Physical Examination & Health Assessment: NSG 211 Quiz 1 Flashcards

Consist of information provided by the affected individual/patient (i.e. what patient says about their history).

The collection of subjective and objective data about a patient’s health state.

Include information obtained by the health care provider through physical assessment, the patient’s record, and laboratory studies (i.e. what you observe by inspecting, percussing, palpating, and auscultating during physical exam).

The totality of information available about the patient (from patient’s records and laboratory studies).

The process of analyzing health data and drawing conclusions to identify diagnoses.

1. Attending to initially available cues (pieces of information, signs, symptoms, or laboratory data).

2. Formulating diagnostic hypotheses (tentative explanations for a cue or a set of cues and can serve as a basis for further investigation).

3. Gathering data relative to the tentative hypotheses.

4. Evaluating each hypothesis with the new data collected (which leads to a final diagnosis).

1. Assessment (Collect data, use evidence-based assessment (EBA) techniques & document relevant data).

2. Diagnosis (Compare clinical findings with normal and abnormal variation and developmental events; Interpret data: identify clusters of clues, make hypotheses, test hypotheses, & derive diagnoses; Validate diagnoses; Document diagnoses).

3. Outcome identification (Identify expected outcomes; Individualize to the person; Culturally appropriate; Realistic and measurable; Include a timeline).

4. Planning (Establish priorities; Develop outcomes; Set timelines for outcomes; Identify interventions; Integrate EB trends and research; Document plan of care (POC)).

5. Implementation (Implement in a safe and timely manner; Use EB interventions; Collaborate with colleagues; Use community resources; Coordinate care delivery; Provide health teaching and health promotion).

6. Evaluation (Progress toward outcomes; Conduct systematic, ongoing, criterion-based evaluation; Include patient and significant others; Use ongoing assessment to revise diagnoses, outcomes, & plan; Disseminate results to patient and family).

The multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment.

1. Identifying Assumptions.

2. Identifying organized and comprehensive approaches.

3. Validation.

4. Normal vs. Abnormal.

5. Making Inferences.

6. Clustering Related Cues.

7. Relevant vs. irrelevant.

8. Recognizing inconsistencies.

9. Identifying patterns.

10. Identifying missing information.

11. Promote Health.

12. Diagnosing actual and potential (risk) problems.

13. Setting priorities with >1 Diagnosis.

14. Identifying Patient (Pt.)-centered outcomes.

15. Specific Interventions.

16. Evaluating & Correcting Thinking.

17. Determining a Comprehensive Plan.

Set priorities by using the three levels of priority problems.

• 1st Level: Emergent/Life-Threatening
  • (ABC’s: Airway, Breathing, Cardiac/Circulation + V [Vital Signs]).
• ​2nd Level: Requires prompt action.
• 3rd Level
  • Example: Teaching/Health Promotion
• Collaborative Problems
  • Team Approach

These problems are emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing.

These priority problems require prompt intervention to prevent deterioration, and may include a mental status change or acute pain.

These problems are important to the patient’s health, but can be addressed after more urgent problems. Examples include lack of knowledge or family coping.

The biomedical model (Western medicine) views health as the absence of disease. It focuses on collecting data on biophysical signs and symptoms and on curing disease.

The holistic health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together.

Evidence-based practice is a systematic approach to practice that uses the best evidence, the clinician’s experience, and the patient’s preferences and values to make decisions about care and treatment.

1. Comprehensive (CPE)
2. Problem-Focused
3. Interval (Follow-up)
4. Emergency

A complete (or total health) database includes a complete health history and a full physical examination.

A focused (or problem-centered) database is used for a limited or short-term problem. It is smaller in scope and more targeted than the complete database.

A follow-up database evaluates the status of any identified problem at regular intervals to follow up on short-term or chronic health problems.

An emergency database calls for rapid collection of data, which commonly occurs while performing lifesaving measures.

A systematic appraisal of an individual’s beliefs, values, and practices conducted for the purpose of providing culturally competent care.

Cultural care is professional health care that is culturally sensitive, appropriate, and competent. To develop cultural care, you must have knowledge of your personal heritage and the heritage of the nursing profession, the health care system, and the patient.

1. It is learned from birth through language acquisition and socialization.
2. It is shared by all members of the same cultural group.
3. It is adapted to specific conditions related to environmental and technical factors.
4. It is dynamic and ever changing.

