Cindy lambert Introduction to Health Assessment Assignment Chapter 1: Nurse’s Role in Health Assessment: Collecting and Analyzing Data 1. What is health assessment? A: Health Assessment is a plan of care that is used to identify specific needs and evaluate a person’s health status by performing a physical exam after taking a health history. To also see how those needs will be addressed by the healthcare system. 2. What is the nurse’s role in health assessment? A: It is the nurse’s role to gather information about a patient, to assess the patient, to be able to identify potential problems, and to act upon it. Not only that but to select and analyze data. 3. What is the nursing process? What are the steps? A: The nursing process is a systematic guide to client-centered care with 5 steps. These five steps are assessment, diagnosis, planning, implementation, and evaluation. 4. Define the four basic types of health assessment and an example of each. A: The four basic types of health assessment is the initial comprehensive assessment which deals with the 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 practice as well as objective data gathered during a step-by-step physical examination. An example would be in a hospital setting the physician usually performs a total physical examination when the client is admitted. Secondly, an ongoing or partial assessment consists of data collection that occurs after the comprehensive database is established. An example would be a partial assessment of a client admitted to the hospital with lung cancer requires a frequent assessment of respiratory rate, oxygen saturation, lung sounds, skin color, and capillary refill. Thirdly, a focused, or problem assessment which is used when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. An example would be if a patient tells you that they are having ear pain you would proceed to ask about the character and location of pain, onset, relieving and aggravating factors, and associated symptoms. Then from there, you would have a physical examination focused on ears, nose, mouth, and throat not on bowel movements because it would be deemed unnecessary. Lastly, an emergency assessment is a very rapid assessment performed in life-threatening situations. An example would be an evaluation of a patient’s airways, breathing, and circulation when cardiac arrest is suspected. Cindy lambert 5. What are the four major steps of the assessment phase of the nursing process? A: Nurses assess patients through four major steps which are to gather information about a patient's psychological, physiological, sociological, and spiritual status. Through conducting a patient interview, physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Chapter 2: Collecting Subjective Data: The Interview and Health History 1. What does the nurse need to understand about the process of communication? A: That this process is used to establish rapport for client and to also make them feel comfortable and ok with sharing private, accurate, and meaningful information. Not only that, it also used to gather holistic information from the patient that can be used to come up with treatments and etc to enhance nursing. 2. What are the phases of a client interview? What is the purpose for each phase? A: The four phases of a client interview are preintroductory, introductory, working, and summary/closing phases. The preintroductory phase is the phase where the nurse would review the client’s medical records before meeting them. Then you have the introductory phase where the nurse will introduce herself or himself to the client, to also explain the reason for 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. After that, you have the working phase which is when the nurse would then document 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 for current health problems, lifestyle and health practices, and developmental level. Lastly, you have the summary and closing phase which is when the nurse would go ahead and summarizes all information obtained during the work phase and to state the validity of the problems and to set up goals for the client. 3. How does age affect the interview process? A: As the body ages this slows down all body systems and which may vary depending on an elderly patient as well as some hearing loss due to these you will have to speak slowly and face the client at all times. The communication process Cindy lambert would be altered to better accommodate the patient. 4. How does culture affect the interview process? A: A client’s culture would affect the interview process due to the fact that everyone’s cultural background does not practice the same thing and have different meanings depending on that culture. For instance, in the American culture looking someone in the eyes is considered as showing respect but whereas another culture it could mean being disrespectful. Without the right knowledge of the cultural differences could lead to not being able to gain the client’s trust therefore not getting accurate information from the client. 5. How do emotional variations affect the interview process? A: Clients emotions can affect the interviewing process by not being able to confide or to give you a significant amount of information which could be unreliable due to them being emotional unstable possible because of things going on in their life, or their health status, or just the simple fact that they might not like having examinations. Whereas if the client was in a good emotional state then the healthcare workers’ job would be a little easier and will be able to obtain reliable information. 6. What is a complete health history? What are the components? A: a complete health history is a way to begin the assessment process because it provides the foundation for identifying nursing problems and provides a focus for the physical examination. The components of complete health history is 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, and developmental level. 7. What information should be included in the source of history? A: Client’s name, address, phone number, gender, and who provided the information— Cindy lambert the client or significant others. the client’s birth date, social security number, medical record number, health insurance information, or similar identifying data 8. What is the “reason for seeking care?” Difference between symptom and a sign? A: Reason for seeking care is a way for the client to explain the current health status or problem, to also address any concerns or lifestyle changes, and to get the client more focus on the most significant concern also known as a personal chief complaint. As well as to discuss the positive or negative affects regarding any fear that the client may be having and to be able to answer any health concerns. The difference between a symptom and a sign is that a symptom can only be described by that person who is experiencing that condition that is related to the symptom. Whereas, a sign is what someone else besides the person that is experiencing that condition notices or observes. 