Health assessment
Nursing Assessment Quiz
Test your knowledge on the essential components of the nursing process with this comprehensive Health Assessment Quiz. Designed for nursing students and professionals alike, this quiz will help you evaluate your understanding of nursing assessments, diagnoses, planning, interventions, and evaluations.
Key Features:
- Multiple-choice questions covering all aspects of health assessment.
- Perfect for preparation for exams or to brush up on your nursing knowledge.
- Instant feedback on your answers.
Is a systematic, rational method of planning, and providing quality and individualized nursing care. • Series of phases describing the practice of nursing
Nursing Process
Health Process
Nursing education
Health Education Process
A statement or conclusion regarding the nature of phenomena • Analyzing subjective and objective data to make a professional judgement • Provides basis for the selection of nursing intervention
Assessment
Diagnosis
Planning
Intervention
Evaluation
Collection, organization, validation and documentation of data. The most important step.Continuous process carried out during all phases of the nursing process. Identifies the patient’s strengths and limitations.
Assessment
Diagnosis
Planning
Intervention
Evaluation
To carry out planned nursing interventions to help the client attain goals and achieve optimal health. The “doing” phase
Assessment
Diagnosis
Planning
Intervention
Evaluation
It should be S.M.A.R.T or Specific, Measurable, Attainable, Realistic, Time-bound
Assessment
Diagnosis
Planning
Intervention
Evaluation
Assessing client’s response to nursing progress toward health care and effectiveness of nursing care plan. Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process.
Assessment
Diagnosis
Planning
Intervention
Evaluation
Deliberative, systematic phase of nursing process that involves decision making and problem solving
Assessment
Diagnosis
Planning
Intervention
Evaluation
First time to see the patient o Completing data base
Initial comprehensive assessment
Emergency assessment
Focused or problem-oriented assessment
Time lapsed
Occurs during physiologic or psychological crisis of the patient
Initial comprehensive assessment
Emergency assessment
Focused or problem-oriented assessment
Time lapsed
Life threatening situation o Rapid identification and intervention of client’s need
Initial comprehensive assessment
Time-lapsed reassessment
Focused or problem-oriented assessment
Time lapsed
After initial assessment o Compare current status to baseline data
Initial comprehensive assessment
Emergency assessment
Focused or problem-oriented assessment
Time lapsed
Choose the right order of assessment steps
Validating, organizing, collecting, documentation of data
Collecting, organizing, validating, documentation of data
Documentation, collecting, organizing, validation of data
What are the two source of data in assessment?
Family of patient & Medical background
Patient & Family
Primary & secondary
Patient & Family/important someone
Data directly/indirectly observed through measurement
Subjective Data
Objective Data
Primary Data
Secondary Data
Data elicited and verified by the client
Subjective Data
Objective Data
Primary Data
Secondary Data
- “I can’t breathe” - “I have a stomach pain” - “I can’t sleep”
Subjective Data
Objective Data
Primary Data
Secondary Data
- Heart rate of 110bpm - UTZ reveals the client is pregnant for 18weeks - X-ray film reveals PTB
Subjective Data
Objective Data
Primary Data
Secondary Data
Disease process of the patient. Is the process of determining which disease or condition explains a person's symptoms and signs.
Medical diagnosis
Nursing diagnosis
Clinical judgement about individuals, family, or community responses to actual and potential health problems and life process. The client response on actual or potential health problem (reaction of patient to illness)
Medical diagnosis
Nursing diagnosis
Describes human response to level of wellness in an individual, family, or community that have a readiness for enhancement
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
Problem does not exist, but the present of risk factors indicate a problem is likely to develop unless nurses intervene
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
Problem is present (+) signs and symptoms
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
Associated with a cluster of other diagnosis
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
Health problem is incomplete or unclear
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
What is NANDA?
