Comprehensive Health Assessment
What are the 3 components of health assessment? - ANSHealth history, physical
examination, documentation
What types of data are collected in health assessment? - ANSSubjective data: Known as
symptoms, the data that is obtained from the patient in the health history.
Objective data: Also known as signs. The data that is obtained from the physical
examination of the patient after subjective is collected.
What are signs vs. symptoms? - ANSSigns are observed, felt, heard, measured. Ex, rash,
enlarged lymph nodes ans swelling.
Symptoms: perceived and reported by the patient. Ex: pain, itching, nausea.
What are the three levels of prevention? - ANSPrimary prevention: prevent a a disease from
developing through the promotion of healthy lifestyles.
Secondary prevention: screening efforts to promote early detection of disease.
Tertiary prevention: minimizing the disability from acute or chronic disease or injury and
helping the patient to maximize death.
Cultural Competence - ANSNurses who are culturally competent have the ability to respect
patients as unique persons; to assess their beliefs, values, preferences and needs; and to
determine the meaning of their illness
Cultural Competence-Knowledge - ANSgaining info about cultural differences and values
that can be acquired through training and education and by talking with people from different
cultures about their beliefs and practices.
Cultural Competence-Consideration - ANSimplemented after knowledge, acquired when
nurses use knowledge of patients' and others' languages, practices, and customs in
providing care
Cultural Competence-Understading - ANSinvolves thoughtful consideration of the effects
and importance of another's values and experiences
Cultural Competence-Respect - ANSis communicated when nurses show appreciation and
regard for patient's cultural differences and for other nurses with whom they work
Cultural Competence-Tailoring - ANSadapting interactions based on cultural practices and
beliefs of others
What are all the components of a health history? - ANSBiographic data, Chief Complaint
(CC) or reason for seeking care, History of Present Illness (HPI), Present Health Status,
Past Health History, Personal & Psych. History Family History, ROS
, Sources of data and reliability of informant - ANSThe patient or a family member, patient is
very reliable but a family member may not be as reliable.
Comprehensive Health History - ANSdetailed history and physical examination performed at
the onset of care in a primary care setting or on admission to a hospital or long term care
facility
Problem-based/focused Health History - ANSinvolves a history and examination that are
limited to a specific problem or complaint
(e.g. sprained ankle). Most commonly used in walk in clinics or the emergency department
Episodic/follow up Health History - ANSusually done when a patient is following up with a
health care provider for a previously identified problem. Ex: patient treated for pneumonia
asked to return after a completed treatment of antibiotics. Also someone with diabetes will
be asked to return for regular visits.
Shift Health History - ANSnurses conduct assessments each shift. Purpose is to identify any
changes in a patient's condition from baseline. Based on the problem the patient is
experiencing
Screening Health History - ANSshort exam focused on disease detection. Performed in a
health care provider's \office or a health fair. Ex: BP screening, glucose-screening,
cholesterol screening, and colorectal screening.
Communication techniques that enhance or diminish data collection - ANSEnhance: Active
listening, facilitation (encourage patients to continue talking, ex: go on? Then? Head
nodding), Clarification (What do you mean by..?), restatement, reflection (asking the patient
to clarify the statement they said), confrontation (when inconsistencies are noted between
the patient report and the objective data), interpretation (conclusions of the data they have
drawn from the patient), summary (condenses and orders data obtained)
Diminish: : Using medical terminology, expressing value judgements (you do use protection
during intercourse, don't you? That's being judgmental), interrupting the patient, being
authoritarian or paternalistic ( I know what is best for you and you should do what I say),
using "why" questions
What is Doppler? - ANSAmplifies sounds difficult to hear with an acoustic stethoscope.
Ultrasound basically. Vascular sounds
What is pulse oximeter? - ANSused to measure oxygen saturation in arteriole blood,
consists of a LED probe connected by a cable to a monitor which shines light that reflects off
oxygenated and deoxygenated hemoglobin in blood
Blood pressure cuff - ANScome in a variety of sizes, you need to select a cuff that is the right
size for the patient to get an accurate reading. If too wide it underestimates the BP, if it is too
narrow it overestimates the BP. The cuff should be 40% of the circumference of the limb, and
the bladder should encircle 80% of the upper arm
What are the 3 components of health assessment? - ANSHealth history, physical
examination, documentation
What types of data are collected in health assessment? - ANSSubjective data: Known as
symptoms, the data that is obtained from the patient in the health history.