9. What is the present health or history of present illness (HPI)? What is the pneumonic COLDSPA? PQRSTU? A: It helps take into account several aspects of the health problem and asks questions whose answers can provide a detailed description of the concern as well as focusing on questions related to the client’s personal history, from the earliest beginnings to the present. Pneumonic COLDSPA AND PQRSTU are mnemonics used to help the nurse to explore and complete the assessment of the sign, symptom, or health concern. For example COLDSPA stands for character, onset, location, duration, pattern, and associated factors and which will be used to better explain the signs and symptoms of the condition. 10. What is included in personal (past) health history? Why is this information relevant to the nurse? Cindy lambert A: Included in a client’s personal health history is any childhood illnesses and immunizations to date, any past surgeries or accidents, allergies, and use of prescription and OTC medications. This information is relevant to assists the nurse in identifying risk factors that stem from previous health problems. 11. What is the significance of family history? Which relatives should family history be collected for? A: The significance of having a client’s family history is due to genetic predisposition and 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. The family history should be collected from maternal and paternal grandparents, aunts, and uncles on both sides, parents, siblings, and the client’s children. 12. What is the purpose of the review of systems? A: The review of systems is used to address each body system and any specific questions that the client may have that could elicit further details of current health problems or problems from the recent past that may still affect the client or that are recurring. 13. What is the purpose of assessing lifestyle and health practice beliefs? What does that include? A: The purpose is to describe how they are managing their lives, their awareness of healthy versus toxic living patterns, and the strengths and supports they have or use. This includes nutritional habits, activity and exercise patterns, sleep and rest patterns, selfconcept and self-care activities, social and community activities, relationships, values and Cindy lambert beliefs system, education and work, stress level and coping style, and environment. 14. How might the complete health history differ for infants & children? Adolescents? A: When trying to obtain health history for an infant primarily the parent would be the one to provide all the information related to the infant whereas a child would have little knowledge of some of their own health but parents would still be responsible for providing information on their behalf. Adolescents on the other hand are considered able and responsible enough to give information about their health and are preferred for them to be alone when asking about sexual health, recreational drug use, mental health. Chapter 3: Collecting Obective Data: The Physical Examination 1. How does the nurse prepare him/herself for the physical exam? A: They would prepare themselves by achieving self-confidence in performing a physical assessment by practicing the techniques on a classmate, friend, or relative. Also to encourage there pretend client to simulate the client role as closely as possible, and to perform some of your practice assessments with an experienced instructor or practitioner who can give you helpful hints and feedback on your technique. Another would also to practice preventing the transmission of microorganisms. 2. How does the nurse prepare the physical environment for the physical exam? A: The nurse would make sure to prepare a comfortable, warm room temperatureprovide a warm blanket if the room temperature cannot be adjusted, a private area free of interruptions from others- Close the door or pull the curtains if possible, quiet area free of distractions - turn off the radio, television, or other noisy equipment, adequate lighting- It is best to use sunlight or a portable lamp (when available), firm examination table or bed at a height that prevents stooping- a rollup stool may be useful when it is necessary for the examiner to sit for parts of the Cindy lambert assessment, and a bedside table/tray to hold the equipment needed for the examination. 3. How does the nurse prepare the client for the physical exam? A: The nurse would need to start off with establishing the nurse-client relationship during the client interview before the physical examination takes place, select a time when the client is comfortable and receptive to the exam, build rapport with the patient, ask the client to void before the exam, pay attention to the pace of the exam and rest if necessary, pay attention to cultural and developmental differences, ask family and friends to leave if they are a distraction. 4. What are standard precautions that should be utilized with all patients? A: The standard precautions to utilized with all patients would be to make use of general practices such as practicing hand hygiene and wearing personal protective equipment which is used to protect healthcare providers from infection and prevent the spread of infection from patient to patient. Also by wearing gowns when dealing with or being exposed to any blood or bodily fluids from a patient. 5. What are the physical exam (assessment) techniques, include a one sentence description of each. A: The physical examination techniques are inspection- is a visual examination of the patient, palpation - is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. , percussion -is tapping the patient's bodily surfaces and hearing the resulting sounds to determine the presence of things like air and solid masses affecting internal organs, and auscultationis listening to an area of the body using a stethoscope. Cindy lambert 6. How does age affect the physical exam? A: Chapter 4: Validating and Documenting Data 1. What is the significance of validating client data? The process? A: Validation of data is the process of confirming or verifying that the subjective and objective data you have collected is reliable and accurate. The process of validation includes deciding whether the data requires validation, determining how to validate the data, and identifying areas for where you think data may be missing from. 2. What situations require client data to be rechecked or verified? A: Client data needing to be rechecked or verified would stem from discrepancies or gaps between the subjective and objective data as well as the information that was told by the client. Also when there are indications of high abnormalities and/or inconsistent with other findings. 