Viewing your way of life, beliefs, culture, etc. is the only way.

The process of adapting to and acquiring another culutre.

Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. They function within a large culture.

The process by which a person develops a new cultural identity and becomes like the members of the dominant culture.

Dual pattern of identification and often of divided loyalty.

Biomedical (or scientific) theory of illness causation is based on the assumption that all events in life have a cause and effect; that the human body functions more or less mechanically, that all life can be reduced or divided into smaller parts (e.g. human person = body+mind+spirit), and that all of reality can be observed and measured.

Naturalistic (or Holistic) Theory is the perspective that believes that human life is only one aspect of nautre and a part of the general order of the cosmos. People may believe that the forces of nature must be kept in natural balance or harmony.

The Yin/Yang Theory (is what Asians usually believe in) states that all organisms and objects in the universe consist of yin and yang energy forces; health is when all aspects of the person are in perfect balance.

Yin energy represents the female and negative forces: emptiness, darkness, and cold (cold foods too); Yang energy represents the male and positive forces: emitting warmth and fullness (hot foods).

The four humors of the body (blood, phlegm, black bile, and yellow bile) regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatmen of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore teh balance of the humors.

According to the hot/cold theory, the person is whole, not just a particular ailment; health consists of a positive state of total well-being, including phyiscal, psychological, spiritual, adn social aspects.

The basic premise is that the world is seen as an arena in which supernatural forces dominate and that the fate of the world, and those in it, depends on the action of supernatural forces for good or evil. Examples: voodoo, witchcraft, faith healing, amulets, acupuncutre, herbal therapies, hypnosis, therapeutic touch and biofeedback.

CHESS:

• C = Culture/ethnicity, language
• H = Health Beliefs
• E = Economic/Education
• S = Spiritual
• S = Significant Other

1. Sender and Receiver

2. Verbal and Nonverbal communication.

3. Internal and external factors.

Internal factors are what you bring to the interview. Three internal factors promote good communication: liking others, expressing empathy, and having the ability to listen.

External factors relate mainly to the physical setting. You can foster good communication with certain external factors, such as by ensuring privacy, preventing interruptions, creating a conducive environment, and documenting responses without interfering with the conversation.

1. An introduction.
2. A working phase.
3. A closing.

• During the first phase, introduce the interview.
  • ​Introduce yourself, state your role in the agency, give reason for interview, and how long it should take.
• During the working phase, gather data.
  • Start with open-ended questions, which ask for narrative information. Then use closed questions, which ask for specific information in short, one- or two-word answers.
• During the closing, signal that the interview is ending.
  • ​Gives the patient one last chance to share concerns or express himself or herself.
  • Briefly summarize what you learned during the interview.
  • Always thank the patient for cooperating.

• Faciliation
  • aka "General leads"
  • Responses that encourage the patient to say more or continue the story.
• Silence
  • Especially after open-ended questions.
  • aka "Thinking silence" for the patient.
• Reflection
  • ​Repeating/echoing part of the patient's words. It focuses further attention on a specific phrase and helps the person continue in their way.
  • Prompts patient to elaborate on the problem.
• Empathy ​
  • Many people have trouble expressing these feelings, perhaps becasue of confusion or embarrassment.
  • An empathic response recognizes a feeling, accepts it (puts it into words), and allows the person to express it without embarrassment.
    • An empathic response helps the patient feel accepted and can deal with the feeling openly.
    • Strengthens rapport.
• Clarification
  • ​Use when the person's word choice is ambiguous or confusing.
  • Also used to summarize the person's words, simplify the words to make them clearer, and then ask if you are on the right track.

Use only when merited by the situation; if used too often, you can take over at the patient's expense.

• Confrontation
  • ​Certain action, feeling, or statement is observed and you now focus the patient's attention on it, giving honest feedback about what you see or feel.
  • Or you may confront the person when you notice parts of the story are inconsistent.
• Interpretation
  • ​Based on your inference or conclusion.
  • It links events, makes associations, or implies cause.
  • Also ascribes feelings and helps the person understand their own feelings in relation to the verbal message.
  • Person may correct it if it's the wrong inference, but it may help prompt further discussion.
• Explanation
  • ​Sharing factual and objective information.
• Summary
  • ​A final review of what you understand the perosn's information/story.
  • Condenses the facts adn presents a survey of how you preceive the health problem or need.
  • Signals that the termination of the interview is near.

