NUR2092: Health Assessment Exam Study Guide for 2022-2023
Module 1:
Chapter 1: Evidence Based Assessment
Assessment: Point of Entry in an
... [Show More] Ongoing Process
Subjective data
➢ What patient says about himself or herself during history taking
Objective data
➢ Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
Database
➢ Formed from these elements, plus patient’s record and laboratory studies
Steps of the Nursing Process:
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Nursing process: Critical Thinking systematically
❖ Assessment
❖ Diagnosis / analysis
❖ Plan
❖ Interventions
❖ Evaluations
Nursing Process: Assessment
❖ Collection of data from multiple sources
➢ Review of clinical record
➢ Interview
➢ Health history
➢ Physical examination
➢ Functional assessment
• Activities of daily living
➢ Cultural and spiritual assessment
➢ Consultation
➢ Review of the literature Nursing Process: Diagnosis
❖ Interpretation of data by identifying clusters of cues so as to make inferences
❖ Compare clusters of cues with definitions and defining characteristics
❖ Validation of inferences based on findings
❖ Identify related factors
❖ Document the diagnosis
Nursing Process: Outcome Identification
❖ Identify expected outcomes related to patient individualization
❖ Ensure outcomes are realistic and measurable
❖ Specify short-term and long-term goal measurement criteria
Nursing Process: Planning
❖ Establish priorities based on meeting identified patient care goals
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Develop outcomes and set time frames for meeting proposed outcomes
❖ Identify relevant interventions and utilize interdisciplinary health care team members in the care planning process for the patient
❖ Document plan of care
Question
The nurse has a “hunch” that the patient’s elevated blood pressure is due to pain level; however, the patient received blood pressure and pain medication 45 minutes ago. What should the nurse consider in regards to this hunch?
1. Research supports that the pain and blood pressure medications will take 30 minutes to become effective. The nurse should wait until the next prescribed time and reevaluate pain level
2. The nurse should consider consulting with the pain management team to evaluate the effectiveness of the pain medication regimen.
3. The nurse should disregard the hunch because hunches are not effective at incorporating evidence-based practices
4. The nurse should administer pain medication based on the hunch Correct Answer: 2
Nursing Process: Implementation
❖ Determine patient readiness and involve patient(s) in health care process
❖ Review planned interventions with interdisciplinary health care team members to facilitate collaborative effort
❖ Utilize principles of delegation, being mindful of supervision and evaluation
❖ Counsel person and significant others
❖ Refer for continuing care
❖ Document care provided
Nursing Process: Evaluation
❖ Refer to established outcomes
❖ Evaluate individual’s condition and compare actual outcomes with expected outcomes
❖ Summarize results of evaluation
❖ Identify reasons for failure to achieve expected outcomes
❖ Take corrective action to modify plan of care
❖ Document evaluation in plan of care
Critical Thinking Principles
❖ Proceed through sequential steps from novice to expert
➢ Incorporation of experience provides foundation for development of clinical practice
❖ Utilize a multidimensional thinking approach to interpret data
➢ Use an organized, systematic assessment format
❖ Validate and confirm findings based on nonjudgmental interpretation of data ➢ Check and corroborate accuracy and reliability of data
❖ Cluster data information to support evidence as well as rule out inconsistent clinical findings in terms of differential diagnosis
➢ Distinguish relevant signs and symptoms
Priority Problems Level
❖ First-level priority
➢ Emergent, life threatening, and immediate
❖ Second-level priority
➢ Next in urgency, requiring attention so as to avoid further deterioration
❖ Third-level priority
➢ Important to patient’s health but can be addressed after more urgent problems are addressed
❖ Collaborative problems
➢ Approach to treatment involves multiple disciplines Problems and Outcomes
❖ Identify patient outcomes and delineate measurable goals
➢ Qualify short-term and long-term goals that are realistic and patient centered
❖ Include evaluation methods that will allow for validation of results or adjustments to care planning
➢ Incorporation of planning methods is a critical element in the delivery of care
❖ Continuously evaluate the plan of care
➢ Analyze and implement changes as needed in order to maintain pathway toward goal achievement
Comprehensive Plan of Care
❖ Evaluate and update plan
❖ Record revised plan and keep it up-to-date
❖ Communicate revised plans to multidisciplinary team
❖ Be aware that this is a legal document, and accurate recording is important for evaluation, insurance reimbursement, and research
Evidence-Based Assessment
❖ Current and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs)
❖ Utilizing evidenced-based practice (EBP) in conjunction with provider experience will lead to better health outcomes for patients
❖ Fostering a “culture of EBP” at both the undergraduate and graduate levels will assist health educators to make EBP the “gold standard” of practice
Question
What is the best electronic resource for incorporating evidence-based practice into health assessment?