3. Why is documentation of client data necessary? A: The reason why client data is necessary is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. Not only that but to identify health problems, make a nursing diagnosis, and to plan Cindy lambert solutions for ongoing interventions. 4. What are the types of assessment forms? A: The three types of assessment forms are initial assessment form, frequent/ongoing, and focused or specialty form. 5. What is SBAR? How is used? Why is it important? A: The SBAR which stands situation, background, assessment, recommendation model of communication is used to show a steady way to communicate assessment data. Not only that, but it also states the situation, background, assessment, and recommendation from health care providers to a healthcare provider. Chapter 5: Thinking Critically to Analyze Data and Make Informed Nursing Judgments 1. What is critical thinking? How do nurses use it to formulate clinical judgments? A: is a way to form reasoning and to evaluate situations. They use this data in the diagnostic process and is how they formulate clinical judgments. 2. What are the steps of data analysis? A: The steps of data analysis are identify strengths and abnormal data, cluster data, draw Cindy lambert inferences, and propose possible nursing diagnoses. 3. What is the end result of data analysis? 4. What is a nursing diagnosis? What are the types? Provide an example of each. 5. What are collaborative problems? Chapter 7: Assessing Psychosocial, Cognitive, & Moral Development 1. Summarize each developmental theory (Freud, Erikson, Kohlberg, and Piaget). A: Freud’s developmental theory was based upon the idea that parents play a crucial role in managing their children’s sexual and aggressive drives during the first few years of life in order to foster their proper development. Erikson’s developmental theory was based upon Freud’s controversial theory of psychosexual development and was changed to be a psychosocial theory. Erikson emphasized that the ego makes positive contributions to development by mastering attitudes, ideas, and skills at each stage of development. This was to believed to have help children grow into successful, contributing members of society. Kohlberg’s developmental theory was believed that moral development had stages and that when focusing on those stages it also helped to build our cognitive development. Also was a way for an individual reason about a dilemma in a positive way. Piaget developed a cognitive-developmental theory based on the idea that children actively construct knowledge as they explore and manipulate the world around them through four stages of development which were formal operational, concrete operational, preoperational, and sensorimotor. Chapter 8: Assessing General Health Status & Vital Signs Cindy lambert 1. What is a survey of general health status (general survey). What are the components? A: A general survey is the first part of the physical examination that begins the moment the nurse meets the client. The components are physical appearance, body structure, mobility, and behavior. 2. What are vital signs? A: Vital signs are a common way of taking a physical assessment procedure that most clients are accustomed to. It also provides data that shows the status of several body systems, including but not limited to the cardiovascular, neurologic, peripheral vascular, and respiratory systems. 3. What is normal temperature? What are the ways it can be measured? Influencing factors? A: A normal temperature is from 97°F to 99°F, but mainly 98.6°F. Temperature can be measured by mouth, ear, armpit, and rectum. It can also be measured on your forehead. Thermometers show body temperature in either degrees Fahrenheit (°F) or degrees Celsius (°C). Some influencing factors can be age, sex, time of day, exercise, stress, meals, drugs and smoking, and etc. 4. What is a pulse? What is the “normal”? What should the nurse measure when assessing pulse? How is pulse documented? A: A pulse is a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck. The normal pulse is 60 to 100 beats per minute. A pulse should be documented by using the fingertips and intensity of the pulse graded on a scale of 0 to 4 5. How should the nurse assess and document normal respirations? Cindy lambert 6. What is blood pressure? What are factors that influence blood pressure? 7. What are additional techniques that may be assessed with vital signs? Chapter 9: Assessing Pain: The Fifth Vital Sign 1. What is pain? A: Pain is an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage or in other terms when a patient says they are in pain. 2. How does pain develop? A: When we feel pain, like touching a hot stove, sensory receptors in our skin send a message via nerve fibers (A-delta fibers and C fibers) to the spinal cord and brainstem then to the brain where the feeling of pain is registered, the information is processed and therefore the pain is perceived. 3. What are the sources of pain? A: Pain stems from damage to the tissues such as the skin, muscle, tendons, bones, and ligaments. 4. What are the types of pain? A: The different types of pain are as followed acute pain, chronic nonmalignant pain, cancer pain, intractable pain, cutaneous pain, visceral pain, deep somatic pain, and phantom pain. 5. Does developmental competence influence pain? If yes, how? A: Yes it does influence pain because, for example, someone who is physically, mentally, and emotionally stable would handle pain a lot more better than someone who is physically, mentally, and emotionally unstable. Cindy lambert 6. Are there gender differences related to pain? A: Yes gender differences do relate to pain. According to the book men or more tolerable to pain than females because men have more pain-relieving hormones in their bodies. 7. What is the best assessment indicator of pain in an adult? A: The best assessment of pain for an adult would be an individual self-assessment basically going based of what that client stated their pain levels were.
