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Health Assessment (317) Exam 1 Information Questions And Accurate Answers
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Health Assessment (317) Exam 1 InformationQuestions And Accurate Answers
Procedure to establish data base, identify nursing diagnoses, monitor status of
identified problems, and screen for health problems
What is being measured during a physical examination?
Complete physical examination
Includes health history interview and complete head-to-toe examination
Focussed physical examination
Examination for a particular topic, body region, or functional capability
System-specific examination
Focussed examination of one body system
Ongoing assessment
Done after initial assessment and preferably in every encounter of the patient Physical
examination sequence of events Inspection, palpation, percussion, auscultation and
sometimes olfaction Description Direct auscultation Listening without an instrument
Indirect auscultation Listening with a stethoscope General survey Assessment of
appearance, behaviour, body type, posture, speech, mental state, dress, grooming,
hygiene, vital signs, height, weight and BMI What is examined in general survey? Skin
temperature, moisture, texture and turgor What to observe during skin examination?
Hyperventilation
Hyperventilation Breathing rapidly and deeply, forcing excessive removal of CO2 by the
alveoli Nail color, shape, and texture What would you expect to look for when examining
the nails? Hypoventilation Breathing rate is slow or shallow; lung exchange of air is at its
minimum Hypoxia Oxygen levels are insufficient in body tissues Bronchodilators
Medications that dilate constricted airways; can be either oral or inhaled Respiratory
anti-inflammatory agents Medications that treat inflammation in airways; important for
sensitive airways Nasal decongestants Medications that help alleviate nasal congestion
by acting on nasal mucosa Antihistamines
Drugs to block the effects of histamine, for allergies of upper respiratory and nasal
Medications for coughs in preparation To decrease coughing (useless) and to increase
productive coughs Hypoxemia Low levels of oxygen in arterial blood Eupnea Normal
rate of breathing (12-20 rpm) Tachypnea Rapid, shallow breathing (24+ rpm) Bradypnea
,Slow respirations (less than 10 rpm) Kussmal respirations Very deep and rapid
respirations, indicative of a metabolic disorder Biot's respirations Irregular respirations
of changing depth - generally shallow Cheyne-Stokes respirations Slow increase and
then decrease in depth of breathing followed by apnea Apnea No breathing Respiratory
exam
What needs to be assessed in a respiratory examination?
Open-ended questions
Request narrative responses and assist the eliciting of the patient's story
Closed/direct questions
Request specific information and elicit short one or two-word answers, a yes or no
answer, or a forced choice
Addressing the patient, active listening, establishment of trust, being assertive,
restating, clarifying, and validation of messages, interpreting body language and
sharing observations, exploration of issues, use of silence, and summarizing of the
conversation
What are some helpful ideas to include to encourage therapeutic communication?
Providing a list of questions, to fire-hose information, asking why, changing the subject
inappropriately, failure to probe, approval or disapproval, advice giving, false
reassurance, stereotyping, and patronizing language
What are some therapeutic communication barriers?
Data collection to allow you to help the patient
What is the purpose of health assessment?
Nursing health history, physical examination, clinical reasoning, and
documenting/communicating findings
What are the four steps to health assessment?
Information the examiner elicits on interview, what the patient says and tells you, and
form the subjective database
What is involved in nursing health history?
What the examiner sees/hears/feels on examination, inspection, palpation, percussion,
auscultation, and forms the objective database
What is involved in the physical examination?
Identifying and interpreting abnormal findings, prioritizing data, making/testing
hypotheses, establishing a nursing diagnosis, and developing/negotiating a plan of care
, What is the process/ steps to clinical reasoning?
Recording/communicating findings
Chart notes are a form of the _______________________ process of health assessment
Onset, location/radiation, duration, character, aggravating factors, relieving factors,
timing, and severity
What does one ask about when taking a history of present illness symptom analysis?
State the major concerns identified by the client, describe what will happen next for the
client and begin the clinical reasoning process
What should be included in the closing the interview/completing the health history?
Assessment findings, client preferences, and evidence-based practices
What should your nursing plan be based on?
Nonmaleficence
To do no harm
Beneficence
To act and promote the good of the client
Autonomy
Client's right to make decisions
Justice
Treat everyone regardless of ability to pay for treatment, social status, gender identity,
or cultural and religious background
Confidentiality
Respect rights of the client to maintain privacy
Identify, situation, background, assessment, recommendations, and read back orders
What is ISBARR?
State team member's name and title
Describe the identify component of the ISBARR
Provide the circumstances that have created the need for the communication
Describe the situation component of the ISBARR
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