1. Providing false assurance or reassurance.
2. Giving unwanted advice.
3. Using authority.
4. Using avoidance language.
5. Engaging in distancing.
6. Using professional jargon.
7. Using leading or biased questions.
8. Talking too much.
9. Interrupting.
10. And using “why” questions.

1. Body Posture
2. Eye Contact
3. Gestures
4. Facial Expressions
5. Tone of Voice
6. Touch
7. Active Listening
8. Physical Apperance

The purpose of the complete health history is to collect subjective data, which is what the person says about himself or herself.

By combining this subjective data with objective data from the physical examination and diagnostic tests, you create a database to make a judgment about the person’s health status.

1. To evulate past and present health state of each body system.
2. To double-check for omission of significant data in the Present Illness section.
3. To evaluate health promotion practices.

1. General Overall Health State
2. Skin
3. Hair
4. Head
5. Eyes
6. Ears
7. Nose and Sinuses
8. Mouth and Throat
9. Neck
10. Breast
11. Axilla
12. Respiratory System
13. Cardiovascular
14. Peripheral Vascular
15. Gastrointestinal
16. Urinary System
17. Male Genital System
18. Female Gential System
19. Sexual Health
20. Musculoskeletal System
21. Neurologic System
22. Hematologic System
23. Endocrine System

The Functional Assessment measures a person's self-care ability in the areas of general physical health or absence of illness.

This assessment usually includes:

1. Self-Esteem/Self-Concept
2. Acitivity/Exercise
3. Sleep/Rest
4. Nutrition/Elimination
5. Interpersonal Relationships/Resources
6. Spiritual Resources
7. Coping and Stress Managment
8. Personal Habits
9. Alcohol
10. Illicit or Street Drugs
11. Environment/Hazards
12. Intimate Partner Violence
13. Occupational Health

• For sick patients, the health history includes a detailed, chronologic record of the health problem.
• For all patients, it is a screening tool for abnormal symptoms, health problems, and concerns. It also records the patient’s responses to health problems.

1. Collect biographic data (such as the patient’s name, address, and date of birth as well as language and communication needs).
2. Note the source of the history (which is usually the patient, but may be someone else, such as a relative or interpreter).
3. Obtain the reason for seeking care, formerly known as the chief complaint (in the patient’s own words, briefly describe the reason for the visit).
4. Record the present health or history of present illness (For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care).
   • When a patient reports a symptom, perform a symptom analysis.
     • A mnemonic that could be used is PQRSTU: Provocative or palliative, Quality or quantity, Region or radiation, Severity scale, Timing, and Understanding the patient’s perception of the problem.
5. Investigate past health events (such as illnesses, injuries, hospitalizations, and allergies [and their rx] as well as current medications).
6. Gather a family history to help detect health risks for the patient (to aid in this process, draw a pedigree or genogram).
7. Perform a review of systems to evaluate the past and present health of each body system, double-check for significant data, and assess health promotion practices (for each body system, assess for symptoms and health-promoting behaviors).
8. Perform a functional assessment (including activities of daily living, such as bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking, and other factors).

1. Lethargic (or Somnolent)
2. Obtunded
3. Stupor or Semi-Coma(tose)
4. Coma
5. Acute Confusional State (delirium)

• Not fully alert.
• Drifts off to sleep if not simulated.
• When aroused when called in a normal voice (to name), but looks drowsy.
• Responds appropriately to questions or commands, but thinking seems slow or fuzzy.
• Inattentive
• Loses train of thought.
• Spontaneous movements decrease.

Traditional it's the state between lethargy and stupor.

• Sleeps most of the time.
• Difficult to arouse: needs loud shout or vigorous shake.
• Acts confused when aroused.
• Converses in monosyllables.
• Speech mumbled and incoherent.
• Requires constant stimulation for cooperation, even marginal cooperation.

• Spontaneously unconscious.
• Responds only to persistent/vigorous shake or pain.
• Has appropriate motor response (i.e. withdraws hand to avoid pain).
• Can only groan, mumble, or move restlessly.
• Reflex activity persists.

• Completely unconscious.
• No response to pain; or any external or internal stimuli
  • E.g. when suctioned, doesn't try to push catheter away.
• Light coma has reflex activity, but no purposeful movement.
  • Deep coma has no motor response.

