NUR2092 Health Assessment Exam 1 Study Guide / NUR 2092 Health Assessment Exam 1 Study Gui, Exercises of Nursing

Download NUR2092 Health Assessment Exam 1 Study Guide / NUR 2092 Health Assessment Exam 1 Study Gui and more Exercises Nursing in PDF only on Docsity! NUR2092 Health Assessment Exam 1 Study Guide * Parts of a data base o Complete (Total Health) Database = Complete Health History « Biographic Data (name, address, phone #, age, DOB, birthplace, gender, marital status, race, ethnic origin, occupation) * Source of History ° Who furnishes info, how reliable, if person is sick or well = Reason For Seeking Care « Brief statement in person’s own words * — Signs (objective data that can be seen, measured) « Symptoms (subjective data provided by client) = Present Health or History of Present Illness (HPI) « Well person: short statement about general state of health «Ill person: chronological record of reason for seeking care ° ° 0000 Location: specific, precise location of pain; superficial/deep Character/Quality: descriptive terms (burning, sharp/dull, aching, gnawing, throbbing, shooting, viselike, etc) Quantity/Severity: 1-10 scale; how it effects ADLs Timing: Onset, Duration, Frequency = When did it start? (onset) = How long since onset? = Howlong does it last? (duration) constant/intermittent = Cycle of remission and exacerbation? (comes and goes) Setting: Where was client when it started? What brings it on? Aggravating/Relieving Factors: What makes pain worse/better? Associated Factors: Is primary symptom related to any others? Patient’s Perception: How symptom affects ADLs? What do you think it means? Any limitations because of symptom? + Past Health ° ooo000000 ° Childhood illnesses Accidents/injuries Serious/chronic illnesses Hospitalizations Operations Obstetric History Immunizations Last Examination Date Allergies Current Medications «Family History ° Highlights diseases/conditions at increased risk for = Grandparents, parents, siblings, aunts/uncles, cousins « Review of Symptoms (evaluate past/present health state of each body system, double-check in case significant data omitted in HPI, evaluate health promotion practices) ° ° General Overall Health State (present weight, fatigue, weakness/malaise, fever/chills, sweats, weight gain/loss) Skin (disease, pigment/color/tone, moles, dryness/moisture, pruritus, excessive/easy bruising, rash/lesion) 0000 Hair (recent loss, change in texture) Nails (change in shape/color/brittleness) Head (headache patterns, injury, dizziness (syncope) or vertigo) Eyes (vision difficulty, decreased acuity, blurring, blind spots, pain, diplopia (double vision), redness, swelling, watering, discharge, glaucoma, cataracts) Ears (aches, infections, discharge w/characteristics, tinnitus, vertigo) (hearing loss, hearing aids, environmental noise, cleaning ears) Nose/sinuses (discharge w/characteristics, frequent/severe colds, sinus pain, nasal obstruction, nosebleeds, allergies, hay fever, change in sense of smell) Mouth/throat (pain, sore throat, gum bleeding, toothache, dysphagia, mouth/tongue lesion, hoarseness/voice change, tonsillectomy, altered taste (dental hygiene practices, dentures/bridges, last dental checkup) Neck (pain, limited ROM, lumps/swelling, enlarged/tender nodes, goiter) Breast (pain, nipple discharge, rash, history of breast disease, surgeries) (breast self-exams, frequency/method used, last mammogram) Axilla (tenderness, lump/swelling, rash) Respiratory System (lung disease, asthma, emphysema, bronchitis, pneumonia, TB, chest pain w/breathing, wheezing/noisy breathing, SoB, cough, sputum w/description (color, amount, viscosity), hemoptysis, toxin/pollution exposure (date of last chest x-ray, last TB skin test) Cardiovascular System (chest pain/pressure/tightness/fullness, palpitation, cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of hear murmur, HTN, CAD, anemia) (date of last ECG/EKG, cardiac stress test, cholesterol screening) Peripheral Vascular (coldness, numbness/tingling, leg swelling (time of day, activity), discoloration in hands/feet (bluish red, pallor, mottling, associated with position, especially around feet/ankles), varicose veins, intermittent claudication, thrombophlebitis, ulcers) (long-term sitting/standing for work? Support hose?; Avoid leg