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NUR 2092 – Health Assessment Essays, Exams and study guide

NUR 2092 – Health Assessment Essays, Exams and study guide

Nursing Experts

NUR 2092 – Health Assessment Essays, Exams and study guide

NUR 2092 – Health Assessment Essays, Exams and study guide.

NUR 2092 – Health Assessment

Written Assignment: HEENT/Skin/Nails

 

Purpose: To apply assessment and documentation skills utilized for physical health assessment.

Overview: After reading/viewing the module assignment and attending lab, conduct an assessment of the

  • Head
  • Eyes
  • Ears
  • Nose
  • Mouth
  • Face
  • Neck
  • Skin
  • Hair
  • Nails

Directions: Conduct a HEENT, skin and nails assessment on a fellow student, friend, or family member. Remember to secure their permission.

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Use the HEENT documentation assignment attached to this assignment module to document your findings. Formulate a SOAP note with both subjective and objective data as indicated on the HEENT attachment.

Submit your work to the Module 7 dropbox. Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates. NUR 2092 – Health Assessment Essays, Exams and study guide.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown: Jstudent_exampleproblem_101504

  

This assignment is worth 20 points and will be graded using the graded rubric below.

 

Components Meets Expectations Needs Improvement Does Not meet Expectations
Assessment Findings and documentation

10 points

 An optimal and thorough assessment and summary is present for each system. Poorly organized/or limited summary of pertinent  assessment

Information.

Less than 50% of pertinent assessment information is addressed or is grossly incomplete and or inaccurate.
 

Soap Note

8 points

Complete and concise summary of pertinent SOAP information. Poorly organized/or limited summary of pertinent SOAP information. NUR 2092 – Health Assessment Essays, Exams and study guide. Less than 50% of pertinent information is addressed or is grossly incomplete and or inaccurate.
Spelling and Grammar

2 point.

No grammar or spelling errors. Errors in grammar or spelling.
Total:           /20

 

Final Exam Study Guide

Geriatrics: functional assessment-what is being tested, best approach to testing; caregiver concerns; IADLs, ADLs; disability concerns; tools to assess
What is being tested

-Identify strengths

-Identify limitations – so interventions can be recognized

-Independence and prevention of functional decline

NUR 2092 – Health Assessment Essays, Exams and study guide

Best approach to testing

 

Caregiver concerns

-Decrease in attention, memory, orientation, language, planning and making decisions

-Depression is not a normal change

-Persistent depression – is concerning if it interferes with ADL’s

-Eating

IADLs

Instrumental activities of daily living

-measures functional abilities necessary for independent community living

-includes shopping, meal preparation, house-keeping, laundry, managing finances, taking medications, and using transportation NUR 2092 – Health Assessment Essays, Exams and study guide.

ADLs

Activities of daily living

-tasks necessary for self-care

-measure domains of eating/feeding, bathing, grooming, dressing, toileting, walking, using stairs, and transferring

Disability concerns

 

Tools to assess

-Katz Activities of Daily Living

-The Lawton Instrumental Activities of Daily Living Scale

-Hospital Admission Risk Profile

-Geriatric Depression Scale (short form)

 

-Inspect for lesions and moles – irregular shapes, change in size or color

-Check for pressure ulcers especially sacrum, heels & trochanters

-Clubbing – cardiac or pulmonary disorder

-Pitting/transverse groves – peripheral vascular disease, arterial insufficiency, or diabetes

-Brittleness – decreased vascular supply

-Yellow or brown nails – fungal infection

-Look for limited range of motion – arthritis or muscle weakness causing pain and discomfort

-While assessing range of motion – watch for reports of pain, dizziness, jerky or abnormal movements: may indicate fractured vertebrae, Parkinson’s disease, transient ischemic attack, or stroke NUR 2092 – Health Assessment Essays, Exams and study guide.

-Look for facial symmetry (asymmetry may indicate a stroke)

-Bowel sounds; Look for hernias, pulsatile masses

-Evaluate muscles for atrophy, tremors, and involuntary movements

-Note warmth, swelling, tenderness, crepitus and deformities

 

 

Cultural assessment: culturally competent care; definition of ethnicity; spirituality; concepts such as assimilation, acculturation, etc.
Culturally competent care

-Know self, understand own heritage

-Identify meaning of health to someone else

-Understand health care delivery system

-Gain knowledge re social backgrounds of clients

-Be familiar with language, resources for interpreters, resources within community

Ethnicity

Associated with culture; NUR 2092 – Health Assessment Essays, Exams and study guide . awareness of belonging to a group in which certain characteristics differentiate from one group to another

-Includes nationality, regional culture, language, ancestry

-Ex: Egyptian, Swedish, Mexican, Jewish, etc.

