Health Assessment Exam I Flashcards
(103 cards)
1
Q
What were you doing when the pain started? What caused it? What makes it better and worse? What seems to trigger it? What relieves it? What aggravates it?
A
P=Provocation/Palliation
2
Q
What does it feel like?
Use words to describe the pain, such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, or stretching.
A
Q= Quality/ Quantity
3
Q
Where is the pain located?
Does it radiate?
Does it feel as if it travels/ moves around?
Did it start elsewhere and is now localized to one spot?
A
R= Region/Radiation
4
Q
How severe is the pain on a scale of 0 to 10 with zero being no pain and 10 being the worst pain ever?
Does it interfere with activities?
How bad is it at its worst?
Does it force you to sit down, lie down, slow down?
How long does the episode last?
A
S=Severity Scale
5
Q
When/ at what time did the pain start?
How long did it last?
How often does it occur: hourly, daily, weekly, monthly? Is it sudden or gradual?
What were you doing when you first experienced it?
When do you usually experience it: daytime, night, early morning?
Are you ever awakened by it?
Does it lead to anything else?
Is it accompanied by other signs and symptoms?
Does it ever occur before, during or after meals?
Does it occur seasonally?
A
T=Timing
6
Q
Emergent, life-threatening, and immediate-ABCs
A
First level priority
7
Q
Next in urgency, requiring attention so as to avoid further deterioration-Pain, mental status changes, infection risk, abnormal lab value, elimination problems
A
Second level priority
8
Q
Important to patient’s health but can be addressed after more urgent problems are addressed.-Lack of knowledge, mobility problems, family coping
A
Third level priority
9
Q
The approach to treatment involves multiple disciplines
A
Collaborative problems
10
Q
What must the nurse assess first when providing culturally competent health care to an Asian American patient?
The tradition of the Asian American culture and the health care practices r/t health and wellness
The nurse’s heritage-based cultural values, beliefs, attitudes, and practices
Any differences between the nurse’s culture and the Asian American culture
The attitudes of Asian American cultures to the health care system in the United States
A
The correct answer is 2.
The nurse first needs to be able to determine what biases or differences exist prior to rendering care to any other culture.
Options 1, 3, and 4 are also important aspects of providing culturally component care; however the nurse must begin with his or her own beliefs.
11
Q
Social group with shared traits
A
Ethnicity
12
Q
Process of adopting culture and behavior of the majority culture
A
Acculturation:
13
Q
Unidirectional in a linear fashion
A
Assimilation
14
Q
Provide a brief description of pertinent patient variables,
demographics, clinical diagnosis, and location
A
Situation-SBAR
15
Q
Provide pertinent history as it directly relates to the patient’s current health status
A
Background- SBAR
16
Q
State pertinent assessment findings obtained with an interpretation of data
A
Assessment-SBAR
17
Q
State what you need or want for the patient in terms of medical treatment and/or assistance
A
Recommendation or Request-SBAR
18
Q
subjective sensation person feels from disorder documented in quotes
A
Symptom
19
Q
objective abnormality that can be detected on physical examination or in laboratory reports
A
Sign
20
Q
a gradual progressive process—causing decreased cognitive function even though the person is fully conscious and awake—and is not reversible.
A
dementia
21
Q
an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
A
Delirium
22
Q
AIDET
A
Acknowledge Introduction Duration Explanation Thank you
23
Q
Appearance
Behavior
Cognition function
Thought process
A
Mental Status Assessment
24
Q
implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing.
A
Culturally sensitive
25
implies that caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care
Culturally appropriate
26
Implies that the caregivers understand and attend to the total context of the invididuals' situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences
Culturally competent
27
Senses in order
Inspection
Palpation
Percussion
Auscultation
28
applies sense of touch to assess the following:
Texture, temperature and moisture
Organ location and size
Swelling, vibration, pulsation or crepitation
Rigidity or spasticity
Presence of lumps or masses
Presence of tenderness or pain
Should be performed slow and systematic
Start with light and proceed to deep.
Bimanual palpation is used for certain body parts or organs.