crossing) Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated w/eating), other ABD pain, pyrosis, N/V/D, history of ABD disease, flatulence, BM frequency, recent changes in BM patterns, stool characteristics (consistency, color, odor), rectal conditions/bleeding (use of antacids, laxatives; diet history, substance habits) Urinary System (frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy, straining, urine characteristics (color, odor), incontinence, history of urinary disease, pain in flank, groin, region or low back (measures to treat/avoid UTIs, use of Kegel exercises after childbirth) Genital System = Male: penis/testicular pain, sores/lesions, penile discharge, lumps, hernia (testicular self-exam? Frequency?) = Female: menstrual history, vaginal itching/discharge w/characteristics, menopausal history (last GYN checkup? PAP test?) Sexual Health (present relationships? Use of protection? Intercourse patterns? Dyspareunia? Changes in erection/ejaculation? Contact w/persons w/STIs?) Musculoskeletal System (history of arthritis/gout, joint pain/stiffness/swelling, deformity, limited ROM, muscle pain/cramps/weakness, gait/coordination problems, back pain/stiffness/limited ROM, history of back pain/disc disease?) (how much walking daily? Effect of limited ROM on ADLs? Mobility aids used?) Neurologic System (history of seizure disorder, stroke, fainting, blackouts) = Motor function: weakness, tic/tremor, paralysis, coordination issues? ¢ Know examples of health promotion activities oO Hair/skin/nails: Amount of sun exposure; use of sunscreen/hats; self-care for skin and hair Eyes: wear glasses/contact lenses; regular vision exams/glaucoma test; coping with loss of vision, if any Ears: regular hearing test; hearing aid use; coping with hearing loss, if any; exposure to environmental noise; method of cleaning ears Mouth/throat: patterns of daily dental care; use of dentures/bridges; regular dental exam Breast: regular self-exam, including frequency/method used; regular mammogram exam Respiratory: last chest x-ray; TB skin test Cardiovascular: last ECG/EKG; cardiac stress test; other cardiac tests; cholesterol screenings Peripheral vascular: does work involve long-term sitting/standing?; avoid crossing legs at knees; wear support hose? Gastrointestinal: use of antacids/laxatives; diet history, substance habits Urinary: measures to avoid/treat UTIs; use of Kegel exercises after childbirth Genital system: testicular self-exam, including frequency/method used (male); regular GYN/PAP exam o Musculoskeletal: how much walking daily?; effect of any limited ROM on ADLs?; mobility aids used? ¢ Know how to assess a person’s judgement o Ability to compare/evaluate alternatives to situation and reach appropriate course of action o Note what person says about job plans, social/family obligations, plans for future o. Plans, actions and decisions should be realistic, rational ¢ Recognize those at high risk for suicide and important questions to ask o High Risk: prior suicide attempts; depressed/hopelessness; firearms in home; family history of suicide; incarceration; family violence/physical/sexual abuse; self-mutilation; anorexia; verbal suicide messages; death themes in art/jokes/writing/behaviors; saying goodbye (giving away prized possessions) oO Have you ever felt that life is not worth living? (risk) oO Have you ever felt so blue that you thought of hurting yourself? (risk) o Doyou feel like hurting yourself now? (intent) oO oO oo oo0o00 000 How would you do it? (plan) What would happen if you were dead? o Whom could you tell if you felt like killing yourself? (support resources) * Define what a mental status assessment is for o Assessment to determine client’s emotional and cognitive function o During traumatic time, used to identify strengths and help client mobilize resources, use coping skills ¢ Know different types of aphasia (global, Broca’s, Dysphonic, Wernicke’s) o Global: most common/severe form; absence of spontaneous speech, reduced to few stereotyped words; comprehension absent/reduced to only person’s own name and few select words; repetition, reading, writing severely impaired; poor prognosis for language recovery; caused by large lesion damaging most of combined anterior and posterior language areas © Broca’s: Expressive aphasia; person can understand but can’t