Spirituality

-Borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life.

-Comes from person’s life experiences

-Attempt to find meaning and purpose of life

-More abstract

-Relationship of self and something larger

Ethnocentrism

To believe one’s own beliefs or way of life is ‘superior’; will interfere with collection and interpretation of data, your development of a plan of care may be skewed; must be aware of your own biases

Acculturation

Adapting to and acquiring another culture

Assimilation

Developing new cultural identity and becoming like the dominant culture

Biculturalism

Divided loyalty, identifies with two cultures

Final Exam Study Guide

  1. Geriatrics: functional assessment-what is it, what is being tested, best approach to testing; caregiver concerns/burnout; IADLs, ADLs; disability concerns; expected changes in the elderly;
  2. Cultural assessment: culturally competent care; religion vs spirituality;
  3. Therapeutic communication: examples of effective and ineffective (barriers) techniques e.g. clarification, reflection, blaming, etc.;
  4. General survey – what is included?
  5. Nutrition: Dietary assessment methods; abnormal eating patterns, for example, anorexia.
  6. Skin: staging of decubitus ulcers, primary skin lesions like nodules, pustules, etc.; common skin lesions, for ex. Psoriasis, contact dermatitis; signs of malignant skin lesions; color differences seen in dark skinned individuals; lesion configurations;
  7. Musculoskeletal – range of motion techniques; points for comparison; osteoporosis risk factors; spinal assessment findings; testing various joints including jaw; types of fractures; problems such as rheumatoid arthritis, gout, etc.
  8. Thorax/Respiratory assessment – auscultation, palpation; normal sounds and locations; abnormal sounds & when you might hear them; proper method of auscultation; methods- e.g. voice sounds such as egophony, thoracic expansion, etc.; chest shapes
  9. Heart: cardiac cycle; auscultation sites; what causes the heart sounds;
  10. HEENT: eye examination techniques; PERRLA; hearing tests; lymph nodes; problems seen in head, ears, eyes, nose, and throat;
  11. Breasts: Risk factors for cancer
  12. GU: testicular cancer; assessing
  13. Pulses- where are they, how do you document information about them, including rate, amplitude, rhythm; peripheral vascular assessment, edema – appearance, scale; arterial vs venous insufficiency NUR 2092 – Health Assessment Essays, Exams and study guide.
  14. Neuro – Glasgow coma scale; reflexes; cranial nerves – how do you test each one; testing for cerebellar function; tests such as graphesthesia, position sense, stereognosis, etc., part of the brain being tested?; headache types
  15. Vital signs: BP – proper method, findings if not done properly; normal ranges; terminology used, e.g. bradycardia, tachypnea, etc.
  16. Abdomen – methods and order of assessment, anatomy, expected findings; colon cancer risk factors
  17. Pain assessment techniques
  18. History taking/symptom analysis – components of a health history (what is in each component, for ex. Past medical history); subjective vs objective data; examples of open and closed ended questions; history first; signs vs symptoms; health promotion levels
  19. Pediatrics – best methods for assessing; pain assessment

 

Health Assessment – NUR 2092 Exam 1

What are the 6 steps of the nursing process?

  1. Assessment
  2. Diagnosis
  3. Outcome
  4. Planning
  5. Implementation
  6. Evaluation

Assessment Definition (nursing process)

  1. Collect data
  2. Use evidence-based assessment techniques
  3. Document relevant data

Diagnosis Definition (nursing process)

  1. Compare clinical findings with normal and abnormal variation and developmental events
  2. Interpret data– make & test hypotheses
  3. Validate diagnoses
  4. Document diagnoses

Outcome Identification Definition (nursing process)

  1. Identify expected outcomes
  2. Individualize to the person
  3. Culturally appropriate
  4. Realistic and measurable
  5. Include a timeline

Planning Definition (nursing process)

  1. ESTABLISH PRIORITIES
  2. Develop Outcomes
  3. Set timelines for outcomes
  4. IDENTIFY interventions
  5. Integrate evidence-based trends and research
  6. Document plan of care

Implementation Definition (nursing process)

  1. Implement in a safe and timely manner
  2. Use evidence-based interventions
  3. Collaborate with colleagues
  4. Use community resources
  5. Coordinate care delivery
  6. Provide health teaching and health promotion
  7. Document implementation and any modifications.

Evaluation Definition (nursing process)

  1. Progress toward outcomes
  2. Conduct systematic, ongoing, criterion-based evaluation.
  3. Include patient and significant others
  4. Use ongoing assessment to revise diagnoses, outcomes, and plan
  5. Distribute results to patient and family

Acute pain

  1. Is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals.
  2. Self-protective purpose; it warns the individual of actual or threatened tissue damage.

Chronic Pain

  1. Over 6 months in duration
  2. Adaptive responses

Phantom pain

  1. Pain where limb used to exist

Malignant pain Vs nonmalignant pain

  1. Malignant pain is cancer-related and is caused by tumor cells that cause necrosis or stretching.
  2. Nonmalignant pain is often associated with musculoskeletal conditions.

Visceral pain

Originates from internal organs.

Somatic pain and deep somatic pain

  1. Somatic pain originates from musculoskeletal tissues or the body surface
  2. Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone NUR 2092 – Health Assessment Essays, Exams and study guide.

Referred pain

Pain that is felt at a particular site but originates from another location.

Nociceptive pain

  1. Develops when functioning and intact nerve fibers in CNS are stimulated.
  2. They are triggered by events outside nervous system from actual or potential tissue damage.
  3. Nociception can be divided into four phases:

(1) Transduction:

(2) Transmission: the pain impulse moves from the level of the spinal cord to the brain.

(3) Perception: signifies the conscious awareness of a painful sensation

(4) Modulation: a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus

Neuropathic pain

  1. Pain caused by a lesion or disease of the somatosensory nervous system.
  2. This implies an abnormal processing of pain message from an INJURY to the NERVE FIBERS.
  3. This pain is very difficult to treat and assess.

Subjective Data

Pain is always subjective. What the patient is complaining of; SYMPTOM

Objective data

What the nurse observes; SIGN

Nutritional Status

This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors

Nutritional Assessment

Food intake

24 hour recall

Food diary

Food frequency

Direct observation

Anthropometric measurements

Swallowing assessment prn

Lab tests

Pain assessment tools

  1. Brief pain inventory: asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep
  2. McGill Pain Questionnaire: The short-form McGill Pain, asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain
  3. Initial Pain assessment: asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. NUR 2092 – Health Assessment Essays, Exams and study guide.
  4. Pain rating scales
  5. Wong-Baker Faces pain rating scale

Pain Assessment

Posture/behavior

Facial expression

Sounds

Skin inspection/palpation

BP/pulse/respirations

Pupil size

How to assess domestic violence

“Abuse assessment screen” is a tool used by many healthcare providers.

Pulse Oximetry

Noninvasive

Estimate arterial oxygen saturation in blood

Normal Resp. Rate for adult

10-20

Normal BP for Adult

120/80

BMI requirements for being underweight, normal weight, overweight, obese.

Underweight = 18.5 BMI

Normal weight = 18.5- 24.9 BMI

Overweight= 25-29.9 BMI

Obese= 30+ BMI

How to document pulse

0=absent

1+= weak

2+= normal

3+= bounding

Definition of Eupnea

Normal/good breathing

Definition of Apnea

Breathing has stopped

What does the acronym PQRSTU stand for?

P= Precipitating/palliative/provocative, what brings it on? What were you doing when you noticed it?

Q= Quality or Quantity, how does it feel, sound? How intense/severe is it?

R=Region or Radiation, Where is it? Does it spread anywhere?

S= Severity Scale, Scale of 1-10. Is it getting better/worse?

T= Timing/ onset. When did it first occur? Duration? How long did it last? Frequency?

U= Understand patient’s perception of the problem. What do you think it means? NUR 2092 – Health Assessment Essays, Exams and study guide.

Vital Signs Influences

Blood Pressure

Age

Gender

Race

Diurnal variations

Emotions

Pain

Personal habits

Weight

Respiratory Rate

Exercise and anxiety

Heart Rate (Pulse)

Exercise, age, gender, anxiety, pain

Temperature

Diurnal variations – Lowest early AM, highest late afternoon/early evening

Exercise – rises

Menstrual cycle – increase mid cycle ovulation to menses

Age – very young wider variation; older typically lower

Drinks hot or cold

Normal pulse rate for adult

50-90

What happens to BP if cuff is too small or big?

