EXAM 1 - ADVANCED HEALTH ASSESSMENT FALL 2013 AGMSN

Identify essential components of the health history - correct answer a. Identifying data and source of the history b. Chief complaint - use "quotes" from patient c. Present illness - chronological order! • Medications, allergies, tobacco use, alcohol and drug use • 7 attributes (OLD CARTS) d. Past illness • Medical, surgical, Obstetric/gynecological, psychiatric • Health maintenance e. Family history f. Personal and social history g. Review of systems - Go through each one! Discuss scope of nursing assessment - correct answer Can be either: 1. Comprehensive Assessment 2. Focused Assessment What are the indications for and what is included in a Comprehensive Assessment? - correct answer a. Comprehensive assessment - a complete assessment. • Includes all elements of the health history and a complete physical assessment. • This is useful for new patients. • Gives a good baseline for future assessments. • Opportunity for health promotion. • Gives you a lot of information about the patient and also gives you time to build a relationship. What are the indications for and what is included in a Focused Assessment? - correct answer b. Focused assessment - is focused on the concern or the problem the patient presents with • Restricted to a specific body system or two • May be useful for an ongoing relationship once you established a baseline if there are no new concerns. Components of the Health History: Identifying Data and Source of the History; Reliability - correct answer a. Identifying data and source of the history: age, gender, occupation, marital status. Who is giving the information? How reliable is it? • Name/Age/Gender • Occupation • Marital status • Source of data (family member, parent) Gives you indication of reliability of the data Child vs. parent confused adult vs. the adult child or family member Components of the Health History: Chief Complaint(s) - correct answer b. Chief complaint: Symptoms that cause the patient to seek care • One or more symptoms causing them to seek care. • Use quotes from patient • Just a phrase Components of the Health History: Present Illness - correct answer c. Present illness: More details about the chief complaint. How long? What does it affect? How does the person feel? Have they done anything about it? • Amplifies the complaint • Symptoms—OLD CARTS Onset—when did it start Location Duration—how long Characteristics—what is it like? (burning, stabbing, etc.) Aggravating factors and Relieving factors Timing—when does it occur Severity—pain from 1-10? • Expands on the chief complaint • Describes how the symptoms develop • Thoughts and feelings about the illness • The "story" of the chief complaint • Medications • Allergies • Tobacco, alcohol and drug use Components of the Health History: Past History - correct answer d. Past illness: childhood illness, health practices. Medical, surgical, obstetrical/gynecological, psychiatric illnesses? Dates. • Childhood illnesses • Medical • Surgical • Obstetrical/gynecological • Psychiatric • Health maintenance practices Lifestyle Home safety Immunizations Screenings Components of the Health History: Family History - correct answer e. Family history: Genogram with health, illnesses, death, etc. Document the absence or presence of illnesses. Specifically ask about diabetes, cancers, HTN, CAD, heart disease, mental illness (especially things that are familial) • Genogram • Causes of death • Ages of death • Illnesses and health • Presence or absence of diseases - ask about key ones: Diabetes HTN CAD Genetics Components of the Health History: Personal and Social History - correct answer f. Personal and social history: educational level, family origin, current household, personal interests, lifestyle—alcohol, drugs? • Educational level • Family of origin, cultural influences • Who is in the household • Personal interests • Lifestyle • Sexual history-partners, frequency • Habits—drugs and alcohol • Nutrition, sleep, exercise • Religious preference • Military Components of the Health History: Review of Systems - correct answer g. Review of systems: go through each body system and document the presence and/or absence to each major body system. People forget things...so you will have to ask about each one and then examples of important illnesses or symptoms in each system. • Series of questions from head to toe: General (may include psychiatric) Skin HEENT (may include neurological) Neck Breasts Respiratory Cardiovascular Gastrointestinal Peripheral Vascular Urinary Genital Musculoskeletal Psychiatric Neurologic Hematologic Endocrine • Prepare the patient for the questions • Start general and then focus questions if there is a concern • Helps uncover problems the patient has overlooked • Be organized. Describe the steps of the process of gathering information - correct answer a. Prepare by considering your approach to the patient b. Professional dress and behavior c. Good lighting; Have all equipment ready d. Be organized, Taking notes? • Respect the patient - privacy, comfort e. Use a chronological and sequential approach f. Greet, establish rapport - Establish an agenda for the interview g. What is the patient's story? h. Respond to cues - Expand and clarify points Discuss interviewing techniques including ways to expand on client information. - correct answer a. Start with open ended questions to get the story of the symptoms b. Go to more specific questions related to the symptom c. End with yes/no questions about the symptoms d. Chronological! e. Techniques for interviewing: • Active listening • Empathetic responses • Guided questioning • Nonverbal communication • Validation • Reassurance • Partnering • Summarizing • Transitions • Empowering the patient Recognize ethical considerations in patient-examiner relationships - correct answer a. Cultural humility - self-awareness, respectful communication, collaborative relationships b. Sexuality - clinician and patient relationships c. Ethics and professionalism • Confidentiality • Non-maleficence or "first, do no harm" • Autonomy—patient's right to determine their care • Beneficence—provider needs to do good for the patient. d. Issues • Seduction • Anxiety • Excessive flattery • Financial concerns The "silent" patient - correct answer • Some issues may be painful to discuss • Tearful, unable to speak • Be attentive • Look for nonverbal cues • Are your questions too quick or offensive? "Altered" capacity - correct answer • Delirium, dementia or other health conditions • What is the decision making capacity? • Durable power of attorney or health care proxy? • Allow them to be fully involved to the limit of his/her ability. "Talkative" patient - correct answer • Let talk for 5-10 minutes and listen closely • Focus on what seems to be most important to the patient • Learn how to set limits when needed • Interrupt only if necessary "Crying" patient - correct answer • "I can see that you are not feeling well, it is alright to cry" • Silence or pausing • Gentle probing and respond empathetically • Be supportive • Give them a tissue Permission to cry "Confused" Patient - correct answer • Multiple symptoms • Neurological disorder? • Mental illness? • Dementia? • Intoxication? • Mental status exam • Family member help? "Angry" patient - correct answer • Face it • It may be displacement on to the HCP because of frustration, illness, or pain • Be calm • Avoid confrontation • No one is happy to be sick.... Describe the components of the clinical reasoning process - correct answer a. Clinical Reasoning - • This is what makes you a nurse - nursing is intellectual • Nurses make nursing diagnoses and use disease process to help with that b. Identify abnormal findings c. Localize findings anatomically d. Interpret findings in terms of a probable cause e. Make a hypothesis about the nature of the finding f. Test the hypothesis g. Develop a plan that is agreeable with the patient h. Use Evidence-based practice! 1. Identify the components of the general survey - correct answer a. Height and weight b. General appearance—by general inspection 2. Formulate health history questions for the general survey - correct answer a. Health history related to general survey • Changes in weight? • Fatigue and/or weakness? • Exercise, sleep, nutritional/diet history • Fever, chills, night sweats? • Pain? (use OLD CARTS) 3. Apply concepts of the general survey to patient situations: Height and Weight - correct answer a. Height and weight: • Height Measure in stocking feet Short or tall? Build (muscular? Slender?) Body symmetry and proportions/deformities • Weight Remove excess clothing and shoes Emaciated, slender, plump, obese? If obese, is fat distributed evenly or concentrated over trunk, upper torso, around the hips? Any rapid change in weight? (fluid retention?) • Calculating the body mass index (BMI) Normal BMI is 19-25. Obesity increases risk for HTN, DM, heart disease, stroke, sleep apnea, depression 3. Apply concepts of the general survey to patient situations: General Appearance - correct answer b. General appearance: • Apparent state of health Acute or chronically ill, frail Age appropriate? • Level of consciousness Awake, alert, responsive or lethargic, obtunded, comatose • Signs of distress Cardiac or respiratory; pain; anxiety/depression • Skin Lesions, turgor, color Sun exposure • Dress, grooming, and personal hygiene Appropriate to weather and temperature Clean, properly buttoned/zipped • Facial expression Eye contact, appropriate changes in facial expression Mood • Odors of body and breath • Posture, gait, and motor activity Blood Pressure (normal and abnormal) - correct answer • Normal < 120/80 • Pre- HTN 120-139/ 80-89 • HTN > 140/90 Stage I 140-159/ 90-99 Stage II >160/ >100 Heart Rate (normal and abnormal) - correct answer • Normal 60-100 Bradycardia < 60 Tachycardia >100 Respiratory Rate (normal and abnormal) - correct answer • Normal rate: 12-20 breaths/minute Tachypnea >20 Bradypnea < 12 Temperature (normal and abnormal) - correct answer • Average oral temperature:37°C or 98.6°F • Fever: 100.4°F or 38°C • Diurnal variation: 35.8°C - 37.3°C (96.4°F - 99.1°F) Pain (normal and ways to assess) - correct answer • Normal - No pain: 0 out of 10 • Ways to assess: Numeric Rating Scale - Rate pain from 0 - 10 Wong-Baker FACES Scale - used by children or patients with language barriers or cognitive impairment FLACC Pain Scale - for newborns or babies Level of consciousness (LOC) - correct answer how aware the person is of his environment Attention - correct answer the ability to focus or concentrate alert - correct answer patient is awake and aware lethargic - correct answer you must speak to the patient in a loud forceful manner to get a response obtunded - correct answer you must shake a patient to get a response stuporous - correct answer the patient is unarousable except by painful stimuli (sternal rub) coma - correct answer the patient is completely unarousable short-term memory - correct answer covers events or memories that occurred minutes to days before long-term memory - correct answer covers events or memories that occurred months to years before orientation - correct answer requires memory and attention - aware of person (who they are) - place (where they are) - time (when is it) perceptions - correct answer awareness of the objects in the environment to the five senses and their interrelationships (hallucinations?) thought processes - correct answer the logic, coherence, and relevance of a patient's thoughts as they lead to thoughts and goals; HOW people think insight - correct answer awareness that thought, symptoms, or behaviors are normal or abnormal; e.g. distinguishing that a daydream or hallucination is not real judgment - correct answer process of comparing and evaluating different possible courses of action affect - correct answer the observable mood of a person expressed through facial expression, body movements, and voice mood - correct answer the sustained emotion of the patient - euthymic: normal - dysthymic: depressed - manic: elated language - correct answer the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory higher cognitive functions - correct answer level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking Mental Status Examination - correct answer • Consists of the following components: Appearance and behavior Speech and language Mood Thoughts and perceptions Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability Assessing Cognitive Functions - correct answer • Assess orientation to person, place, and time • Assess attention Digital span: give the patient a string of numbers to recite back to you Serial 7s: ask the patient to subtract serial "7s" from 100 Spelling backward: ask the patient to spell W-O-R-L-D backwards • Assess remote memory by asking about past historical events • Assess recent memory by asking about something recent (weather, national event, etc.) • Assess new learning ability by giving the patient three or four words to remember; then ask him to repeat the words after several minutes Assessing Higher Cognitive Functions - correct answer • Through your conversation, you can often assess the patient's higher cognitive functions • Information and vocabulary • Calculating ability: ask the patient to perform more difficult calculations such as making change (e.g., if you had a dollar's worth of nickels and someone needed 65 cents how many nickels would you have left?) • Abstract thinking Interpreting proverbs: "A stitch in time saves nine" Similarity exercises: What do a ball and an orange have in common?