• Clouding of consciousness.
  • Dulled cognition, impaired alertness.
• Inattentive.
• Incoherent conversation.
• Impaired recent memory and confabulatory (fabricate imaginary experiences as compensation for loss of memory) for recent events.
• Often agitated and having visual hallucinations.
• Disoriented, with confusion worse at night when environment stimuli are decreased.

1. Flat affect (blunted affect)
2. Depression
3. Anxiety
4. Inappropriate Affect
5. Fear
6. Irritation
7. Rage
8. Ambivalence

Definition: Lack of emotional response; no expression of feelings; voice monotonous and face immobile.

Clinical Example: Topic varies, expression doesn't.

Definition: Furious, loss of control.

Clinical Example: Person has expressed violent behavior toward self or others.

Definition: Annoyed, easily provoked, impatient.

Clinical Example: Person internalizes a feeling of tension, and a seemingly mild stimulus "sets them off."

Definition: Worried, uneasy, apprehensive; external danger is known and identified.

Clinical Example: Fear of flying in airplanes.

Definition: Affect clearly discordant with the content of the person's speech.

Clinical Example: Laughs while discussing admission for liver biopsy.

Definition: Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown.

Clinical Example: "I feel nervous and high strung; I worry all the time; I can't seem to make up my mind."

Definition: The existence of opposing emotions toward an idea, object, person.

Clinical Example: A person feels love and hate toward another at the same time.

Definition: Sad, gloomy, dejected; symptoms may occur with rainy weather, after a holiday, or with an illness; if the situation is temporary, symptoms fade quickly.

Clinical Example: "I've got the blues."

Abnormalities of Thought Content:

1. Phobia
2. Delusions

Abnormality of Perception:

1. Hallucination

Abnormalities of Thought Content:

1. Phobia
   • ​​Definition: Strong, persistent, irrational fear of an object or situation; feels driven to avoid it.
   • Clinical Example: Cats, dogs, heights, enclosed spaces, etc.
2. Delusions
   • ​​Definition: Firm, fixed, false beliefs; irrational; person clings to delusion despite objective evidence to contrary.
   • Clinical Example: Grandiose = person believes they are God; famous, historical, or sports figure; or other well-known person.
     • ​Persecution = "They are out to get me."

Abnormalities of Perception:

1. Hallucination
   • ​​Definition: Sensory perceptions for which there are no external stimuli; may strike any sense: visual, auditory, tactile, olfactory, gustatory.
   • Clinical Example:
     • Visual: seeing an image (ghost) of a person who is not there.
     • ​Auditory: hearing voices or music.

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

• It's concentrated watching and always comes first.
  • Involves no touching.
• A careful scrutiny of the individual as a whole and then of each body system.
• Compare right and left sides of the body.

• Follows inspection and confirms points noted during it.
• It applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, signs of swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.

• Fingertips: fine tactile discrimination.
  • Skin texture, swelling, pulsation, and determining presence of lumps.
• Grasping between fingers and thumb: detects position, shape, and consistency of an organ or mass.
• Dorsa (backs) of hands and fingers: determining temperature.
  • Because skin is thinner than palms.
• Base of fingers (metacarpophalangeal joints) or ulnar surface of hands: vibrations.

It's tapping the person's skin with short, sharp strokes to assess underlying structures.

This technique is used to assess the location, size, and density of an organ, detect an abnormal mass, or elicit a deep tendon reflex.

• Place your interphalangeal joint firmly on the patient’s skin with the rest of your hand lifted off the skin.
• Then use the middle finger of your dominant hand (striking finger) to strike the stationary finger at a right angle.
• Deliver two short, sharp taps, using a quick wrist action.

1. Resonant
2. Hyperresonant
3. Tympany
4. Dull
5. Flat

• Amplitude: M edium-loud.
• Pitch: L ow.
• Quality: C lear, hollow.
• Duration: Moderate.
• Sample Location: O ver normal lung tissue.

• Amplitude: L ouder.
• Pitch: L ower.
• Quality: Booming.
• Duration: Longer.
• Sample Location: Normal over child's lung; abnormal in adult's: over lungs with increased amount of air, as in emphysema.

• Amplitude: Loud.
• Pitch: High.
• Quality: Muscial and drumlike (like kettle drum).
• Duration: Sustained l ongest.
• Sample Location: Over air-filled viscus (e.g. the stomach, the intestine).

