical record before meeting with the client. Knowing some of the client's already documented biographical information may assist the nurse with conducting the interview. Introductory Phase After introducing herself to the client, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential. Interview Tip: Conducting the interview at eye level with the client demonstrates respect and places the nurse and the client at equal levels. At this point in the interview, it is also essential for nurses to develop trust and rapport, which are essential to promote full disclosure of information. The nurse can begin this process by conveying a sense of priority and interest in the client. Developing rapport depends heavily on verbal and nonverbal communication on the part of the nurse. Working Phase During this phase, the nurse elicits the client's comments about major biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems (ROS) for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals. Summary and Closing Phase During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. She also identifies and discusses possible plans to resolve the problem (nursing diagnoses and collaborative problems) with the client. Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions. Communication During the Interview - types: The client interview involves two types of communication—nonverbal and verbal. Nonverbal Communication - Appearance First take care to ensure that your appearance is professional. The client is expecting to see a health professional; therefore, you should look the part. Wear comfortable, neat clothes and a laboratory coat or a uniform. Be sure that your nametag, including credentials, is clearly visible. Your hair should be neat and pulled back if long. Fingernails should be short and neat; jewelry should be minimal. Nonverbal Communication - Demeanor Your demeanor should also be professional. When you enter a room to interview a client, display poise. Focus on the client and the upcoming interview and assessment. Do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath. This appears unprofessional to the client and will have an effect on the entire interview process. Greet the client calmly, by name and not with references such as honey, sweetie, or sugar. Focus your full attention on the client. Do not be overwhelmingly friendly or "touchy"; many clients are uncomfortable with this type of behavior. It is best to maintain a professional distance. Nonverbal Communication - Facial Expression Facial expressions are often an overlooked aspect of communication. Because facial expressions often show what you are truly thinking (regardless of what you are saying), monitor them closely. No matter what you think about a client or what kind of day you are having, keep your expression neutral and friendly. If your face shows anger or anxiety, the client will sense it and may think it is directed toward him or her. If you cannot effectively hide your emotions, you may want to explain briefly that you are angry or upset about a personal situation. Admitting this to the client may also help in developing a trusting relationship and genuine rapport. Displaying a neutral expression does not mean that your face lacks expression. It means using the right expression at the right time. If the client looks upset, you should appear and be understanding and concerned. Conversely, smiling when the client is on the verge of tears will cause the client to believe that you do not care about his or her problem. Nonverbal Communication - Attitude One of the most important nonverbal skills to develop as a health care professional is a nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices. Do not act as though you feel superior to the client or appear shocked, disgusted, or surprised at what you are told. These attitudes will cause the client to feel uncomfortable about opening up to you, and important data concerning his or her health status could be withheld. Being nonjudgmental involves not "preaching" or imposing your own sense of ethics or morality on the client. Focus on health care and how you can best help the client to achieve the highest possible level of health. Nonverbal Communication - Silence Another nonverbal technique to use during the interview process is silence. Periods of silence allow you and the client to reflect and organize thoughts, which facilitate more accurate reporting and data collection. Nonverbal Communication - Listening Listening is the most important skill to learn and develop fully in order to collect complete and valid data from your client. To listen effectively, you need to maintain good eye contact, smile or display an open, appropriate facial expression, and maintain an open body position (open arms and hands, and lean forward). Avoid preconceived ideas or biases about your client. To listen effectively, you must keep an open mind. Avoid crossing your arms, sitting back, tilting your head away from the client, thinking about other things, looking blank or inattentive, or engaging with an electronic device instead of the client. Becoming an effective listener takes concentration and practice. Nonverbal Communication to Avoid - Excessive or Insufficient Eye Contact - Distraction and Distance - Standing Verbal Communication to Avoid - Biased or Leading Questions - Rushing Through the Interview - Reading the Questions Open-ended Question Open-ended questions are used to elicit the client's feelings and perceptions. They typically begin with the words "how" or "what." An example of this type of question is: "How have you been feeling lately?" These types of questions are important because they require more than a one-word response from the client and, therefore, encourage description. Asking open-ended questions may help to reveal significant data about the client's health status. Close-ended Question Use closed-ended questions to obtain facts and to focus on specific information. The client can respond with one or two words. Closed-ended questions typically begin with the words "when" or "did." An example of this type of question is: "When did your headache start?" Closed-ended questions are useful in keeping the interview on course. They can also be used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions. Laundry List Another way to ask questions is to provide the client with a list of words to choose from in describing symptoms, conditions, or feelings. This laundry list approach helps you to obtain specific answers and reduces the likelihood of the client perceiving or providing an expected answer. Rephasing Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said. Well-Placed Phrases The nurse can encourage client verbalization by using well-placed phrases. For example, if the client is in the middle of explaining a symptom or feeling and believes that you are not paying attention, you may fail to get all the necessary information. Listen closely to the client during his or her description and use phrases such as "uh-huh," "yes," or "I agree" to encourage the client to continue. Inferring Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true Providing Information Another important thing to do throughout the interview is to provide the client with information as questions and concerns arise. Make sure that you answer every question as thoroughly as you can. If you do not know the answer, explain that you will find out. Special Considerations During the Interview Three variations in communication must be considered as you interview clients: gerontologic, cultural, and emotional. Gerontologic Variations in Communication -Access hearing acuity -May be scared, need to trust the nurse to open up Cultural Variations in Communication Ethnic/cultural variations in communication and self-disclosure styles may