Class notes
NURS 261 Midterm Notes
- Course
- NURS 261
- Institution
- Virginia Commonwealth University
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Virginia Commonwealth University School of NursingNURS 261 – Health Assessment for Nursing Practice
Spring 2019
Study Guide for Midterm
1. What are the different types of health assessments, and when would each be performed?
P. 3 Box 1-3
a. Comprehensive onset in primary care, admission to hospital, long term care (detailed
hx and physical examination)
b. Problem-Based/Focus walk-in clinic, ER (assessment limited to a specific problem) e.g.
sprained ankle
c. Episodic/Follow-up when a pt is following up with a healthcare provider about a
previously identified problem or an individual being treated for an ongoing illness (e.g.
diabetes; follow up after taking antibiotics)
d. Shift changes of each shift for hospitalized patients
e. Screening/Examination health care provider office- preventative care or health fair
2. What are the purposes of a nursing health assessment? P1
a. Systematic model of collecting and analyzing data for the purpose of planning patient
centered care. Develop a plan of care that will help maximize patient’s potential.
i. Objective and Subjective information
1. What the patient feels/communicates (subjective)
• Clinical findings (objective) collected during physical examination
3. What are the steps in clinical judgement process? P. 5 (thinking like a nurse)
4. What are the factors in symptom analysis? P. 15
, ● Systematic method of collecting data about the history and status of symptoms
● Onset, location, duration, characteristics, aggravating and alleviating factors, related
symptoms, treatment, severity of symptoms
5. How does the nurse assess pain?
a. Collect subjective data, interviews patients about present health status, how they
manage their pain. Use OLD CARTS
b. Rely on self-report of patient
c. Pain Scales
d. Numeric (NRS) 0-10 , 0 no pain 5 moderate 10 worst pain possible
e. Wong-Baker FACES, No Hurt-Hurts to Hurts Worst Alternative coding 0-10 (2)
6. Compare health promotion and health protection. P. 5 Table 1-1
a. Health Promotion- desire to increase well-being (individual)
i. Primary- prevent a disease from developing (immunizations)
ii. Secondary-screening effort (BP screening)
iii. Tertiary-acute or chronic disease minimize, max health benefits (diabetes mgt)
b. Health Protection- desire to actively avoid illness (guidelines prevent spread of
communicable diseases)
i. Detect illness early
ii. Maintaining functioning within its constraints
7. Describe the differences between a screening assessment and a follow up assessment. P. 3
i. Screening assessment- short exam focused on disease detection/prevention
1. Blood pressure, glucose, cholesterol, colorectal
ii. Follow-up assessment- previously identified problem
1. Pneumonia after antibiotics
2. Diabetes follow ups
, 8. Identify infection control procedures to be used when conducting a health assessment.
(i.e. when do you wear gloves, and when don’t you) Box 3-1 P. 22
a. Gloves
i. To protect from bloodborne pathogens carried by patient
ii. To protect patient from microorganism on the hands of the nurse
iii. To reduce the potential of infection transmission from patient to patient via the
nurse
1. giving an injection
2. emptying a urinary catheter drainage bag
3. giving a bed bath
4. inserting a peripheral IV (an IV in a smaller vein)
5. removing a peripheral IV
6. removing a urinary catheter
b. Mask, Eye/Face shield
i. During procedures that may result in splashes or sprays of blood, fluids,
secretions
ii. Not usually done during health assessment.
c. Gowns
i. To protect arms-exposed skin and prevent contamination of clothing with
patients’ blood or fluids
9. What are the differences between subjective and objective data? See above
- Symptoms are considered subjective data
- data that is perceived and reported by the patient (e.g. pain, itching, nausea)
- Signs are considered objective data
- data that can observed, felt, heard, or measured (e.g. rash, swelling)
10. What assessment techniques are used to evaluate vital signs? P. 23
1. BP
2. Pulse
3. RR
4. Pulse O2
5. Temperature
11. Techniques of Physical Assessment:
a. Inspection- Pain, Respiration, Visual exam of body, movement and posture.
b. Palpation- HR hands to feel texture, size, shape, consistency, pulsation
c. Percussion-evaluate size, boarders, consistency of internal organs (fluid)
d. Auscultation- BP listening to sounds heat blood vessels, lungs, intestine.
12. Define orthostatic hypotension and describe how to assess for it. P. 42
a. Series of BP measurements Lying, sitting and standing position
b. It is a 20 to 30 mm drop when patient goes from lying to sitting position to standing
13. State the rationale and technique for the two step blood pressure measurement.
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