If too small it will increase BP

If too big it will lower BP

Normal Oral temp + range

98.6. Range of 96.4 to 99.1

Is it normal for new born infant’s rectal temps to be higher?

Yes, average is 100

How do you measure BP cuff size?

With of bladder should equal 40% of circumference of persons arm.

Length of bladder should equal 80% of circumference.

What is the working phase of the interview?

The working phase is the data-gathering phase.

What are the steps to the “Tools of a physical Assessment”, 4 Steps

  1. Inspection—Visual examination of body
  2. Palpation—texture, temp., rigidity, lumps, masses
  3. Percussion—to evaluate size, borders, consistency, tenderness, extent of fluid
  4. Auscultation—listening to sounds body produces; pitch, loud or soft, duration, and quality

Delirium Vs Dementia

  1. Delirium is an ACUTE confusion state
  2. Dementia is a CHRONIC progressive loss of cognitive & intellectual functions. Disorientation, judgment loss, memory loss, impaired. NUR 2092 – Health Assessment Essays, Exams and study guide.

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

Concerns mainly one problem, one cue complex, or one body system

History and examination follow direction of presenting concern

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

Two primary components of health assessment

Health history

Physical examination

Health history = Subjective data

Physical Assessment – Objective Data

Therapeutic Communication

Open ended questions: narrative information; tell me about you, how are you doing today?

Closed ended questions: specific information; do you have pain

BARRIERS TO COMMUICATION

Lack of interest or attention/ lack of respect

Physical barriers – a curtain, a door, a computer, a monitor, pain, room temperature

The patient’s inability to hear you, hearing deficit, or language barrier

Language/ use of jargon, or speaking above someone’s educational level

Safety – fear

Psychological barriers – embarrassment, disbelief, shock, anger, fear, grief, fatigue, hostility

Culture

Nonphysical traits – values, attitudes, beliefs, customs

Race – Identification of individuals or groups by shared genetic heritage and biological or physical characteristics

Ethnicity – associated with culture; awareness of belonging to a group in which certain characteristics differentiate from one group to another

Material – dress, tools, art and ways they are used

NON material – verbal and nonverbal language, beliefs, customs, social structures.

Ethnocentrism – to believe one’s own beliefs or way of life as ‘superior’

Acculturation– Adapting to and acquiring another culture NUR 2092 – Health Assessment Essays, Exams and study guide

Assimilation– Developing new cultural identity and becoming like the dominant culture; more two way; new affecting old

Biculturalism– Divided loyalty, identifies with two cultures

Causes of illness

Biomedical

Disease caused by bacteria, viruses, etc.

Involves scientific theories for cause of illness

Naturalistic

Illness caused when there is loss of natural balance

May align with yin/yang, hot & cold theory

Magicoreligious

Illness caused by supernatural force

May use folk remedies

Culturally Competent

Know self, understand own heritage

Identify meaning of health to someone else

Understand health care delivery system

Gain knowledge re social backgrounds of clients

Be familiar with language, resources for interpreters, and resources within community

6 steps of nursing process

Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation

Assessment

Interview, health history, ROS, physical examination, functional assessment, spiritual and cultural assessment

Subjective data

What patient SAYS

Objective data

What you OBSERVE

SMART component in outcome identification

Specific
Measurable
Attainable
Relevant
Time bound

First level priority

Emergent situations, life threading and needs immediate attention

Second level priority

Requires attention to avoid further deterioration

Third level priorirty

Can be addressed after more important problems are addressed

Complete total health Database

Full health history, and physical exam
Yields first diagnosis
Current and past health state

Focused or problem centered database

Limited and short term problems
Concerned with mainly one problem, or one body system

Follow up database

Follow up care to evaluate if problem is getting better or worse

Emergency database

Rapid urgent collection of data
Radio diagnosis

Primary prevention

Preventing health problems
Ex: vaccines, safety glasses

Secondary prevention

Timely screenings to catch a problem early and reduce impact
Example: mammograms

Tertiary prevention

Decrease impact of ongoing problem
Example: cardiac rehab, support group.

