Health Assessment: Types of Assessment, Interviewing Phases, Communication Skills, and Mental Status, Exams of Nursing

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HEALTH ASS BLUEPRINT EXAM WITH COMPLETE SOLUTIONS Chapter 1: Types of Assessment ie initial comprehensive assessment, etc. • Initial: subjective, objective; ROS, history, Lifestyles/health practices • Ongoing/Partial: occurs after database est.; Reassessment; readmitted for the same problem • Focused/problem-oriented: performed in relation to a specific health concern; what is the current problem • Emergency: VERY rapid; performed in life-threatening situations o Ex) weakness on one side, cardiac arrest Nursing Process • Assessment: collect data o Prepare for the assessment o Collect subjective/ objective data o Validate the information o document • Diagnose: analyze data; make dx • Planning : plan of care; determine outcomes; what is the goal and timeframe • Implement: carrying out the plan; monitor • Evaluate: assess whether outcomes has been met; revise if necessary Difference between medical and nursing assessment • Medical dx: looks at the pathological cause/ disease • Nursing dx: looks at the response to the health status; look at the functional ability of the pt Chapter 2: Interviewing phases Introduction: • Purpose; who you are, what is occurring, what is your role; INTRO; let pt know you will be taking notes • Confidentiality; make pt comfortable; environment private • Develop trust and rapport Working – SUBJECTIVE DATA • Getting the information from the actual interview • Documentation: health insurance, beliefs, understandings, family contact • Reason for seeking care; Hx of present health concern • PH, FH, ROS, Lifestyles/health practices Summary/Closing • Summarize info: “this is what you told me” • Validates problems and goals; ID possible plans • Q&A; agreement to information, plan, objectives Communication/Interview skills – verbal and nonverbal – effective and ineffective Effective: - one question at a time Active listener: pay attention, face the patient, sit during interview, maintain eye contact; look interested Guided questioning • Open ended questions • Graded questions: how many/how much…-range of amount • Multiple choice questions: is the pain sharp or dull; is it constant or intermediate (this may min. the pt responses/ max distorted information) • Clarify : ask pt to clarify something you may be unsure about • Encouragement : “uh huh”: look at them when they are speaking- take notes of importance • Reflection : pt responds: “pain got worse and spreading now” Nurse responds: “spread…?” --> use the pt’s language; what do you mean by…. Nonverbal communication: posture, facial expressions; your behavior during the interview Empathetic responses: NOT: “I am sorry about your mom’s death”; YES: “It must be very heartbreaking for you.” HEALTH ASS BLUEPRINT EXAM WITH COMPLETE SOLUTIONS Validation: acknowledge what is occurring; ask about how the patient feels Reassurance: “it is okay to feel like this” when a patient feels angry or in denial Summarization: this is what the pt told the nurse; how the nurse interprets it; pt should correct the nurse if needed Transitions: “now I am going to ask you questions about...” Empowering the patient: nurse encourages pt to feel in control; help pt deal w/ situation; EXPLAIN everything Ineffective: Do not use LEADING questions: it did happen to you yesterday, right? False assurance: “everything will be okay” Unwanted advice: do not give advice Using authority: sounding like you are demanding the pt Use of Avoidance lang.: Engaging in distancing: Professional jargon: explain in laymen terms unless pt is capable of understanding Talking too much/interrupting Using “why” questions How/when to use different types of questions Open-ended: What happened today; tell me what the problem is Closed-ended: did this happen to you yesterday? Laundry list: choice of words to choose from Rephrasing: clarify the information the client is providing Well-places phrases--> encouragement skill: “yes, I see”; “I