Identify essential components of the health history - correct answer a. Identifying data and source of the history
b. Chief complaint - use "quotes" from
... [Show More] patient
c. Present illness - chronological order!
• Medications, allergies, tobacco use, alcohol and drug use
• 7 attributes (OLD CARTS)
d. Past illness
• Medical, surgical, Obstetric/gynecological, psychiatric
• Health maintenance
e. Family history
f. Personal and social history
g. Review of systems - Go through each one!
Discuss scope of nursing assessment - correct answer Can be either:
1. Comprehensive Assessment
2. Focused Assessment
What are the indications for and what is included in a Comprehensive Assessment? - correct answer a. Comprehensive assessment - a complete assessment.
• Includes all elements of the health history and a complete physical assessment.
• This is useful for new patients.
• Gives a good baseline for future assessments.
• Opportunity for health promotion.
• Gives you a lot of information about the patient and also gives you time to build a relationship.
What are the indications for and what is included in a Focused Assessment? - correct answer b. Focused assessment - is focused on the concern or the problem the patient presents with
• Restricted to a specific body system or two
• May be useful for an ongoing relationship once you established a baseline if there are no new concerns.
Components of the Health History: Identifying Data and Source of the History; Reliability - correct answer a. Identifying data and source of the history: age, gender, occupation, marital status. Who is giving the information? How reliable is it?
• Name/Age/Gender
• Occupation
• Marital status
• Source of data (family member, parent)
Gives you indication of reliability of the data
Child vs. parent
confused adult vs. the adult child or family member
Components of the Health History: Chief Complaint(s) - correct answer b. Chief complaint: Symptoms that cause the patient to seek care
• One or more symptoms causing them to seek care.
• Use quotes from patient
• Just a phrase
Components of the Health History: Present Illness - correct answer c. Present illness: More details about the chief complaint. How long? What does it affect? How does the person feel? Have they done anything about it?
• Amplifies the complaint
• Symptoms—OLD CARTS
Onset—when did it start
Location
Duration—how long
Characteristics—what is it like? (burning, stabbing, etc.)
Aggravating factors and Relieving factors
Timing—when does it occur
Severity—pain from 1-10?
• Expands on the chief complaint
• Describes how the symptoms develop
• Thoughts and feelings about the illness
• The "story" of the chief complaint
• Medications
• Allergies
• Tobacco, alcohol and drug use
Components of the Health History: Past History - correct answer d. Past illness: childhood illness, health practices. Medical, surgical, obstetrical/gynecological, psychiatric illnesses? Dates.
• Childhood illnesses
• Medical
• Surgical
• Obstetrical/gynecological
• Psychiatric
• Health maintenance practices
Lifestyle
Home safety
Immunizations
Screenings
Components of the Health History: Family History - correct answer e. Family history: Genogram with health, illnesses, death, etc. Document the absence or presence of illnesses. Specifically ask about diabetes, cancers, HTN, CAD, heart disease, mental illness (especially things that are familial)
• Genogram
• Causes of death
• Ages of death
• Illnesses and health
• Presence or absence of diseases - ask about key ones:
Diabetes
HTN
CAD
Genetics
Components of the Health History: Personal and Social History - correct answer f. Personal and social history: educational level, family origin, current household, personal interests, lifestyle—alcohol, drugs?
• Educational level
• Family of origin, cultural influences
• Who is in the household
• Personal interests
• Lifestyle
• Sexual history-partners, frequency
• Habits—drugs and alcohol
• Nutrition, sleep, exercise
• Religious preference
• Military
Components of the Health History: Review of Systems - correct answer g. Review of systems: go through each body system and document the presence and/or absence to each major body system. People forget things...so you will have to ask about each one and then examples of important illnesses or symptoms in each system.
• Series of questions from head to toe:
General (may include psychiatric)
Skin
HEENT (may include neurological)
Neck
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Peripheral Vascular
Urinary
Genital
Musculoskeletal
Psychiatric
Neurologic
Hematologic
Endocrine
• Prepare the patient for the questions
• Start general and then focus questions if there is a concern
• Helps uncover problems the patient has overlooked
• Be organized.
