Hung Phan

NURS 3013

Jones

14 January 2019

Introduction to Health Assessment

Chapter 1:

1. What is health assessment?

Health assessment is criteria that is utilized to help with the diagnosis and treatment of human
responses.

2. What is the nurse’s role in health assessment?

The role can be divided into two subjects: holistic and physical medical. The holistic role of
nurses in health assessment is to collect holistic subjective and objective data to determine a
client’s overall level of functioning in order to make a professional clinical judgment. The
physical medical assessment focuses primarily on the client’s physiologic development status.

3. What is the nursing process? What are the steps?

The nursing process is a system of steps that nurses take in order to effectively assess and
provide treatment for your client or patient. The steps are assessment, diagnosis, planning,
implementation, and evaluation

4. Define the four basic types of health assessment and an example of each.

The four basic types of health assessment are initial comprehensive assessment, ongoing or
partial assessment, focused or problem-oriented assessment, and emergency assessment.

An initial comprehensive assessment involves collection of subjective data about the client’s
perception of his or health of all body parts or systems, past health history, family history, and
life style and health practices as well as objective data gathered during a step-by-step physical
examination. An example would be a nurse continuing to assess a client as needed to monitor
progress and client outcomes after a total physical examination performed by a physician.

An ongoing or partial assessment of the client consists of data collection that reassesses any
problems that were initially found in the initial assessment. It occurs after the comprehensive
database is established. An example would be a partial assessment of a client admitted to the
hospital with lung cancer requires frequent assessment of respiratory rate, oxygen saturation,
lung sounds, skin color, and capillary refill.

A focused or problem-oriented assessment is performed when a comprehensive database exists

for a client who comes to the health care agency with a specific health concern. It consists of a
thorough assessment of a particular client problem and does not address areas not related to
 the problem. An example would be if a patient came in with an ear pain, the nurse would ask
him questions about the character and location of pain, onset, relieving, and aggravating
factors, and associated symptoms.

Emergency Assessment is a very rapid assessment performed in life threatening situations. An

example would be if the client is choking, cardiac arrest or drowning.

5. What are the four major steps of the assessment phase of the nursing process?

The four major steps of the assessment phase of the nursing process are: collection of subjective
data, collection of objective data, validation of data, and documentation of data

Chapter 2:

1. What does the nurse need to understand about the process of communication?

That communication is not only expressed verbally but also nonverbally as well such as
appearance, demeanor, facial expression, or attitude. Also its purpose is to establish rapport
and a trusting relationship with the client to elicit accurate and meaningful information.

2. What are the phases of a client interview? What is the purpose for each phase?

The phases of a client interview are preintroductory, introductory, working, and

summary/closing phases. The purpose of the preintroductory phase is review the client’s
medical record to obtain additional and beneficial information that can be used for medical
assessment. The purpose of the introductory phase is to explain the process of the interview
itself and to ensure the client that he or she is secure and ensure confidentiality. The purpose of
the working phase is to elicit the client’c comments about major biographical data, reasons for
seeking care, history of present health concern, past health history, family history, ROS, and for
current health problems, lifestyle and health practices and developmental level. The purpose of
the summary/ closing phase is to summarize the information obtained during the working phase
and validates problems and goals with the client.

3. How does age affect the interview process?

Age influences the approach and expectations of the interview. Older clients may have more
health concerns than younger clients and may seek health care more often. Many times, older
adult clients with health problems feel vulnerable and scared.

4. How does culture affect the interview process?

Culture significantly affects the interview process because it could possibly cause
misinterpretation and incorrect information obtained during the interview.

5. How do emotional variations affect the interview process?

Emotional variations can affect the accuracy of the information obtained from the client. They
may be scared or anxious about their health or about disclosing personal information, angry that
 they are sick or about having to have an examination, depressed about their health or other life
events, or they may have an ulterior motive for having an assessment performed (they are
trying to avoid work/school).

6. What is a complete health history? What are the components?

When a client is having a complete, head-to-toe physical assessment, collection of subjective

data usually requires that the nurse take a complete health history. The complete health history
is modified or shortened when necessary. The components are Biographical data, Reasons for
seeking health care, History of present health concern, Personal health history, Family health
history, ROS for current health problems, Lifestyle and health practices profile, and
Developmental level.

7. What information should be included in the source of history?

The information that should be included in the source of history are date and place of birth;
nationality or ethnicity; marital status; religious or spiritual practices; and primary and
secondary languages spoken, written, and read.

8. What is “reason for seeking care?” Difference between symptom and a sign?

The “reason for seeking care” consists usually of two questions. “What is your major health
problem or concern at this time?” and “How do you feel about having to seek health care?” The
first question assists the client in focusing on the most significant health concern and answers
the nurse’s question, “Why are you here?” or “How can I help you?” The second question, “How
do you feel about having to seek health care?” encourages the client to discuss fears or other
feelings about having to see a health care provider.