1. Wikipedia.org 2. Nursingworld.org.
3. Mayoclinic.com
4. WebMD.com
Correct Answer: 2
Collecting Four Types of Data
❖ Complete total health database
➢ Includes complete health history and full physical examination
➢ Describes current and past health state and forms baseline to measure all future changes
➢ Yields first diagnoses
Episodic or problem-centered database
➢ For limited or short-term problems
➢ Collect “mini” database, smaller scope and more focused than complete database
➢ Concerns mainly one problem, one cue complex, or one body system
➢ History and examination follow direction of presenting concern Collecting Four Types of Data (Cont.)
❖ Follow-up database
➢ Status of all identified problems should be evaluated at regular and appropriate intervals
➢ Note changes that have occurred
➢ Evaluate whether problem is getting better or worse
➢ Identify coping strategies being used
❖ Emergency database
➢ Rapid collection of data, often compiled concurrently with lifesaving measures
➢ Diagnosis must be rapid and comprehensive in nature Expanding the Concept of Health
❖ Assessment: collection of data about an individual’s health state
❖ A clear idea of health is important because it determines assessment data to be collected
Holistic Model of Health
❖ Mind, body and spirit are interdependent and function as a whole
❖ Multifaceted basis of disease
❖ Individual and human environment are open systems
❖ Expanded assessment factors such as lifestyle behaviors, culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, failures and frustrations of life
❖ Health promotion and disease prevention form the core of nursing
Healthy People 2020 Web Site
❖ http://www.healthypeople.gov/
❖ Review the tabs at the top of the website
Healthy People 2020 Goals
❖ Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
❖ Achieve health equity, eliminate disparities, and improve the health of all groups.
❖ Create social and physical environments that promote good health for all.
❖ Promote quality of life, healthy development, and healthy behaviors across all life stages
Frequency of Assessment
❖ Interval of assessment varies with illness and wellness needs
➢ Ill people seek care because of pain or abnormal signs and symptoms
➢ This prompts an assessment: gathering a complete, episodic, or emergency database
• Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices
• Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health
Frequency of Assessment (Cont.)
❖ Routine periodic examination might include the following services for preventive health care:
➢ Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices
➢ Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health
➢ Immunizations
➢ Chemoprophylaxis for multivitamin with folic acid for females capable of or planning pregnancy
Frequency of Assessment (Cont.)
❖ For well persons, opinions are changing about assessment intervals
➢ Annual checkup is vague: What does it constitute? Is it necessary? Does it sometimes give an implicit promise of health and thus provide false security?
➢ Timing of formerly accepted procedures is now variable: for example, annual Pap tests
➢ Same annual routine physical examination cannot be recommended for all persons because health priorities vary among individuals, age groups, and risk categories
Assessment through the Life Cycle
❖ Age-specific charts for periodic health examinations are a positive approach to health assessment
➢ Define lifetime schedule of health care, organized into packages for four specific age groups
➢ Each chart lists a frequency schedule for periodic health visits and preventive services for age group
• These services include screening factors to gather during the history, and age-specific items for physical examination and laboratory procedures, counseling topics, and immunizations
Assessment through the Life Cycle (Cont.)