Describe the steps of the process of gathering information - correct answer a. Prepare by considering your approach to the patient
b. Professional dress and behavior
c. Good lighting; Have all equipment ready
d. Be organized, Taking notes?
• Respect the patient - privacy, comfort
e. Use a chronological and sequential approach
f. Greet, establish rapport - Establish an agenda for the interview
g. What is the patient's story?
h. Respond to cues - Expand and clarify points
Discuss interviewing techniques including ways to expand on client information. - correct answer a. Start with open ended questions to get the story of the symptoms
b. Go to more specific questions related to the symptom
c. End with yes/no questions about the symptoms
d. Chronological!
e. Techniques for interviewing:
• Active listening
• Empathetic responses
• Guided questioning
• Nonverbal communication
• Validation
• Reassurance
• Partnering
• Summarizing
• Transitions
• Empowering the patient
Recognize ethical considerations in patient-examiner relationships - correct answer a. Cultural humility - self-awareness, respectful communication, collaborative relationships
b. Sexuality - clinician and patient relationships
c. Ethics and professionalism
• Confidentiality
• Non-maleficence or "first, do no harm"
• Autonomy—patient's right to determine their care
• Beneficence—provider needs to do good for the patient.
d. Issues
• Seduction
• Anxiety
• Excessive flattery
• Financial concerns
The "silent" patient - correct answer • Some issues may be painful to discuss
• Tearful, unable to speak
• Be attentive
• Look for nonverbal cues
• Are your questions too quick or offensive?
"Altered" capacity - correct answer • Delirium, dementia or other health conditions
• What is the decision making capacity?
• Durable power of attorney or health care proxy?
• Allow them to be fully involved to the limit of his/her ability.
"Talkative" patient - correct answer • Let talk for 5-10 minutes and listen closely
• Focus on what seems to be most important to the patient
• Learn how to set limits when needed
• Interrupt only if necessary
"Crying" patient - correct answer • "I can see that you are not feeling well, it is alright to cry"
• Silence or pausing
• Gentle probing and respond empathetically
• Be supportive
• Give them a tissue
Permission to cry
"Confused" Patient - correct answer • Multiple symptoms
• Neurological disorder?
• Mental illness?
• Dementia?
• Intoxication?
• Mental status exam
• Family member help?
"Angry" patient - correct answer • Face it
• It may be displacement on to the HCP because of frustration, illness, or pain
• Be calm
• Avoid confrontation
• No one is happy to be sick....
Describe the components of the clinical reasoning process - correct answer a. Clinical Reasoning -
• This is what makes you a nurse - nursing is intellectual
• Nurses make nursing diagnoses and use disease process to help with that
b. Identify abnormal findings
c. Localize findings anatomically
d. Interpret findings in terms of a probable cause
e. Make a hypothesis about the nature of the finding
f. Test the hypothesis
g. Develop a plan that is agreeable with the patient
h. Use Evidence-based practice!
1. Identify the components of the general survey - correct answer a. Height and weight
b. General appearance—by general inspection
2. Formulate health history questions for the general survey - correct answer a. Health history related to general survey
• Changes in weight?
• Fatigue and/or weakness?
• Exercise, sleep, nutritional/diet history
• Fever, chills, night sweats?
• Pain? (use OLD CARTS)
3. Apply concepts of the general survey to patient situations: Height and Weight - correct answer a. Height and weight:
• Height
Measure in stocking feet
Short or tall? Build (muscular? Slender?)
Body symmetry and proportions/deformities
• Weight
Remove excess clothing and shoes
Emaciated, slender, plump, obese?
If obese, is fat distributed evenly or concentrated over trunk, upper torso, around the hips?
Any rapid change in weight? (fluid retention?)
• Calculating the body mass index (BMI)
Normal BMI is 19-25.
Obesity increases risk for HTN, DM, heart disease, stroke, sleep apnea, depression
3. Apply concepts of the general survey to patient situations: General Appearance - correct answer b. General appearance:
• Apparent state of health
Acute or chronically ill, frail
Age appropriate?