agree” Inferring: do not lead rather get more information: “it seems you have more difficulty w/ your …”; use the pt’s words Providing information: answer every question the pt; be honest if do not know the answer Focus question: more specific toward the problem: So you woke up short of breath; has this happened before? How to deal with anxious, angry, depressed, manipulative patient Anxious • Structure info • Explain who you are, your role, and purpose of visit • Questions = simple/concise • Nurse needs to stay Relax • Do not hurry; decrease external stimuli Angry • Calm, in-control mannerisms and tone o Let patient vent o If excessive, do not touch or argue back • Obtain info from other health professionals as much as needed • Do not argue back; provide personal space Depressed • Show interest and understanding to client and situation • Do not be upbeat or encouraging Manipulative • Provide structure and limitations • Fine line b/w manipulative and reasonable requests What constitutes as subjective data • ANYTHING elicited by the patient; must be verified by the patient • ROS for current health problem: need to ask about the specific systems • Lifestyle and Health practices: o Nutrition/ weight management: meals of the past 24 hrs --Self-concept/self care/relationships o Activity level/exercise/ social activities -- values and beliefs o Sleep and rest: naps? -- edu/work; stress levels/coping o Medication and substance use/ herbal preps HEALTH ASS BLUEPRINT EXAM WITH COMPLETE SOLUTIONS • ID areas where more data is needed o Ex) pt weighs 98lbs: want to know if pt has lost weight or this has been normal for some time o Ex) pt tells you he lives alone: want to know if he has a support group, ability to function alone Documentation Purpose: • Chronological source, prevents repetition, helps w/ dx,, determines edu. & teachings, eligibility for reimbursement, legal record What do you document: • Subjective/ Objective data: sub- if there is nothing write DENIED • Present health concern via COLDSPA • Follow health hx: PH, FH, lifestyle/health practices Guidelines: • Legible w/ non-erasable ink or print; correct grammar/spelling; Abbreviations approved by institution • Wordiness will create redundancy • Phrases not sentences • Record findings not method of obtaining; what you see; judgment free • Record pt’s understanding and response to info/tx • Do not use “normal” Chapter 5: Analyze data • Critical thinking o ID abnormal data and strengths of pt o Cluster data o Draw inferences o Purpose possible nursing dx check for defining characteristics; confirm/rule out dx o Document conclusions • Similar to ADPIE o Assess areas of concern and strengths o Dx based on abnormal findings and pt’s abilities o Plan what outcomes and expectations via the dx; implement plan Interventions come from the problem o Evaluate and document Chapter 6: Mental status • One’s orientation and consciousness o Orientation: person, place, time, situation – looking for cognitive consciousness ▪ Orientation to time is the 1st to be lost ▪ Orientation to person is the 2nd to be lost • Mental Health assessment o Observe the pt; ask them questions How to assess dementia, delirium • Looking for Dementia Mini Mental SLUMS Montreal CAM • Not early dementia • Test for dementia; outdated- not preferred • Use when pt is disoriented • No Executive Functioning • No consideration for age, culture • Early Dementia • Considers edu. level, language, age • Executive functioning • Considers edu level • Early signs of Alzheimer’s dementia • Executive function • Mild cog impairment • Spatial component • Acute onset • Inattention • Disorganized thinking • Altered level of consciousness • Based on OBSERVATION • Talk w/ pt; observe attentiveness; thought process; confusion; consciousness • IDs DELIRIUM Alzheimer’s Guide • All Alzheimer is dementia; not all dementia is Alzheimer • Lose executive functioning • Repeatedly ask the same questions o Pt consistently asks the same questions about the same topic/situation o Caregiver/families need to constantly remind pt how and what to do • lost/disoriented to places and of time; cannot follow directions • Do not recognize family • Difficulty performing routine tasks • Neglects personal hygiene • CANT RECALL RECENT EVENTS; remembers remote events Dementia vs. Alzheimer Dementia • Not consistent memory lost of recent information- more forgetfulness • Pathological process that can be “fixed”; cause of the forgetfulness o Ex) Thyroid problem; kidney failure; diabetes – can CAUSE the pathological process of forgetting Alzheimer • Don’t remember anything of recent memory; consistent recent memory loss Health Assessment Chapter 7: General Survey • Apparent state of health : general observation for acute (focused assess.) or chronic illness (full assess.) • Level of consciousness: stages of consciousness o Alertness: speaking to pt in normal tone ▪ eyes are open, pt looking at you, responds fully and appropriately o Lethargy: Speaking to pt in loud voice-call pt’s name; “how are you” ▪ Pt= drowsy; eyes open; looks at you; responds to questions but then falls asleep after o Obtundation : (dull) speak in loud voice; shake pt gently ▪ Pt opens eyes and looks at you; responds slowly; somewhat confused ▪ Alertness and interest in environment = decreased o Stupor: (dazed state; unconscious) Apply painful stimuli ▪ Arouses ONLY from PAINFUL stimuli ▪ Verbal responses are slow/absent ▪ Lapses into an unresponsive state when stimulus stops ▪ Minimal awareness of self or environment o Coma : Apply repeated painful stimuli ▪ Remain unaroused w/ eyes closed; no evident response to inner need or external stimuli 1. Decorticate rigidity: arms flexed tight to body; legs extended; rotated inward- corticospinal issue 2. Hemiplegia: sudden unilateral brain damage; one side is paralyzed 3. Decerebrate rigidity: jaw clenched; neck extended; arms adducted stiff; wrist flex – diencephalon, midbrain, pons • Facial expressions : eye contact, facial movements o Parkinson’s Disease- pt has a masklike facial expression • Odors of the body or breath o Fruity scent = diabetes is out of control o Alcohol?/ Marijuana? • Personal hygiene/dress: appropriate? Clues to weight loss; cleanliness? o Can get cold easier as you age- less body muscle • Posture, gait, motor activity o Stooped over posture (-); straight/upright posture (+) o Walking heals to toes and swinging arms? (+) o Facial muscles appropriate? Abnormal = twitches, muscle spasms; observe overall muscle control ▪ Weakness = difficulty in moving muscle; loss of muscle power ▪ Fatigue = you don’t feel like doing anything/something; has normal muscle function • Speech : articulating appropriately; no slurred words/ awkward pauses Voice and speech problems o Aphonia: no, voice; loss of voice; from disease affecting larynx (voicebox) o Dysphonia: faulty, voice; speak in a whisper/ hoarse ▪ can be disease oriented; something affecting larynx or vocal cords = cancer? 1. Laryngitis, laryngeal tumors, unilateral vocal cord paralysis 2. Vagus nerve o Dysarthria: defect in muscular control; slurred speech – MS/ Parkinson’s o Aphasia: disorder of producing or understanding lang.; pathological component/cause- lesion ▪ Wernicke’s: can produce language but cannot understand language; can’t process 1. Production of speech is intact 2. Cannot comprehend, name (temporal lobe) ▪ Broca’s: production of lang. impaired; can understand lang. 1. FRUSTRATION enhances problem 2. Not fluent; production of speech highly impaired Health Assessment Normal & Abnormal findings for physical exam of skin, hair, nails Skin Inspection/Palpate 1. General skin coloration + odor a. Normal: even colored skin tones i. Older people –pale skin➔ decrease melanin produced/ dermal vascularity b. Abnormal: i. Pallor: loss of color 1. O2 deficiency, decrease hematocrit • Anemia, shock ii. Cyanosis: white skin – blue-tinged 1. Central cyanosis (areas near the heart): cardiopulmonary problem • Look at oral mucosa 2. Peripheral cyanosis: localized; vasoconstriction, exposure to cold • Look at extremities iii. Jaundice: yellow skin tones 1. In sclera (whites of eyeball), oral