• Amplitude: Soft.
• Pitch: High.
• Quality: Muffled thud.
• Duration: Short.
• Sample Location: Relatively dense organ (e.g. liver or spleen).

• Amplitude: Very s oft.
• Pitch: High.
• Quality: A dead stop of sound, absolute dullness.
• Duration: Very short.
• Sample Location: When no air is present; over thigh muscles, bone, or over tumor.

• It's listening to sounds made by the body, usually using a stethoscope.
• The heart, blood vessels, lungs, and abdomen are commonly auscultated areas.

• It's your overall impression of the patient and begins when you first encounter him or her.
• The F our areas covered are:
  1. Physical appearance
  2. Body structure
  3. Mobility
  4. Behavior
• Changes in any of these areas may indicate illness.

Includes an assessment of the person’s:

• Age
• Sex /Gender
• Level of consciousness
• Skin color
• Facial features (as well as any signs of distress).

Assessment includes the person’s:

• Stature
• Nutrition
• Symmetry
• Posture
• Position
• Body build (or contour).
  • In this area, obvious physical deformities are noted.

Assessment includes the person’s:

• Gait and Range of Motion.

Assessment includes the person’s:

• Facial expression
• Mood and Affect
• Speech
• Dress
• Personal hygiene.

• The Oral Route is accurate and convenient.
  • However, it may not be appropriate for a patient who is comatose or confused, has a wired mandible or facial dysfunction, or cannot close the mouth.
• The Rectal Route is used when other routes are not practical.
  • Disadvantages of the rectal route are patient discomfort and the time-consuming and disruptive nature of the activity.
• The Tympanic Route requires a tympanic membrane thermometer, which is a noninvasive, nontraumatic device that is quick and efficient to use.

• For a resting person, the normal temperature is: 37 degrees C (98.6 degrees F).
• The normal range is: 35.8 degrees to 37.3 degrees C (96.4 degrees to 99.1 degrees F).

• The three qualities are: rate, rhythm, and force.
• For an adult at rest, the rate normally ranges from 60 to 100 bpm (beats per minute), but varies with age and sex.
• The pulse rhythm normally has an even, regular tempo.
• The force of the pulse shows the strength of the heart’s stroke volume.
  • Record the force on a three- or four-point scale, depending on your agency’s policy.

• It's a heart rate of less than 50 bpm.
• It's normal within the well-trained athlete whose heart muscle develops along with the skeletal muscle.
  • It's stronger and more efficient; able to push out a larger stroke volume with each beat.
    • Thus requiring fewer beats per minute to maintain stable cardiac output.

• It's a heart rate of over 90 bpm.
• It occurs normally with anxiety or increased exercise.
  • To match the body's demand for increased metabolism.

• Sinus Arrhythmia: the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing down to normal with expiration.
  • ​Inspiration momentarily causes a decreased stroke volume from the left side of the heart and to compensate, the heart rate increases.

• Systolic pressure: the maximum pressure felt on the artery during left ventricular contraction (or systole).
• Diastolic pressure: the elastic recoil (or resting) pressure the blood exerts constantly between contractions.

120/80 mmHg (millimeters of mercury)

• Systolic: Less than 120 mmHg.
• Diastolic: Less than 80 mmHg.

• Systolic: 120-139 mmHg.
• Diastolic: 80-89 mmHg.

• Systolic: 140-159 mmHg.

​ Or...

• Diastolic: 90-99 mmHg.

• Systolic: 160 mmHg or higher.

​Or...

• Diastolic: 100 mmHg or higher.

• I: Systolic pressure
• IV: muffling of sounds
• V: Diastolic pressure

• Acute myocardial infarction (AMI): decreases cardiac output.
• Shock: decreases cardiac output.
• Hemorrhage: decreases total blood volume.
• Vasodilation: decreases in peripheral vascular resistance.
• Addison's disease (hypofunction of adrenal glands).

• Use when patient c/o (complains of) dizziness/syncope or suspect fluid depletion.

• A drop in systolic pressure of more than 20 mmHg.
  • Or an orthostatic pulse increase of 20 bpm or more when a quick change of position (laying down, or sitting to a standing position).

• Measures Pulse & Oxygen saturation
• Normal Spo2 (Adult): >97%