• Level of consciousness
Awake, alert, responsive or lethargic, obtunded, comatose
• Signs of distress
Cardiac or respiratory; pain; anxiety/depression
• Skin
Lesions, turgor, color
Sun exposure
• Dress, grooming, and personal hygiene
Appropriate to weather and temperature
Clean, properly buttoned/zipped
• Facial expression
Eye contact, appropriate changes in facial expression
Mood
• Odors of body and breath
• Posture, gait, and motor activity
Blood Pressure (normal and abnormal) - correct answer • Normal < 120/80
• Pre- HTN 120-139/ 80-89
• HTN > 140/90
Stage I 140-159/ 90-99
Stage II >160/ >100
Heart Rate (normal and abnormal) - correct answer • Normal 60-100
Bradycardia < 60
Tachycardia >100
Respiratory Rate (normal and abnormal) - correct answer • Normal rate: 12-20 breaths/minute
Tachypnea >20
Bradypnea < 12
Temperature (normal and abnormal) - correct answer • Average oral temperature:37°C or 98.6°F
• Fever: 100.4°F or 38°C
• Diurnal variation: 35.8°C - 37.3°C (96.4°F - 99.1°F)
Pain (normal and ways to assess) - correct answer • Normal - No pain: 0 out of 10
• Ways to assess:
Numeric Rating Scale - Rate pain from 0 - 10
Wong-Baker FACES Scale - used by children or patients with language barriers or cognitive impairment
FLACC Pain Scale - for newborns or babies
Level of consciousness (LOC) - correct answer how aware the person is of his environment
Attention - correct answer the ability to focus or concentrate
alert - correct answer patient is awake and aware
lethargic - correct answer you must speak to the patient in a loud forceful manner to get a response
obtunded - correct answer you must shake a patient to get a response
stuporous - correct answer the patient is unarousable except by painful stimuli (sternal rub)
coma - correct answer the patient is completely unarousable
short-term memory - correct answer covers events or memories that occurred minutes to days before
long-term memory - correct answer covers events or memories that occurred months to years before
orientation - correct answer requires memory and attention
- aware of person (who they are)
- place (where they are)
- time (when is it)
perceptions - correct answer awareness of the objects in the environment to the five senses and their interrelationships (hallucinations?)
thought processes - correct answer the logic, coherence, and relevance of a patient's thoughts as they lead to thoughts and goals; HOW people think
insight - correct answer awareness that thought, symptoms, or behaviors are normal or abnormal; e.g. distinguishing that a daydream or hallucination is not real
judgment - correct answer process of comparing and evaluating different possible courses of action
affect - correct answer the observable mood of a person expressed through facial expression, body movements, and voice
mood - correct answer the sustained emotion of the patient
- euthymic: normal
- dysthymic: depressed
- manic: elated
language - correct answer the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory
higher cognitive functions - correct answer level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking
Mental Status Examination - correct answer • Consists of the following components:
Appearance and behavior
Speech and language
Mood
Thoughts and perceptions
Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability
Assessing Cognitive Functions - correct answer • Assess orientation to person, place, and time
• Assess attention
Digital span: give the patient a string of numbers to recite back to you
Serial 7s: ask the patient to subtract serial "7s" from 100
Spelling backward: ask the patient to spell W-O-R-L-D backwards
• Assess remote memory by asking about past historical events
• Assess recent memory by asking about something recent (weather, national event, etc.)
• Assess new learning ability by giving the patient three or four words to remember; then ask him to repeat the words after several minutes
Assessing Higher Cognitive Functions - correct answer • Through your conversation, you can often assess the patient's higher cognitive functions
• Information and vocabulary
• Calculating ability: ask the patient to perform more difficult calculations such as making change (e.g., if you had a dollar's worth of nickels and someone needed 65 cents how many nickels would you have left?)
• Abstract thinking
Interpreting proverbs: "A stitch in time saves nine"
Similarity exercises: What do a ball and an orange have in common? [Show Less]