9. What is the present health or history of present illness (HPI)? What is the pneumonic COLDSPA?
PQRSTU?

Present health or history of present illness takes into account several aspects of the health
problem and asks questions whose answers can provide a detailed description of the concern.
COLDSPA is Character, Onset, Location, Duration, Severity, Pattern, Associated factors/ how it
affects the client. PQRSTU is another acronym used in health history.

10. What is included in personal (past) health history? Why is this information relevant to the nurse?

This portion of the health history focuses on questions related to the client’s personal history,
from the earliest beginnings to the present. Ask the client about any childhood illnesses and
immunizations to date. Adult illnesses (physical, emotional, and mental) are then explored. Ask
the client to recall past surgeries or accidents. Ask the client to describe any prolonged episodes
of pain or pain patterns he or she has experienced. Inquire about any allergies (food, medicine,
pollens, other) and use of prescription and OTC medications.

11. What is the significance of family history? Which relatives should family history be collected for?
 As researchers discover an increasing number of health problems that seem to run in families
and that are genetically based, the family health history assumes greater importance. In
addition to genetic predisposition, it is also helpful to be aware of other health problems that
may have affected the client by virtue of having grown up in the family and being exposed to
these problems. The family history should include as many genetic relatives as the client can
recall. Include maternal and paternal grandparents, aunts and uncles on both sides, parents,
siblings, and the client’s children.

12. What is the purpose of the review of systems?

In the review of systems (or review of body systems, ROS), each body system is addressed and
the client is asked specific questions to elicit further details of current health problems or
problems from the recent past that may still affect the client or that are recurring.

13. What is the purpose of assessing lifestyle and health practice beliefs? What does that include?

This is a very important section of the health history because it deals with the client’s human
responses, which include nutritional habits, activity and exercise patterns, sleep and rest
patterns, self-concept and self-care activities, social and community activities, relationships,
values and beliefs system, education and work, stress level and coping style, and environment.

14. How might the complete health history differ for infants & children? Adolescents?

The health history will differ greatly for infants & children and adolescents because they may
not have necessarily a complex history of medical conditions as those of the elderly or adults.

Chapter 3

1. How does the nurse prepare him/herself for the physical exam?

The nurse prepares him/herself in three aspects in order to ensure the quality of the data you
elicit from the client. As a beginning examiner, it is helpful to assess your own feelings and
anxieties before examining the client. Anxiety is easily conveyed to the client, who may already
feel uneasy and self-conscious about the examination.

2. How does the nurse prepare the physical environment for the physical exam?

By preparing the physical environment using these conditions. Comfortable, warm room
temperature: Provide a warm blanket if the room temperature cannot be adjusted. Private area
free of interruptions from others: Close the door or pull the curtains if possible. Quiet area free
of distractions: Turn off the radio, television, or other noisy equipment. Adequate lighting

3. How does the nurse prepare the client for the physical exam?

At the end of the interview, explain to the client that the physical assessment will follow and
describe what the examination will involve. Respect the client’s desires and requests related to
the physical examination. Some client requests may be simple, such as asking to have a family
member or friend present during the examination.
 4. What are standard precautions that should be utilized with all patients?

Assume that every person is potentially infected or colonized with an organism that could be
transmitted in the health care setting, and apply the following infection control practices during
the delivery of health care.

5. What are the physical exam (assessment) techniques, include a one sentence description of
each.

The physical exam techniques are inspection, palpitation, percussion, and auscultation.
Inspection involves using the senses of vision, smell, and hearing to observe and detect any
normal or abnormal findings. Palpation consists of using parts of the hand to touch and feel for
characteristics such as texture, temperature, moisture, etc. Percussion involves tapping body
parts to produce sound waves. Auscultation is a type of assessment technique that requires the
use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular
system, movement of the bowel, and movement of air through the respiratory tract.

6. How does age affect the physical exam?

Patients of the older age/ geriatric conditions may have trouble getting into anatomical
positions. Nurses should allow for rest periods and provide clear and concise directions

Chapter 4

1. What is the significance of validating client data? The process?

Validation of data is the process of confirming or verifying that the subjective and objective data
you have collected are reliable and accurate. The steps of validation include deciding whether
the data require validation, determining ways to validate the data, and identifying areas for
which data are missing. Failure to validate data may result in premature closure of the
assessment or collection of inaccurate data.

2. What situations require client data to be rechecked or verified?

Discrepancies or gaps between subjective and objective data. Discrepancies in what the client
says at one time versus another time. Also when there are abnormal and/or inconsistent
findings

3. Why is documentation of client data necessary?

Provides a chronologic source of client assessment data and a progressive record of assessment
findings that outline the client’s course of care. Ensures that information about the client and
family is easily accessible to members of the health care team; provides a vehicle for
communication; and prevents fragmentation, repetition, and delays in carrying out the plan of
care.

4. What are the types of assessment forms?

 The types of assessment forms are Open-ended forms (traditional), Cued or checklist forms,
Integrated cued checklist, and Nursing minimum data set.