Objective data: Also known as signs. The data that is obtained from the physical
examination of the patient after subjective is collected.
What are signs vs. symptoms? - ANSSigns are observed, felt, heard, measured. Ex, rash,
enlarged lymph nodes ans swelling.
Symptoms: perceived and reported by the patient. Ex: pain, itching, nausea.
What are the three levels of prevention? - ANSPrimary prevention: prevent a a disease from
developing through the promotion of healthy lifestyles.
Secondary prevention: screening efforts to promote early detection of disease.
Tertiary prevention: minimizing the disability from acute or chronic disease or injury and
helping the patient to maximize death.
Cultural Competence - ANSNurses who are culturally competent have the ability to respect
patients as unique persons; to assess their beliefs, values, preferences and needs; and to
determine the meaning of their illness
Cultural Competence-Knowledge - ANSgaining info about cultural differences and values
that can be acquired through training and education and by talking with people from different
cultures about their beliefs and practices.
Cultural Competence-Consideration - ANSimplemented after knowledge, acquired when
nurses use knowledge of patients' and others' languages, practices, and customs in
providing care
Cultural Competence-Understading - ANSinvolves thoughtful consideration of the effects
and importance of another's values and experiences
Cultural Competence-Respect - ANSis communicated when nurses show appreciation and
regard for patient's cultural differences and for other nurses with whom they work
Cultural Competence-Tailoring - ANSadapting interactions based on cultural practices and
beliefs of others
What are all the components of a health history? - ANSBiographic data, Chief Complaint
(CC) or reason for seeking care, History of Present Illness (HPI), Present Health Status,
Past Health History, Personal & Psych. History Family History, ROS
, Sources of data and reliability of informant - ANSThe patient or a family member, patient is
very reliable but a family member may not be as reliable.
Comprehensive Health History - ANSdetailed history and physical examination performed at
the onset of care in a primary care setting or on admission to a hospital or long term care
facility
Problem-based/focused Health History - ANSinvolves a history and examination that are
limited to a specific problem or complaint
(e.g. sprained ankle). Most commonly used in walk in clinics or the emergency department
Episodic/follow up Health History - ANSusually done when a patient is following up with a
health care provider for a previously identified problem. Ex: patient treated for pneumonia
asked to return after a completed treatment of antibiotics. Also someone with diabetes will
be asked to return for regular visits.
Shift Health History - ANSnurses conduct assessments each shift. Purpose is to identify any
changes in a patient's condition from baseline. Based on the problem the patient is
experiencing
Screening Health History - ANSshort exam focused on disease detection. Performed in a
health care provider's \office or a health fair. Ex: BP screening, glucose-screening,
cholesterol screening, and colorectal screening.
Communication techniques that enhance or diminish data collection - ANSEnhance: Active
listening, facilitation (encourage patients to continue talking, ex: go on? Then? Head
nodding), Clarification (What do you mean by..?), restatement, reflection (asking the patient
to clarify the statement they said), confrontation (when inconsistencies are noted between
the patient report and the objective data), interpretation (conclusions of the data they have
drawn from the patient), summary (condenses and orders data obtained)
Diminish: : Using medical terminology, expressing value judgements (you do use protection
during intercourse, don't you? That's being judgmental), interrupting the patient, being
authoritarian or paternalistic ( I know what is best for you and you should do what I say),
using "why" questions
What is Doppler? - ANSAmplifies sounds difficult to hear with an acoustic stethoscope.
Ultrasound basically. Vascular sounds
What is pulse oximeter? - ANSused to measure oxygen saturation in arteriole blood,
consists of a LED probe connected by a cable to a monitor which shines light that reflects off
oxygenated and deoxygenated hemoglobin in blood
Blood pressure cuff - ANScome in a variety of sizes, you need to select a cuff that is the right
size for the patient to get an accurate reading. If too wide it underestimates the BP, if it is too
narrow it overestimates the BP. The cuff should be 40% of the circumference of the limb, and
the bladder should encircle 80% of the upper arm