significantly affect the information obtained Cultural Variations in Communication Examples: -Reluctance to open up -Variation in willingness to openly express emotional distress or pain. -Variation in ability to receive information (listen). -Variation in meaning conveyed by language. -Variation in use and meaning of nonverbal communication: eye contact, stance, gestures, demeanor. -Variation in disease/illness perception: culture-specific syndromes or disorders are accepted by some groups (e.g., in Latin America, susto is an illness caused by a sudden shock or fright). -Variation in past, present, or future time orientation (e.g., the dominant US culture is future oriented; other cultures may focus more on the past or present). -Variation in the family's role in the decision-making process: a person other than the client or the client's parent may be the major decision maker regarding appointments, treatments, or follow-up care for the client. You may have to interview a client who does not speak your language. To perform the best interview possible, it is Emotional Variations in Communication Not every client you encounter will be calm, friendly, and eager to participate in the interview process. Clients' emotions vary for a number of reasons. They may be scared or anxious about their health or about disclosing personal information, angry that they are sick or about having to have an examination, depressed about their health or other life events, or they may have an ulterior motive for having an assessment performed (they are trying to avoid work/school). Clients may also have some sensitive issues with which they are grappling and may turn to you for help. COMPLETE HEALTH HISTORY The health history is an excellent way to begin the assessment process because it provides the foundation for identifying nursing problems and provides a focus for the physical examination. The importance of the health history lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual's lifestyle and current health status. Data from the health history also provide the examiner with specific cues to health problems that are most apparent to the client. Health History Parts: -Biographical data -Reasons for seeking health care -History of present health concern -Personal health history -Family health history ROS for current health problems --Lifestyle and health practices profile -Developmental level Biographical Data Biographical data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, social security number, medical record number, health insurance information, or similar identifying data may be included in the biographical data section. Reason(s) for Seeking Health Care This category includes two questions: "What is your major health problem or concern at this time?" and "How do you feel about having to seek health care?" The first question assists the client in focusing on the most significant health concern and answers the nurse's question, "Why are you here?" or "How can I help you?" Primary care providers call this the client's chief complaint (CC), but a more holistic approach for phrasing the question may draw out concerns that reach beyond a physical complaint and may address stress or lifestyle changes. History of Present Health Concern Using COLDSPA -Character (How does it feel, look, smell, sound, etc.?) -Onset (When did it begin; is it better, worse, or the same since it began?) -Location (Where is it? Does it radiate?) -Duration (How long does it last? Does it recur?) -Severity (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever experienced]?) -Pattern (What makes it better? What makes it worse?) -Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities [leisure or exercise]?) History of Present Health Concern This section of the health history takes into account several aspects of the health problem and asks questions whose answers can provide a detailed description of the concern. First, encourage the client to explain the health problem or symptom in as much detail as possible by focusing on the onset, progression, and duration of the problem; signs and symptoms and related problems; and what the client perceives as causing the problem. Personal Health History This portion of the health history focuses on questions related to the client's personal history, from the earliest beginnings to the present. Ask the client about any childhood illnesses and immunizations to date. Adult illnesses (physical, emotional, and mental) are then explored. Ask the client to recall past surgeries or accidents. Ask the client to describe any prolonged episodes of pain or pain patterns he or she has experienced. Inquire about any allergies (food, medicine, pollens, other) and use of prescription and OTC medications. Family Health History As researchers discover an increasing number of health problems that seem to run in families and that are genetically based, the family health history assumes greater importance. In addition to genetic predisposition, it is also helpful to be aware of other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems. Genogram Helps to organize and illustrate the client's family history. Lifestyle and Health Practices Profile This is a very important section of the health history because it deals with the client's human responses, which include nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept and self-care activities, social and community activities, relationships, values and beliefs system, education and work, stress level and coping style, and environment. Description of Typical Day This information is necessary to elicit an overview of how the client sees his usual pattern of daily activity. Activity Level and Exercise Next, assess how active the client is during an average week either at work or at home. Inquire about regular exercise. Some clients believe that if they do heavy physical work at their job, they do not need additional exercise. Make it a point to distinguish between activities done when working, which may be stressful and fatiguing, and exercise, which is designed to reduce stress and strengthen the individual. Sleep and Rest Inquire whether the client feels he is getting enough sleep and rest. Questions should focus on specific sleep patterns, such as how many hours a night the person sleeps, interruptions, whether the client feels rested, problems in sleeping (e.g., insomnia), rituals the client uses to promote sleep, and concerns the client may have regarding sleep habits. Substance Use The information gathered about substance use provides the nurse with data concerning lifestyle and a client's self-care ability. Substance use can affect the client's health and cause loss of function or impaired senses. In addition, certain substances can increase the client's risk for disease. Also, because many people use vitamins or a variety of herbal supplements, it is important to ask which ones and how often. These supplements and prescription medications may interact (e.g., garlic decreases coagulation and interacts with warfarin [Coumadin]). Self-Concept and Self-Care Responsibilities This includes assessment of how the client views herself and investigation of all behaviors that a person does to promote her health. Examples of subjects to be addressed include sexual responsibility; basic hygiene practices; regularity of health care checkups (i.e., dental, visual, medical); breast/testicular self-examination; and accident prevention and hazard protection (e.g., seat belts, smoke alarms, and sunscreen). Social Activities Questions about social activities help the nurse to discover what outlets the client has for support and relaxation and if the client is involved in the community beyond family and work. Information in this area also helps to determine the client's current level of social development.