express using language; nonfluent, dysarthric, effortful speech; mostly nouns/verbs (telegraphic speech); auditory/reading ability intact; caused by lesion in anterior language area called motor speech cortex (Broca area) o Dyphonic: difficulty/discomfort in talking w/abnormal pitch/volume; caused by laryngeal disease; voice sounds hoarse or whispered but articulation and language intact o Wernicke’s: Receptive aphasia; opposite of Broca’s; person can hear sounds/words but can’t relate them to previous experiences; speech fluent, effortless, well-articulated; many paraphasias (malformed/ wrong word substitutions) and neologisms (made up words); speech can be incomprehensible; great urge to speak; repetition, reading, writing impaired; lesion in posterior language area called association auditory cortex (Wernicke’s area) ¢ Know the signs of alcoholism oO Ingestion of large amounts or longer period of time than intended oO. Persistent desire/unsuccessful efforts to cut down/control alcohol use o Craving/desire/urge to drink oO. Use results in failure to fulfill major role obligations (work, family, school) oO Use results in reduction of social, occupational, recreational activities oO. Increased tolerance (need for more to reach desired effect) ¢ Know the signs of cocaine ingestion and overdose o Ingestion: pupil dilation, tachycardia/bradycardia, elevated/lowered BP, sweats/chills, N/V, weight loss; euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, fighting, grandiosity, impaired judgment, impaired social/occupational functioning o Overdose: elevated heart rate, rapid heartbeat, headache, fever and psychosis * What is tolerance to substances? o Requirement for increased amount of substance to produce same effect ¢ Know why you do an abuse assessment screen o Violent experiences have significant immediate and long-term effects on the health of the abused oO. Increased risk for chronic health problems; neurologic, GI, GYN problems; chronic pain o Abuse assessment screen help support realization and opportunity to get help with problem ¢ Know how to explain things to patients so they understand o Avoid using professional jargon, rephrase in layman’s terms o Adjust vocabulary to assure understanding without sounding condescending o Correct misunderstanding to ensure compliance ¢ How to assess a child i.e. don’t show them scary things!! o Always greet by name, smile, make eye contact o Show/explain equipment as appropriate to comprehension level oO. Notify of intent on what you are going to do before you do it ¢ Know what radiation regarding temperature represents o Body maintains steady temp through thermostat/feedback mechanism; regulated by hypothalamus o Heat production (from metabolism, exercise, food digestion, external factors) © Heat loss (through radiation, evaporation of sweat, convection, conduction) ¢ Understand weight loss related to illness o Unexplained weight loss may be sing of short term illness (fever, infection, mouth/throat disease) or chronic illness (endocrine disease, malignancy, depression, anorexia nervosa, bulimia) ¢ What is a TMT and why it is used © Tympanic Membrane Thermometer: senses infrared emissions of tympanic membrane (eardrum) © Accurate measurement of core temperature o Non-invasive, non-traumatic, extremely quick/efficient, minimal chance of cross-contamination = Ear is lined with skin, not mucous membrane ¢ Know how to doa rectal temperature on an adult o Wear gloves, insert lubricated rectal probe cover on electronic thermometer only 2-3 cm (1 inch) into rectum, directed toward the umbilicus; for glass thermometer keep in for 2 % minutes; do not let go of the temperature probe while it is inserted into the rectum ¢ What the parts of a pulse are © Pressure wave resulting from stroke volume (amount of blood pumped into the aorta) ©. Gives rate and rhythm of heartbeat and local data on condition of the artery o. Assess pulse including a) rate, b) rhythm, c) force « Rate: beats per minute; range average of 60 to 100 bpm « Rhythm: tempo; sinus arrhythmia (decreased stroke volume on left side of heart) is an irregular tempo « Force: strength of heart’s stroke volume o 3+ is full, bounding o 2+ is normal o 1+ is weak, thread o Ois absent ¢ Why you would have a false high or false low when taking a blood pressure