Palpation
29
Close, careful scrutiny, first of individual as a whole and then of each body system
Begins when you first meet person with a general survey
As you proceed through examination, start assessment of each body system
always comes first.
requires
good lighting.
adequate exposure.
occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view.
Inspection
30
Different parts of hands are best suited for assessing different factors:
Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps
Fingers and thumb: detection of position, shape, and consistency of an organ or mass
Dorsa of hands and fingers: best for determining temperature because skin here is thinner than on palms
Base of fingers or ulnar surface of hand: best for vibration
Palpation Techniques
31
Tapping person’s skin with short, sharp strokes to assess underlying structures
has following uses:
Mapping location and size of organs
Signaling density of a structure by a characteristic note
Detecting a superficial abnormal mass
vibrations penetrate about 5 cm deep.
Deeper mass would give no change in percussion.
Eliciting pain if underlying structure is inflamed
Eliciting deep tendon reflex using percussion hammer
Technique should be practiced to achieve competence.
Stationary hand: Pleximeter—middle finger hyperextension
Striking hand: Plexor—striking finger
Percussion
32
practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition.
Body mass index
33
pressure forcing blood into tissues, averaged over cardiac cycle
Mean arterial pressure (MAP
34
is force of blood pushing against side of its container, vessel wall.
Blood pressure (BP)
35
elastic recoil, or resting, pressure that blood exerts constantly between each contraction
Diastolic pressure
36
maximum pressure felt on artery during left ventricular contraction or systole
Systolic pressure
37
Short-term and self-limiting:
Often follows a predictable trajectory, and dissipates after an injury heals
Self-protective purpose
Acute pain
38
can be further divided into malignant (cancer related) and nonmalignant.
In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer.
Chronic pain
39
Transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome
Can result from:
End of dose medication failure
Result of incident or episodic pain
Treatment:
Shorten interval dosing and/or increase medication
Experience of pain is a complex biopsychosocial mechanism.
More clinical research is needed.
Rely on patient report as best indicator of pain
Breakthrough pain
40
reflects average blood glucose levels for the prior 2 to 3 months.
range from 5% to 7%.-normal
Glycosylated Hb, also known as HbA1c
41
format uses numbers to identify a response.
Three domains: alcohol consumption, drinking behavior or dependence, and adverse consequences (Maximum score: 40)
Useful in primary care with adolescents and older adults
Relatively free of gender and cultural bias
AUDIT-C: shorter form for acute and critical care units (maximum score: 12)
The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders.
Helpful with emergency department (ED) and trauma patients because it is sensitive to current as opposed to past alcohol problems.
AUDIT-Alcohol Use Disorders Identification Tests Questionnaire
42
Data collected by examiner asking questions
If patient is currently intoxicated or going through substance withdrawal, collecting any history data is difficult and unreliable.
However, when sober, most people are willing and able to give reliable data, provided that the setting is private, confidential, and nonconfrontational.
Ask about alcohol use
Do you sometimes drink beer, wine, or other alcoholic beverages?
If the answer is yes, then ask screening question about heavy drinking days, such as “How many times in the past year have you had five or more drinks a day (for men) or four or more drinks a day (for women)?
Use screening tools.
Identify problem drinking.
Require further assessment.
Subjective Data-Substance Abuse
43
Caregivers possess basic knowledge and understanding
Culturally sensitive
44
Caregivers apply knowledge to improve health outcomes.
Culturally appropriate
45
Caregivers apply a universal concept of understanding to all contextual aspects of care.
Culturally competent
46
Provision of health care across cultural boundaries in consideration of context
Cultural care
47
Data-gathering phase
Verbal skills include questions to patient and your responses to what is said.
Two types of questions
Open-ended—asks for narrative information
Closed—asks for specific information leading to a forced choice (yes or no)
Each has a different place and function in interview.