❖ Age-specific charts focus on major risk factors specific for each age group based on lifestyle, health needs, and problems
➢ Shift emphasis from an annual physical examination toward rational and varying periodicity
➢ Incorporate health promotion and disease prevention at every health visit, not just at one annual physical examination
➢ Health education and counseling are highlighted as means to promote health
Cross-Cultural Care Concepts
❖ A holistic model of health care assessment must include culture
❖ Inclusion of heritage assessment is of paramount importance to gather meaningful data and intervene with culturally sensitive and appropriate care
➢ With the rapid increases in numbers of individuals from diverse cultural backgrounds in the United States, a concern for the cultural beliefs and
practices of people is increasingly important in health care Cross-Cultural Care Principles
A serious conceptual problem arises as nurses and physicians are expected to know, understand, and meet health needs of people from culturally diverse backgrounds without formal preparation for doing so
❖ International interchanges are increasing among nurses and physicians, making attention to cultural aspects of health and illness an even greater priority
High-Level Assessment Skills
❖ Attention to life cycle, holism, and culture must not detract from the importance of assessment skills themselves
❖ Assessment skills require hands-on expertise refined to a high level
➢ The nurse is the first and often only health professional to see an individual in many communities
➢ The nurse is the only health professional continually present at bedside in hospitals
Cost Containment Principles
❖ Efforts at cost containment result in hospital populations composed of people with increased acuity, shorter stays, and earlier discharges than in the past
➢ Nurses must make faster, more efficient assessments
➢ Nurses required to go people’s homes for follow-up assessment and diagnosis
➢ First-rate assessment skills grounded in holistic approach and knowledge of age-specific problems are required
Healthfinder.gov
❖ A BOLD new initiative from the USDHHS, Center for Disease Control, Centers for Medicaid and Medicare, Food and Drug Administration and NIH. to help Americans live longer, better and healthier lives.
nih.gov advances
❖ NIH-supported research has led to:
❖ Death rates from heart disease and stroke fell by 40% and 51%, respectively, between 1975 and 2000.
❖ Overall 5-year survival rate for childhood cancers rose to nearly 80% during the 1990s from under 60% in the 1970s.
❖ Number of AIDS-related deaths fell by about 70% between 1995 and 2001.
❖ Sudden infant death syndrome rates fell by more than 50% between 1994 and 2000.
❖ Infectious diseases—such as rubella, whooping cough, and pneumococcal pneumonia—that once killed and disabled millions of people are now prevented by vaccines.
nih.gov more advances
❖ Quality of life Americans suffering with depression has improved due to more effective medication and psychotherapy.
❖ The sequencing of the human genome set a new course for developing ways to diagnose and treat diseases like cancer, Parkinson's Disease and Alzheimer's Disease.
❖ In response to the anthrax attacks of 2001, the NIH launched and expanded research to prevent, detect, diagnose, and treat diseases caused by potential bioterrorism agents. What else have we done?
❖ New and improved imaging techniques let scientists painlessly look inside the body and detect disease in its earliest stages when it is often most effectively treated.
❖ Progress in understanding the immune system may lead to new ways to treat and cure diabetes, arthritis, asthma and allergies.
❖ New, more precise ways to treat cancer are emerging, such as drugs that zero in on abnormal proteins in cancer cells.
❖ Novel research methods are being developed that can identify the causes of outbreaks, such as Severe Acute Respiratory Syndrome (SARS), in weeks rather than months or years
Lab Book Practice Questions:
1. The concept of health and healing has evolved in recent years. Which is the best description of health?
a. Health is the absence of disease.
b. Health is a dynamic process toward optimal functioning.
c. Health depends on an interaction of mind, body, and spirit within the environment. d. Health is the prevention of disease.
2. Which would be included in the database for a new patient admission to a surgical unit?
a. All subjective and objective data gathered by a health practitioner from a patient
b. All objective data obtained from a patient through inspection, percussion, palpation, and auscultation
c. A summary of a patient’s record, including laboratory studies
d. All subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed
3. You are reviewing assessment data of a 45-year-old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of:
a. Hypothetical reasoning
b. Diagnostic reasoning
c. Data cluster
d. Signs and symptoms
4. A patient is in the emergency department with nausea and vomiting. Which would you include in the database?
a. A complete health history and full physical examination
b. A diet and GI history
c. Previously identified problems
d. Start collection of data in conjunction
with lifesaving measures
5. A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond? [Show Less]