Milestone HESI Retake
Levels of Health Promotion - ANS primary, secondary, tertiary
Application Examples of Levels of Promotion - ANS primary- weight loss, diet, smoking cessation
Secondary- papsmears, mammograms, testicular exams
Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot care education to
diabetic care
Primary - ANS promotes health and preventing development of disease process or injury
Secondary - ANS screening for early detection of disease
Tertiary - ANS begins after illness is diagnosed and treatment. Aims to prevent long-term consequences
of chronic illnesses or disabilities
Nursing Assessments - ANS Comprehensive- (Head to Toe) = Can be done inpatient and through primary
care (Physical assessment- annual exam)
Focused- Health and physical hx of specific problem.- ex. Sick visit
Emergency- crisis, life threatening. ex. airway, breathing, injury, disability, exposure, med reconciliation
Phases of Interview process - ANS Pre-interaction, beginning, working (open and close ended questions),
closing
Data sources - ANS Primary- individual patient
Secondary- chart info, family members
,Purposes of Documentation - ANS verbal communication, SBAR, written document
Lifespan Nutritional Considerations - Nutrition: Pregnant Women - ANS need additional 300-500 cal/day
(whole foods
Lifespan Nutritional Considerations - Nutrition: infants/children - ANS infants/children: whole milk for
ages 2-5 fat intake-brain development
Lifespan Nutritional Considerations - Nutrition: Older - ANS BMR declines, Vitamin D supplements,
Problems: decreased thirst, increase risk for osteoarthritis, osteoporosis, dementia, obesity, social
isolation
General Survey - ANS mental note of overall health (hygiene/appearance). Assessing pain:
documentation, OLDCARTS/OPQRST. Aggravating and alleviating factors, pain goal and funtional goal
Assessing Pain - Documentation - ANS Acute vs. Chronic-Location
Priority - ANS Priority pain: stones (kidney, gallbladder, calcium and/or struvite), myocardial infarcation
(HA), burns and sickle cell
Heart Rate Elevated - ANS above 100 beats per minute
Blood Pressure- Normal - ANS above systolic- 120-129, diastolic- less than 80,
Blood Pressure- elevated - ANS Hypertension: Stage 1: 130-139 or 80-89, Stage Hypertension 2: more
than 140, or greater than or equal to 90
When should BP be taken? - ANS after patient rests for 5 minutues or 30 minutes after caffeine, smoking
, Assessment of the Head and Neck - ANS Inspect, palpate, auscultate
Infection - ANS If nodes are palpable, warm, tender = infection
Assessment of the Ear - Techniques - ANS Adults: up and back
Children: down and back
Assessment of the Ear - Techniques Part 2 - ANS observe behavioral responses to speech, inspect ear
formation (size, shape & any malformation to the auricle, condition)
Perform whisper test & Rinne test. Pt plug one ear at a time
Perform weber test (evaluate unilateral hearing loss
Assessing the Chest - ANS inspect, palpate, percuss, auscultate
Assessing Lung Sounds - Technique - ANS IPPA- inspect, palpate, percuss, auscultate
Normal Lung Sounds - ANS Normal: bronchial (heard anteriorly) over larynx and trachea (INSPIRIATION
slightly shorter than expiration),
Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION EQUAL ,
Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN EXPIRATION)
Abnormal lung sounds: Rhonchi - ANS low- heard mainly in expiration when pt is breathing out (made up
of one sound- whistle or whine and high pitch, musical instrument sound MULTIPLE sounds- mainly
heard in expiration CONDITION: PNEUMONIA
Levels of Health Promotion - ANS primary, secondary, tertiary
Application Examples of Levels of Promotion - ANS primary- weight loss, diet, smoking cessation
Secondary- papsmears, mammograms, testicular exams
Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot care education to
diabetic care
Primary - ANS promotes health and preventing development of disease process or injury
Secondary - ANS screening for early detection of disease
Tertiary - ANS begins after illness is diagnosed and treatment. Aims to prevent long-term consequences
of chronic illnesses or disabilities
Nursing Assessments - ANS Comprehensive- (Head to Toe) = Can be done inpatient and through primary
care (Physical assessment- annual exam)
Focused- Health and physical hx of specific problem.- ex. Sick visit
Emergency- crisis, life threatening. ex. airway, breathing, injury, disability, exposure, med reconciliation
Phases of Interview process - ANS Pre-interaction, beginning, working (open and close ended questions),
closing
Data sources - ANS Primary- individual patient
Secondary- chart info, family members
,Purposes of Documentation - ANS verbal communication, SBAR, written document
Lifespan Nutritional Considerations - Nutrition: Pregnant Women - ANS need additional 300-500 cal/day
(whole foods
Lifespan Nutritional Considerations - Nutrition: infants/children - ANS infants/children: whole milk for
ages 2-5 fat intake-brain development
Lifespan Nutritional Considerations - Nutrition: Older - ANS BMR declines, Vitamin D supplements,
Problems: decreased thirst, increase risk for osteoarthritis, osteoporosis, dementia, obesity, social
isolation
General Survey - ANS mental note of overall health (hygiene/appearance). Assessing pain:
documentation, OLDCARTS/OPQRST. Aggravating and alleviating factors, pain goal and funtional goal
Assessing Pain - Documentation - ANS Acute vs. Chronic-Location
Priority - ANS Priority pain: stones (kidney, gallbladder, calcium and/or struvite), myocardial infarcation
(HA), burns and sickle cell
Heart Rate Elevated - ANS above 100 beats per minute
Blood Pressure- Normal - ANS above systolic- 120-129, diastolic- less than 80,
Blood Pressure- elevated - ANS Hypertension: Stage 1: 130-139 or 80-89, Stage Hypertension 2: more
than 140, or greater than or equal to 90
When should BP be taken? - ANS after patient rests for 5 minutues or 30 minutes after caffeine, smoking
, Assessment of the Head and Neck - ANS Inspect, palpate, auscultate
Infection - ANS If nodes are palpable, warm, tender = infection
Assessment of the Ear - Techniques - ANS Adults: up and back
Children: down and back
Assessment of the Ear - Techniques Part 2 - ANS observe behavioral responses to speech, inspect ear
formation (size, shape & any malformation to the auricle, condition)
Perform whisper test & Rinne test. Pt plug one ear at a time
Perform weber test (evaluate unilateral hearing loss
Assessing the Chest - ANS inspect, palpate, percuss, auscultate
Assessing Lung Sounds - Technique - ANS IPPA- inspect, palpate, percuss, auscultate
Normal Lung Sounds - ANS Normal: bronchial (heard anteriorly) over larynx and trachea (INSPIRIATION
slightly shorter than expiration),
Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION EQUAL ,
Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN EXPIRATION)
Abnormal lung sounds: Rhonchi - ANS low- heard mainly in expiration when pt is breathing out (made up
of one sound- whistle or whine and high pitch, musical instrument sound MULTIPLE sounds- mainly
heard in expiration CONDITION: PNEUMONIA