Working Phase-Communication
48
encourages patient to say more
Facilitation-verbal response
49
directed attentiveness
Silence-verbal response
50
echoes to help express meaning
Reflection-verbal response
51
names a feeling and allows its expression
Empathy-verbal response
52
asking for confirmation
Clarification-verbal response
53
clarifying inconsistent information
Confrontation-verbal response
54
makes association to identify cause or
Interpretation-verbal response
55
informing person by sharing factual and objective information
Explanation-verbal response
56
provides conclusion based on verified information which in turn identifies that the interview process is closing
Summary-verbal response
57
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Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using “why” questions
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Ten Traps of Interviewing
58
Gentle handling with quiet, calm voice
Birth-12 months
Cognitive Development
Communication Competence
59
Give one direction at a time and provide simple explanations
12 to 36 months-Toddlers
Cognitive Development
Communication Competence
60
Short directions with concrete explanation
3 to 6 years old-Preschoolers
Cognitive Development
Communication Competence
61
Ask questions to gather data and be nonjudgmental
7 to 12 years old: School-Age
Cognitive Development
Communication Competence
62
Respectful, honest attitude with focus on the individual
Starts with puberty-Adolescents
Cognitive Development
Communication Competence
63
Developmental task of finding purpose and evaluating existence
Address respectfully
Typically the interview process will take longer.
Consider appropriate pacing
Physical limitations
May need increased response time to process
May have more information to provide
Use therapeutic touch to provide empathy
The Older Adult -Communication Competence
64
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Method of interviewing focuses on assessment of:
Home environment
Education and employment
Eating
Activities (peer related)
Drugs
Sexuality
Suicide and depression
Safety from injury and violence
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Adolescent-HEEADSSS
Complete history
65
a person’s emotional and cognitive functioning.
mental status
66
aims toward simultaneous life satisfaction in work, caring relationships, and within the self
optimal functioning
67
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Posture
Body movements
Dress
Grooming and hygiene
Pupils
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Appearance-Mental Status Examination
68
Level of consciousness
Facial expression
Speech (quality, pace, articulation, word choice)
Mood affect
Behavior-Mental Status Examination
69
Orientation
Attention span
Recent and remote memory
New learning-the FOUR unrelated word test
Cognitive function-Mental Status Examination
70
Thought process
Thought content
Perceptions
Screen for suicidal thoughts
Thought Process-Mental Status Examination
71
Four main headings of mental status assessment: A-B-C-T
Appearance
Behavior
Cognition
Thought processes
72
Highly sensitive and valid memory test
Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall
Assessment Process
Pick four words with semantic and phonetic diversity; ask person to remember the four words.
To be sure person understood, have him or her repeat the words.
Ask for the recall of four words at 5, 10, and 30 minutes.
Normal response for persons younger than 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes.
New Learning: The Four Unrelated Words Test
73
loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident
Word comprehension: point to articles in the room or articles from pockets and ask person to name them
Reading: ask person to read available print; be aware that reading is r/t educational level
Writing: ask person to make up and write a sentence; note coherence, spelling, and parts of speech
Aphasia
74
Concentrates only on cognitive functioning
Standard set of 11 questions requires only 5 to 10 minutes to administer.
Useful for both initial and serial measurement
Detect dementia and delirium and to differentiate these from psychiatric mental illness.
Normal mental status average 27; scores between 24 and 30 indicate no cognitive impairment
Scores that occur with dementia and delirium are classified as follows: 18 to 23 = mild cognitive impairment; 0 to 7 = severe cognitive impairment.
As the score noted is 15, this would indicate that the patient had more than just mild cognitive impairment.
Mini-Mental State Exam (MMSE)
Supplemental Mental Status Examination
75
Examines more cognitive domains, more sensitive to mild cognitive impairment
Ten minutes to administer
Total score of 30 with a score of greater to or equal than 26 considered normal
Montreal Cognitive Assessment (MoCA)
Supplemental Mental Status Examination
76
screening test gives a chance to interact directly with child to assess mental status.
For child from birth to 6 years of age, Denver II helps identify those who may be slow to develop in behavioral, language, cognitive, and psychosocial areas.
An additional language test is the Denver Articulation Screening Examination.
Denver II screening test -Screening Tests-mental exam
77
school-age children, ages 7 to 11, is tool given to parent along with the history.
Covers five major areas: mood, play, school, friends, and family relations
It is easy to administer and lasts about 5 minutes.
“Behavioral Checklist” -Screening Tests-mental exam
78
Follow same A-B-C-T guidelines as for adults.
Adolescents-Screening Tests for mental exam
79
Check sensory status, vision, and hearing before any aspect of mental status.