5. What is SBAR? How is used? Why is it important?

The SBAR (Situation, Background, Assessment, Recommendation) model of communication will

be used throughout this book to demonstrate a consistent way to communicate assessment
data. It is one of the most common handover mnemonic models used in health care. The Joint
Commission recognizes it as a best practice for standardized communication among health care
providers.

Chapter 5

1. What is critical thinking? How do nurses use it to formulate clinical judgments?

Critical thinking for nurses is using. reasoning skills to interpret data accurately. Diagnostic
reasoning is a form of critical thinking. Due to the complex nature of nursing as both a science
and an art, the nurse must think critically in a rational, self-directed, intelligent, and purposeful
manner.

2. What are the steps of data analysis?

The steps of data analysis are: identify strengths and abnormal data, cluster data, draw
inferences, propose possible nursing diagnoses, check for defining characteristics, confirm or
rule out diagnosis, document conclusions.

3. What is the end result of data analysis?

The end result of data analysis are the records for diagnoses.

4. What is a nursing diagnosis? What are the types? Provide an example of each.

Nursing diagnosis is clinical judgment about individuals, family, or community responses to

actual and potential health problems and life processes (NANDA), provides the basis for
selecting nursing interventions to achieve outcomes for which the nurse is accountable.

5. What are collaborative problems?

Physiologic complications that nurses monitor to detect their onset or changes in status

Chapter 7

1. Summarize each developmental theory (Freud, Erikson, Kohlberg, and Piaget).

Freud’s developmental theory was the concept of psychoanalysis and believed that personality
development was based on understanding the individual life history of a person. Erikson
developmental theory that expanded Freud’s theory with psychosocial being defined as the
intrapersonal and interpersonal responses of a person to external events. Erikson concluded
that societal, cultural, and historical factors—as well as biophysical processes and cognitive
 function—influence personality development. Kohlberg’s developmental theory that proposed
that individual morality has been viewed as a dynamic process that extends over one’s lifetime,
primarily involving the affective and cognitive domains in determining what is “right” and
“wrong.” Piaget’s developmental theory is a description and an explanation of the growth and
development of intellectual structures. He focused on how a person learns, not what the person
learns.

Chapter 8

1. What is a survey of general health status (general survey). What are the components?

The general survey is the first part of the physical examination that begins the moment the
nurse meets the client. It requires the nurse to use all observational skills while interviewing and
interacting with the client. These observations will lead to clues about the health status of the
client. The outcome of the general survey provides the nurse with an overall impression of the
client’s whole being. The components are Physical development and body build, Gender and
sexual development, Apparent age as compared to reported age, Skin condition and color, Dress
and hygiene, Posture and gait, Level of consciousness, Behaviors, body movements, and affect,
Facial expression, Speech, Vital signs.

2. What are vital signs?

Vital signs are the body’s indicators of health such as temperature, pulse, respirations, blood
pressure, and pain.

3. What is normal temperature? What are the ways it can measured? Influencing factors?

Normal temperature is between 96.0°F and 99.9°F orally. Temperature can be measured orally,
axillary, and rectally. Influencing factors include strenuous exercise, stress, and ovulation.

4. What is a pulse? What is the “normal”? What should the nurse measure when assessing pulse?
How is pulse documented?

A pulse is a shock wave is produced when the heart contracts and forcefully pumps blood out of
the ventricles into the aorta. The “normal” is a shock wave with an amplitude for 2+. The nurse
should measure characteristics such as rhythm, amplitude and contour, and elasticity. It can be
documented radially.

5. How should the nurse assess and document normal respirations?

The nurse should observe respirations without alerting the client by watching chest movement
while continuing to palpate the radial pulse. Notable characteristics of respiration are rate,
rhythm, and depth.

6. What is blood pressure? What are factors that influence blood pressure?

Blood pressure is the pressure exerted on the walls of the arteries. The factors that influence
blood pressure are cardiac output, elasticity of arteries, blood volume, heart rate, and viscocity.
 7. What are additional techniques that may be assessed with vital signs?

Pain screening is an additional technique that may be assessed with vital signs

Chapter 9

1. What is pain?

Pain is an unpleasant sensory and emotional experience, which we primarily associate with
tissue damage or describe in terms of such damage

2. How does pain develop?

Pain develops from messages from the nervous system in response to abnormalities in health.

3. What are the sources of pain?

The source of pain stimulates peripheral nerve endings (nociceptors), which transmit the
sensations to the central nervous system (CNS). They are sensory receptors that detect signals
from damaged tissue and chemicals released from the damaged tissue

3. What are the types of pain?

The types of pain are acute, chronic, and cancer.

4. Does developmental competence influence pain? If yes, how?

Yes because toddlers and infants often exhibit signs of pain even with just discomfort and the
elderly become less sensitive due to aging tissues.

5. Are there gender differences related to pain?

Yes, women tend to tolerate and have a higher pain threshold due to their responsibility of
childbirth

6. What is the best assessment indicator of pain in an adult?

The best assessment indicator of pain in an adult is the universal pain assessment tool.