mucosa, palms, soles • Hepatic (liver) dysfunction iv. Erythematic: Redness of skin 1. Increased blood flow, increased RBC in area, infection o white patches (vitiligo- cow patches) o Abnormal= rash: red ➔ ex) butterfly rash across nose and cheeks =Lupus erythematosus o Litchentification= thickened skin- looks like dry pussy skin o Fungus: under ultraviolent light fluoresce blue-green c. Body odor i. Abnormal 1. Strong odor – sweat gland disorder, poor hygiene- need teachings 2. Temperature: use dorsal surface of hand a. Abnormal i. Cold skin- shock, hypotension ii. Cool skin – arterial disease iii. Very warm skin – febrile state, hyperthyroidism (increased movement) 3. Moisture: use dorsal side of hand a. Normal: appropriate amt of moisture i. Older people - dryer skin - decrease sebum (oil) production b. Abnormal: i. Increased moisture, diaphoresis (SWEATING) – fever, hyperthyroidism ii. Decreased moisture- dehydration, hypothyroidism (slowww) iii. Clammy skin – shock, hypotension 4. Texture- light touch a. Abnormal: i. Rough, flaky, dry skin – hypothyroidism 1. Obese people usually complain of dry, itchy skin 5. Thickness a. Normal: normally thin w/ potential calluses in areas constantly exposed to pressure b. Abnormal: i. VERY thin – arterial insufficiency; steroid therapy 6. Edema: thumbs to press down on skin or feet and ankles a. Edema: swelling related to accumulation of fluid in the tissue ii. Normal: skin rebounds; does not remain indented when pressure is released iii. Abnormal: 1. Indentations on skin 7. Mobility and turgor a. Mobility: how easily the skin can be pinched b. Turgor: skin’s elasticity; how quickly does skin return to original shape c. Normal: easily pinched, returns to place immediately iv. Older people: decrease in turgor- decrease elasticity & collagen fibers = saggy/wrinkled skin Health Assessment d. Abnormal: v. decreased mobility ➔ edema vi. Decreased turgor ➔ slow return of the skin – dehydration 8. Lesions: Size, Shape, Color, Texture, surface relationship, exudate, tenderness, body location (Sam Sells Coats to SET B) a. Normal: smooth- no lesions; stretch marks, healed scars, freckles, moles, birthmarks i. Look around skin folds ii. Older people : common skin lesions- senile keratoses (small, raised, dark sun exposed area)/lentigines (flat ?,darker sun exposed skin), cherry angiomas, purpura, cutaneous tags b. Abnormal i. Local or systemic lesions 1. Primary: arise from normal skin due to irritation or disease Size: less than 0.5 cm - usually Shape: Macules/ Patch- flat (</> 1 cm); Wheal- elevated, red (2cm) Vesicle/ bulla- blister/fluid filled (</> .05) Color: Pustules- white/yellow-white & pus filled Petechia: red, round, macule (flat <1cm); flat; bleeding from superficial capillaries Purpura: red to purplish Texture: macules- smooth; warts- rough; psoriasis- scaly Surface location: flat nonpalpable – macules/patches, purpura, ecchymoses (>petechia), spider angioma Raised palpable solid- papule/plaque (</>.5), nodules/tumor (.5-2/>2 cm), wheals Raised palpable cystic- vesicles/bullea, pustuale, cyst Depressed: atrophy, erosion, ulcer, fissures Pedunculated (having a stalk): skin tags Exudate: Serous: clear/white/pale (GOOD)--> vesicles/bullea (blister) Purulent: gross, infected, a lot, colorful; Pus: yellow --> acne, impetigo Tenderness: bullae or bruise- underlying cause/ pain Body Location: where is it on the body Configuration of lesion: Annular/circular: in a ring shape--> ringworm Round/oval: coin shaped --> eczema Confluent: runs together --> rubella Discrete: separate; apart; isolation; no association w/ another --> moles Grouped: cluster; individual entities but grouped together --> herpes Gyrate: twisted/coiled; worm like --> gyrate erythema (twisted red skin) Target/iris: concentrated rings of color; bull’s eye like --> lyme disease Linear: line, streak, stripe --> poison ivy/ herpes zoster (shingles) Polycyclic: annular lesions growing together; slowly growing into one nearby; distinct w/ little grouping Zosteriform: linear growing on nerve root; never crosses midline always stays on one side; can cross front to back but not left to right Distribution of lesions: Diffuse/generalized: occurring all over --> full body rash; urticaria (skin rash) from allergic reaction Scattered: sparsly distributed --> seborrheic keratosis (warts, moles) Localized: one area of body; discrete area; usually unilateral Regional: bilateral; one body area --> tinea capitis (skin fungus) Torso: just on the torso (below neck to below belly button)--> pityriasis rosea (flaky dry skin) Extensor surfaces: posterior elbows; anterior knee Dermatome lines: zosteriform (configuration)- along a nerve root --> herpes zoster (shingles) Hairy areas: where people grow hair- not scalp --> herpes II (sexual), lice Health Assessment 2. Secondary: lesion change; lose superficial epidermis- moist areas; rupture vessels • Erosion, ulcer, scar, fissure (linear cracks in skin) New scars- red and raises; old scars- white or silver --> healed wound Pressure point areas: Back of the head, shoulder blades, elbows, iliac crest, sacrum, soles/heels Sitting: behind knee; Laying on side- ear, trochanter, thigh, lower leg, ankles, knee Prone- chin, ribs, keep cap, big toe Braden scale-predict risk: factors that cause ulcer; PUSH tool- assess: what does ulcer look like Abnormal: Skin breakdown- red area; progresses to serious and painful pressure ulcer Ulcer scale: I- sores are not open wound II-skin breaks open, wears away, tender, and painful III- sore, more pain; extends into tissue beneath the skin; forming small crater IV- very deep; reaching muscle or bone; extensive damage 3. Vascular: reddish-bluish lesions • Petechia: red, round, macule (flat <1cm); flat; bleeding from superficial capillaries • Keloid: excessive collagen formation 4. ABCDE rule = for mole and skin cancer assessment A: asymmetry; B: border; C: color; D: diameter; E: elevation/evolution Benign moles/skin cancer: Malignant moles/skin cancer: Not asymmetric; symmetric all around asymmetric- two sides do not match Borders are even borders uneven One color 2 or more colors Smaller than 0.6inch larger than 0.6inch Does not change; relatively flat changes in size, shape, color, elevation Diameter is not important if the preceding steps present (+) for malignancy Surgery/excising: need 2 in around and 2in deep to remove 5. Skin cancer: primary or secondary • Basal cell carcinoma: most common; 40-80 yrs old i. Nodule(medium solid), papule (small solid), pearly border; volcano like- depressed center • Squamous cell carcinoma: 2nd most common; invasive skin cancer; 50 yrs old; blue eyes/freckles = increase risk i. At risk with sunbathing ii. Head and neck iii. Central ulcer w/ reddened scaly borders; well defined • malignant melanoma: worst form; very dark Scalp and hair Inspection and Palpation 1. General color and condition a. Normal: natural hair color- amt of melanin b. Abnormal: patchy gray hair ➔ nutritional deficiencies i. African American children – severe malnutrition – copper-red hair 2. Cleanliness, dryness, oiliness, parasites, lesions (texture and lesions) a. Normal: clean and dry; sparse dandruff; hair is smooth and firm- somewhat elastic i. Aging brings on coarser and drier hair ii. African Americans: dry scalps; dry, fragile hair; may use oil or Vaseline product in hair iii. No lesions b. Abnormal: i. Excessive scaliness ➔ dermatitis ii. Raised lesions ➔ infections; tumor growth iii. Dull, dry hair ➔ hypothyroidism; malnutrition iv. Poor hygiene v. Pustules w/ hair loss in patches = tinea capitis --> ringworm vi. Infections of the hair follicle- folliculitis – pus surrounded by erythema Health Assessment Headaches Character Onset/triggers Location Duration Severity Pattern Assoc. Factors Migrain e Nausea/vomiting Sensitive: noise/lights Visual/auditory Vertigo Numbness/tingling Emotions/feelings Food/alcohol Eyes Temples Cheeks Forehead Few days Severe throbbin g Recurrin g Relief: rest women Cluster Teary/drooping/ red eyes Runny nose Sudden Alcohol Eye/orbit Radiates to face/templ e Evenings & nights Intense stabbing Relief: movement Young males Tension Anxiety, tension, depressed No prodromal stage Stress Frontal, temporal, occipital lobes Days, months, years Dull, aching, tight; diffused Relief: local heat, massage, meds women Tumor Neurological/menta l symptoms: nausea/vomiting No prodromal stage Coughing/sneezing , sudden movements of head Tumor location Morning - for hours Steady aching Intensity varies Relief: time --------- Physical exam: normal findings + abnormal findings – head and neck Inspection and Palpation of head 1. Inspect head- size, shape, configuration, involuntary movement a. Normal: no visible lesions; symmetrically round, erect, midline i. Can hold head still and upright b. Abnormal: i. Features: • Larger skull and bones ➔ acromegaly – increased production of GH • Acorn-shaped, enlarged skull bones ➔ Paget’s disease of bone ii. Movements: • Tremors- neurological disorders- horizontal jerking movement • Involuntary nodding – aortic insufficiency • Head tilted – unilateral vision, hearing deficiency, sternomastoid muscle shortening 2. Palpate head a. Normal: smooth and hard- no lesions b. Abnormal: lesions, lumps ➔ trauma or cancer 3. Inspect face – symmetry, features, movement, expression, skin condition a. Normal: symmetrically round, oval, elongated, square i. Old people : wrinkles – SQ fat decrease w/ age; lower face shrinks, inward mouth b. Abnormal: i. Asymmetry in front of earlobes –parotid gland enlargement ➔abscess or tumor ii. Unusual/asymmetric face movements- organic disease/ neurological problem iii. Drooping to one side – result of stroke (CVA); Bell’s palsy iv. “masklike” face- Parkinson’s disease v. “sunken” face w/ depressed eyes, hollow cheeks- cachexia (wasting away) vi. Pale, swollen face – nephritic syndrome (kidney) 4. Palpate temporal artery a. Normal: elastic; not tender b. Abnormal: hard, thick, tender w/ inflammation – temporal arteritis ➔ lead to blindness 5. Palpate temporomandibular joint (TMJ) a. Ask pt to open mouth; explore pt’s Hx of headaches b. Normal: no swelling, tenderness, or crepitation (cracking/ sound) w/ movement i. Full ROM of mouth c. Abnormal: limited ROM; swelling , tenderness, crepitation ➔ TMJ Health Assessment Inspection of neck 1. Inspect the neck – slightly extended neck for symmetry, lumps or masses Side lighting a. Abnormal: i. Swelling, enlarged masses/nodules ➔ enlarged thyroid gland (huge bulge on anterior neck) ii. Inflammation of lymph nodes ➔ tumor/ infection 2. Inspect movement of neck structures a. Pt swallows small sip of water; observe movement of thyroid cartilage/thyroid gland i. Normal: thyroid cartilage, cricoids cartilage, thyroid gland move up and down ii. Abnormal: asymmetric movement or generalized enlargement of thyroid gland 3. Inspect cervical vertebra a. Pt flex neck- move neck in different directions i. Normal: C7 visible and palpable; sometimes T1 • Older people : cervical curvature- increase b/c of kyphosis (hunchback) a. Dowager’s hump- in older women ii. Abnormal: prominence or swellings other than the C7 vertebrae 4. Inspect ROM- move head around a. Normal: movement is smooth and controlled i. Older people : somewhat decreased ROM- arthritis b. Abnormal: i. Stiffness, rigidity, limited mobility➔ Muscle spasm, inflamed, cervical arthritis • affects daily functioning Palpate 1. Trachea: fingers on sterna notch; feel each side of the notch a. Abnormal: i. Not midline ➔ tumor, thyroid gland enlargement, aortic aneurysm, pneumothorax (air or gas in pleural cavity), atelectasis (collapse of lung), fibrosis 2. Thyroid gland a. Hyoid bone- bone that does not articulate with any other bone; high anterior neck b. Thyroid cartilage – “adam’s apple” c. Cricoid cartilage- above sterna notch i. Abnormal: not midlined; obscured ➔ masses; abnormal growth • Palpable thyroid if enlarged ➔ hyperthyroidism (Grave’s disease) o Edemic goiter, thyroiditis caused by Grave’s disease o Rapid enlargement of a single nodule ➔ malignancy Thyroid Auscultation 1. Only if enlarged - Bell on lateral lobes; pt holds breath & blood work i. Abnormal: soft, blowing, swishing ➔ hyperthyroidism- increase blood flow