Confusion is common and is easily misdiagnosed.
Presence of delirium can have serious affects.
Overall presence of dementia has decreased. determination of delirium versus dementia must be evaluated when cognitive impairment is present upon examination of the older adult.
Developmental Care of Aging Adults
80
Behavior: level of consciousness
Glasgow Coma Scale is useful in testing consciousness in aging persons in whom confusion is common.
Gives numerical value to person’s response in eye-opening, best verbal response, and best motor response
Avoids ambiguity when numerous examiners care for same person
Testing Aging Adults
81
Reliable and quick instrument to screen for cognitive impairment in healthy adults
Consists of three-item recall test and clock-drawing test
Tests person’s executive function, including ability to plan, manage time, and organize activities, and working memory
Those with no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested.
Score less than 3= Dementia
Mini-Cog
Aging Adults: Supplemental Mental Status Testing
82
involves problem solving and interpretation of analogies.
abstract reasoning
83
an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
A 78-year-old male presents with new onset confusion in the physician’s office.
An 89-year-old male has a urinary tract infection and is confused on admission to the hospital
Delirium
84
a gradual progressive process—causing decreased cognitive function even though the person is fully conscious and awake—and is not reversible.
The 65-year-old patient should be evaluated for dementia, as this is an ongoing problem.
Dementia
85
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
Alcohol problems underdiagnosed both in primary care settings and in hospitals
Excessive alcohol use often unrecognized until patients develop serious complications
Gold standard of diagnosis is well defined in
Diagnosing Substance Abuse
86
questions help identify at-risk drinking in women, especially pregnant women.
Tolerance: how many drinks can you hold? Or how many drinks does it take to make you feel high?
Worry: have close friends or relatives complained about your drinking?
Eye-opener: do you sometimes take a drink in morning when you first get up?
Amnesia: has a friend or family member told you about things you said but could not remember?
Kut down: do you sometimes feel the need to cut down?
Screening women for alcohol problems-TWEAK Questions
87
questionnaire for older adults who report social or regular drinking of any amount of alcohol.
Older adults have specific emotional responses and physical reactions to alcohol.
10 questions with yes/no responses that address these factors.
Two or more “yes” questions indicate alcohol problem.
SMAST-G Questionnaire
88
4 drinks/day for 8 weeks increases biochemical marker of alcohol drinking
Serum protein, gamma glutamyl transferase (GGT):
89
elevated 50-80 gram alcohol/day
Carbohydrate-deficient transferring (CDT)
90
Chronic drinking for months can elevate this
Serum aspartate aminotransferase (AST)
91
Sensitive indicator used to evaluate abstinence
Direct biomarker phosphatidylethanol(Peth)
92
not sensitive enough to use as only biomarker.
| Can detect earlier drinking after long period of abstinence
Mean corpuscular volume (MCV) index of red blood cell size
93
detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized.
Breath alcohol analysis
94
10 measured criteria with individual scoring to arrive at a composite score
Includes vital signs and oxygen saturation
Individual subscales include 7 criteria with the exception of Orientation which includes 4 criteria.
Based on continued assessment provides trended results to determine level of monitoring that is needed.
Score of 0 to 7 can monitor every 4 hours.
All scores below 8 for 72 hours, you can discontinue
Clinical Institute Withdrawal Assessment Scale (CIWA)
Most sensitive scale for objective measurement of withdrawal
95
maladaptive behavioral changes due to effects on CNS from substance
Intoxication
Substance-Abuse Disorders
96
daily or recurrent use such that impairment and decreased functioning has occurred leading to ongoing problems
Abuse
Substance-Abuse Disorders
97
physiological reliance
Dependence
Substance-Abuse Disorders
98
requires more to get the desired effect
Tolerance
Substance-Abuse Disorders
99
cessation of substance leads to physiological effects
Withdrawal
Substance-Abuse Disorders
100
failure to provide for children’s basic needs
Neglect:
101
nonaccidental injury that leads to harm of a child
Physical abuse
102
fondling, sexual acts, exploitation, and trafficking
Sexual abuse
103
pattern of behavior that harms a child’s sense of self-worth or development
Emotional abuse:
