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.
ORDER A PLAGIARISM-FREE PAPER HERE
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
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;
Cultural assessment: culturally competent care; religion vs spirituality;
Therapeutic communication: examples of effective and ineffective (barriers) techniques e.g. clarification, reflection, blaming, etc.;
General survey – what is included?
Nutrition: Dietary assessment methods; abnormal eating patterns, for example, anorexia.
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;
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.
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
Heart: cardiac cycle; auscultation sites; what causes the heart sounds;
HEENT: eye examination techniques; PERRLA; hearing tests; lymph nodes; problems seen in head, ears, eyes, nose, and throat;
Breasts: Risk factors for cancer
GU: testicular cancer; assessing
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.
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
Vital signs: BP – proper method, findings if not done properly; normal ranges; terminology used, e.g. bradycardia, tachypnea, etc.
Abdomen – methods and order of assessment, anatomy, expected findings; colon cancer risk factors
Pain assessment techniques
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
Pediatrics – best methods for assessing; pain assessment
Health Assessment – NUR 2092 Exam 1
What are the 6 steps of the nursing process?
Assessment
Diagnosis
Outcome
Planning
Implementation
Evaluation
Assessment Definition (nursing process)
Collect data
Use evidence-based assessment techniques
Document relevant data
Diagnosis Definition (nursing process)
Compare clinical findings with normal and abnormal variation and developmental events
Interpret data– make & test hypotheses
Validate diagnoses
Document diagnoses
Outcome Identification Definition (nursing process)
Identify expected outcomes
Individualize to the person
Culturally appropriate
Realistic and measurable
Include a timeline
Planning Definition (nursing process)
ESTABLISH PRIORITIES
Develop Outcomes
Set timelines for outcomes
IDENTIFY interventions
Integrate evidence-based trends and research
Document plan of care
Implementation Definition (nursing process)
Implement in a safe and timely manner
Use evidence-based interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
Provide health teaching and health promotion
Document implementation and any modifications.
Evaluation Definition (nursing process)
Progress toward outcomes
Conduct systematic, ongoing, criterion-based evaluation.
Include patient and significant others
Use ongoing assessment to revise diagnoses, outcomes, and plan
Distribute results to patient and family
Acute pain
Is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals.
Self-protective purpose; it warns the individual of actual or threatened tissue damage.
Chronic Pain
Over 6 months in duration
Adaptive responses
Phantom pain
Pain where limb used to exist
Malignant pain Vs nonmalignant pain
Malignant pain is cancer-related and is caused by tumor cells that cause necrosis or stretching.
Nonmalignant pain is often associated with musculoskeletal conditions.
Visceral pain
Originates from internal organs.
Somatic pain and deep somatic pain
Somatic pain originates from musculoskeletal tissues or the body surface
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
Develops when functioning and intact nerve fibers in CNS are stimulated.
They are triggered by events outside nervous system from actual or potential tissue damage.
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
Pain caused by a lesion or disease of the somatosensory nervous system.
This implies an abnormal processing of pain message from an INJURY to the NERVE FIBERS.
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
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
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
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.
Pain rating scales
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
Inspection—Visual examination of body
Palpation—texture, temp., rigidity, lumps, masses
Percussion—to evaluate size, borders, consistency, tenderness, extent of fluid
Auscultation—listening to sounds body produces; pitch, loud or soft, duration, and quality
Delirium Vs Dementia
Delirium is an ACUTE confusion state
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?
Assessment
Diagnosis
Outcome identification
Planning
Implementation
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?
Actual diagnoses
Risk diagnoses
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? 