2 primary components of health assessment

Health history= subjective
Physical examination = objective

PQRSTU method of pain assessment

Provocative/ palliative
Quality/ quantity
Region/ radiation
Severity scale
Timing (onset)
Understand patient perception of the problem

Organic disorder

Disorder of the brain

Psychiatric disorders

Not yet determined to be organic

More complete mental assessment maybe necessary if:

Patients has anxiety/depression
If family is concerned
Deterioration in status from last visit
Aphasia
Acute psychiatric illness

Objective cues of mental health
ABCT

Appearance
Behavior
Cognitive function
Thought process

Delirium

Sudden onset
Altered consciousness
Rapid mood swings
Rapid, inappropriate, rambling speech
Can be reversed
Can cause fever, pain, low blood glucose, infection

Dementia

Slow and gradual onset
Flat agitation
Consciousness not altered
Repetitious speech
Can’t be reverse
Can cause HIV, chronic alcoholism, Alzheimer’s

Ethnocentrism

belief in the superiority of one’s own ethnic group

Ethnicity

Associated with culture
Awareness of belonging to a group in which certain characteristics differentiate from one group to another NUR 2092 – Health Assessment Essays, Exams and study guide

Race

Identification of individual groups by shared genetic heritage and biological or physical characteristics

Acculturation

Adapting to and acquiring another culture

Assimilation

Developing a new culture identity and becoming like the dominant culture

Biculturalism

Identifies with two cultures

Biomedical cause of illness

Disease caused by bacteria, viruses
Involves scientific theories

Naturalistic cause of illness

Illness caused due to loss of natural balance
Yin/yang or hot and cold theory

Magioreligious

Illness caused by supernatural forces

Percussion

The sharp striking of one thing against another.
Used to evaluate the size, borders, consistency, tenderness, extent of fluid
Striking produces vibration

Direct percussion

Sinuses, CVA tenderness

Indirect percussion

Thorax, abdomen

Flatness

Bone or muscle

Dullness

Heart, liver, spleen

Resonance

Air filled lungs. Hollow

Hyper resonance

an abnormal booming sound produced during percussion of the lungs. Emphysematous lung

Tympany

Air filled stomach (drumlike)

Auscultation

Listening to sound produced by body

Pulse oximetry

Estimates oxygen saturation in blood
Normal value: 95-100%
COPD patients might have high 80s

Temperature

Normal range: 96.4 to 99.1 F

Most accurate temperature

Rectal

Pulse

Normal range 50-95 bpm

Ear canal in older

Pull and up

Ear canal in children

Pull and down

Pulse and respiration rate is _________ in infants

Faster

Nociceptive pain

Acute pain starts outside the nervous system
Responsive to anti-inflammatory and opiates

Neuropathic pain

Chronic pain
Abnormal processing
Numbness, tingling, shooting, burning, phantom pain
From injury to nerve fibers or CNS

Phantom pain

Pain felt in a body part that is no longer there

Referred pain

Felt at a site different from organ affected

Breakthrough pain

Pain restarts or escalates before next scheduled analgesic dose

What does OLDCARTS stand for?             

Onset

Location

Duration

Characteristics

Aggravating/associated factor

Relieving factors

Treatments thus far

Significance of symptoms

When do you use “old carts”?  

Whenever a patient reports a symptom, it needs to be explored

What does IPPA stand for?        

Inspection

Palpation

Percussion

Auscultation

-perform in that order

What is an assessment?

Collection of data about the individual’s health state

Compare subjective and objective data.              

Subjective data is what the person says about themselves during history taking; objective data is data you observe by inspecting, percussing, palpating, and auscultating during the physical exam

What elements form the database?      

-patients record

-lab studies

-subjective data (in pt. history)

-objective data (in physical)

What is the purpose of assessment?     

Make a judgement or diagnoses

What is diagnostic reasoning?  

Process of analyzing health data and drawing conclusions to identify diagnoses

What are the six phases of the nursing process?             

  1. Assessment
  2. Diagnosis
  3. Outcome identification
  4. Planning
  5. Implementation
  6. Evaluation

What are the six parts of a health assessment?

-review of the clinical record

-health history

-physical examination

-functional assessment

-risk assessment

-review of the literature

What is a nursing diagnosis?     

A clinical judgement about a person’s response to an actual or potential health state NUR 2092 – Health Assessment Essays, Exams and study guide

What are the three types of nursing diagnoses?              

  1. Actual diagnoses
  2. Risk diagnoses
  3. Wellness diagnoses

What is a medical diagnosis?    

Diagnosis that evaluates the cause or etiology of the disease

What are the four different types of databases?             

-complete

-focused or problem centered

-follow-up

-emergency

What is a complete database? 

Complete health history and full physical exam

What is a focused or problem centered database?         

For a limited or a short term problem

What is a follow up database? 

When the status of identified problems are evaluated at regular and appropriate inte

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