Unit 1 Outline
Chapter 1 Nurse’s Role in Health Assessment
Things to Know
Role of Professional Nurse
4 main goals of nursing
Scope and Standards of Practice
Code of Ethics
Care Responsibilities
Managing Care
Member of a Profession
RN vs APRN
Registered nurse education
ADN, Diploma, BSN
NCLEX
APRN education
BSN, MSN, Doctorate
Nurse Practitioner, Certified Nurse Midwife, Certified Registered Nurse Anesthetist,
Clinical Nurse Specialist
Nursing and Health Promotion
Wellness and Illness
National model for health promotion, risk reduction-Healthy People
Interventions Promoting Healthy Change
Primary
Secondary
Tertiary
What is Health Assessment
“Gathering information about the health status of the patient, analyzing and synthesizing those
data, making judgments about nursing interventions based on the findings and evaluating
patient care outcomes” (AACN, 2011)
Nursing Process
Assessment
Nursing Diagnosis
Plan
Implement
Evaluate
Requires critical thinking and diagnostic reasoning
Common Types of Assessments/Data bases
Emergency
Comprehensive assessment
Focused
Follow-up
Reexamination of a medical problem
Acute: surgery, sutures, I&D
Chronic: HTN, Diabetes, Asthma, Renal Failure
Prioritizing Care
Emergent or life threatening: ABCs, severely abnormal vital signs
High Priority: Require prompt intervention. (mental status changes, acute urinary problems,
untreated medical problems, abnormal laboratory values, risks of infection, or risk to
safety or security.
Low Priority: Chronic illness, allergies
Frequency of Assessment: based on patient condition and needs
Components of the Health Assessment
Subjective Data
Objective Data
Documentation and Communication
Documentation is essential
Legal
Communication with other providers
Various forms and formats
Confidentiality is essential
Frameworks for Health Assessment
Gordon’s Functional Health Patterns
Head-to-toe assessment
Body systems approach
Erikson’s Developmental Stages
Evidence-Based Practice
Chapter 2 The Health History and Interview
Purpose
Subjective Data
The Communication Process
Non-verbal Communication Skills
Verbal Communication Skills
Active listening
Restatement (patients words)
Reflection (summarize)
Elaboration (facilitation)
Silence
Focusing (redirect)
Clarification (find meaning)
Summarizing
Non-Therapeutic Communication
False reassurance
Sympathy
Unwanted advice
Using leading or biased questions
Changes of subject
Distractions
Technical or overwhelming language (professional jargon)
Interrupting
Why questions
Professional Boundary
Intercultural Communication
Space and distance
Intimate zone 0-1 ½ ft
Personal zone 1 ½ - 4 ft
Social zone 4 – 12 ft
Public zone 12+ ft
Etiquette
Use of an interpreter
Gender and sexual orientation
Phases of the Interview Process
Preinteraction Phase
Beginning Phase
Working Phase
Closing Phase
Closed or direct questions
Health History Sources
Primary Sources
Secondary Sources
Reliable Sources
Components of a Comprehensive Health History
Biographic data
Occupation
Chief Complaint
History of Present Illness or Symptom Analysis
Location
Quality
Quantity
Timing (onset, duration, frequency)
Setting
Aggravating or Alleviating Factors
Associated factors
Patient Perception
Past medical history (chronic medical problems, surgeries, hospitalizations, pregnancy)
Current medications
Family history (chronic medical problems)
Social history (smoke, drink, illegal drugs)
Review Of Body Systems
Functional assessment (nutrition, coping, self-concept, ADLs, sexuality, etc.)
Chapter 3 Physical Examination Techniques and Equipment
Objective Data
Hand Hygiene
Inspection
Palpation
Types of Palpation
Light <1cm
Moderate 1-2 cm
Deep 2.5-5 cm
Bimanual
Percussion
Methods of Percussion
Sound Production
Classification of Percussion Tones
Auscultation
Age Specific Exams
General Approach
Position
Sequence
Preparation
Chapter 4
Documentation
Know documentation tips
Know components of health history form
N314 Class Activities
Subjective/Objective Data & Data Bases (Types of Assessments)
Case 1: Ms, Hy Sugar, known to the health care provider, comes to the local diabetes center. The last
visit was 6 months prior to this visit. She brings a record of blood glucose levels and insulin doses for the
past 6 months. When asked how she has been feeling, she states she had a sore elbow form playing
tennis 2 weeks ago but otherwise feels well.
Subjective:
Objective:
Types of Assessment/Data base:
Case 2: BK Biker is brought to the ER complaining of a sore shoulder. He states that he was forced off the
road while riding his motorcycle and sideswiped a telephone pole. BK did not lose consciousness. A
urine specimen reveals gross hematuria. BK also states that a tape player in the right pocket of his
leather jacket is shattered.
Subjective:
Objective:
Types of Assessment/Data base:
Case 3: Mr. Hy Blood is a 65-year-old African American man who comes into the clinic for periodic health
visits. He has a history of hypertension. During the visit, he has no other complaints other than having to
wake up frequently to urinate.
Subjective:
Objective:
Types of Assessment/Data base:
Case 4: Ms. Complainita, known to the health center, calls for an emergency appointment. She is
complaining of a sore throat and an earache. Upon examination both the pharynx and eardrum are
reddened.
Subjective:
Objective:
Types of Assessment/Data base:
Symptom Analysis
1.
Match the symptom criteria on the left with the appropriate question on the right.
_____1.
_____2.
_____3.
_____4.
_____5.
2.
setting
quality
location
alleviating factors
perception
a.
b.
c.
d.
e.
“show me where it hurts”
“what were you doing when it began”
“what makes it better”
“what does it feel like”
“why do you think it started”
One of Mr. Bush’s chief complaints is abdominal pain. Match the criteria in Column A with the data
in Column B.
Column A
_____ 1.
_____ 2.
_____ 3.
_____ 4.
_____ 5.
_____ 6.
_____ 7.
_____ 8.
_____ 9.
_____10.
Location
Quality
Onset
Quantity
Duration
Aggravating Factors
Associated factors
Frequency
Alleviating Factors
Perception
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Column B
The pain is a 7 on a 1-10 scale
The pain started about 3 months ago
It feels like a knife
It lasts about an hour
I get nauseated when it occurs.
It comes at least once or twice a week
It’s always in the LLQ
It’s worse after I’ve stayed all night
I think I have a stress ulcer.
I feel better after taking Pepto-Bismol
3.
Your patient complains of difficulty breathing. Write a symptom analysis in paragraph form.
4.
Phases of the Interview
Following are examples of a nurse’s comments during an interview. Place these comments in the
correct sequence.
_____
“Mr. Ima Pain, you have identified the following health concerns: intermittent
numbness and tingling in your left leg, the need to control low back pain and the desire
to perform ADLs with minimal discomfort”
_____
“Now let us move to a nice, quiet place.”
_____
“Hello, may name is Jan Painless. I am your nurse for the day.”
_____
“Mr. Pain, is your low back pain associated with exercise or activity changes?”
Communication Techniques
Match the question or technique on the left with the appropriate example on the right.
5.
_____ 1.
Directive question
a.
_____ 2.
Reflection
b.
_____ 3.
Empathy
c.
_____ 4.
_____ 5.
Clarification
d.
Open-ended question e.
6.
“I can see you are angry. Would you like to talk
about what’s bothering you?”
“You say you feel anxious. Tell me what you
mean.”
“I see you’re holding your stomach. Are you
experiencing any pain?”
“Have you had any problems with headaches?”
“Tell me about the problem you are experiencing.”
A male client in an auto accident has been experiencing back pain for 2 ½ years. He is describing his
pain and anxiety about his disabled state to the nurse. Match the non-therapeutic communication
to the response.
_____1.
_____2.
_____3.
_____4.
_____5.
7.
“Oh, don’t worry, it will be alright
as time passes.”
“Chiropractic care is wonderful for
bad backs.”l
“Are you on a special diet?”
“You’re not a risk-taker, are you?”
“Do you need information about filing
for disability?”
a.
Biased question
b.
Giving advise
c.
d.
e.
False reassurance
Jumping to conclusions
Changing the subject
Identify what type of question the examples illustrate.
a. “Tell me what brings you here today?”
b.
“How old are you?”
c.
“Have you experienced any problems with headaches in the past?”
8.
Patient:
Nurse:
Communication Techniques
I was sick during the night.
Use an open ended statement
Use a direct question.
9.
Patient:
Nurse:
I am afraid of Chemotherapy (frightened look on face).
Reflection
10.
Patient:
Nurse:
The doctor is trying to kill me.
Confrontation
11.
Patient:
Nurse:
I feel so sick. My hand is numb and pain runs up my arm.
General lead (facilitation)
12.
Patient:
Nurse:
The doctor is trying to kill me.
Clarification
13.
Patient:
I have so much to do. I take care of my elderly parents and work
and school seems to never end.
Empathy
Nurse:
Assessment Techniques
1.
Identify the 4 physical assessment techniques and their use in the clinical setting.
2.
Identify the two end pieces of the stethoscope, the sounds that are best heard with each piece,
and give an example of these sounds.
3.
Mr. Wilson arrives at the ER complaining of severe abdominal pain for one hour. His wife reports
that he fell from a tree while pruning after he heard a scream from Dennis. Mr. Wilson was
briefly knocked unconscious. Based on this information, what three major body systems would
you assess as a priority for Mr. Wilson and why?
4.
Identify the 5 percussion sounds, their quality, and location