North american nurses diagnosis association
North american nursing diagnosis association
National American Nursing Diagnosis Association
Client response to a problem
Problem
Etiology
Defining characteristic/ Sign & symptoms
evidence of the problem
Problem
Etiology
Defining characteristic/ Sign & symptoms
What's causing to the clients problem/ causative factor for diagnosis
Problem
Etiology
Defining characteristic/ Sign & symptoms
Interventions are treatments performed through interaction with patient.
Direct Care
Indirect Care
Intervention are treatments performed away from a patient but on behalf of the group of / patient.
Direct Care
Indirect Care
Normal Temperature
36.5 – 37.2 °C
37.5 – 37.9 °C
35.5 – 36 °C
37.5 – 38.2 °C
Normal Adult pulse rate
60 – 100 bpm
55 – 110 bpm
80 – 100 bpm
Normal Respiratory rate
16-20
16-24
18-20
Is a small region located at the base of the brain that plays a vitals role such as releasing of hormones • Temperature regulatory center found in the brain
Thymus
Muscle
Hypothalamus
Cerebrum
A response to prolonged exposure to cold or need for oxygen of the body, hypoglycemia, hypothyroidism, starvation
Pyrexia / Hyperthermia / Febrile
Hyperpyrexia
Hypothermia
Body temperature above the usual range
Pyrexia / Hyperthermia / Febrile
Hyperpyrexia
Hypothermia
A response to prolonged exposure to cold or need for oxygen in the body
Pyrexia / Hyperthermia / Febrile
Hyperpyrexia
Hypothermia
Wide range of temperature fluctuations all of which are above normal (pyrexia) throughout the day over 24-hour period
Intermittent fever
Remittent fever
Relapsing fever
Constant fever
Alternates at regular interval where temperature is elevated for several hours or periods of fever and followed by an interval of normal temperature
Intermittent fever
Remittent fever
Relapsing fever
Constant fever
Fluctuates minimally but always remain above normal o Temperature does not touch the baseline and remain above normal throughout the day
Intermittent fever
Remittent fever
Relapsing fever
Constant fever
Short periods of high fever (40oC) with periods of 1 or 2 days of normal temperature
Intermittent fever
Remittent fever
Relapsing fever
Constant fever
Occurs when the cause of fever is suddenly removed, patient’s body temperature returns to normal. This event is known as crisis, the flush defervesce stage of pyrexia
Onset / Chill
Course / Plateau
Defervescence
After the core temperature has reach a new set point, the person neither feels warm nor cold
Onset / Chill
Course / Plateau
Defervescence
Set point increases from normal to higher than normal
Onset / Chill
Course / Plateau
Defervescence
Pressure of blood as result of contraction of the ventricles
Systolic pressure
Diastolic pressure
Lower pressure as result of ventricular relaxation
Systolic pressure
Diastolic pressure
The difference between systolic and diastolic pressure
Pulse pressure
Stroke volume
The volume of blood ejected with each heartbeat
Pulse pressure
Stroke volume
Abnormally high blood pressure over 140/90, o confirmed by a minimum of 2 consecutive visits.
Hypertension
Hypotension
Orthostatic hypotension
Abnormally low blood pressure below 100 mmHg systolic. o Between 85-100 mmHg systolic.
Hypertension
Hypotension
Orthostatic hypotension
Is a sudden drop in blood pressure when you stand from seated or lying down position.
Hypertension
Hypotension
Orthostatic hypotension
It is located on the apex of the heart on the left side of the chest that is monitored using a stethoscope. o The apex is usually found at the 5th intercostal space just inside the midclavicular line
Central or Apical pulse
Peripheral
Pulses that can be felt on the periphery of the body by palpating an artery over a bony prominence.
Central or Apical pulse
Peripheral
Located in front of the ear and lateral to eyebrow
Temporal
Carotid
Brachial
Radial
Located beside the larynx
Temporal
Carotid
Brachial
Radial
Located in the medial antecubital fossa (hollow in front of the elbow)
Temporal
Carotid
Brachial
Radial
Located on the thumb side of the forearm at wrist
Temporal
Carotid
Brachial
Radial
Located halfway between the anterior superior iliac spine and the symphysis pubis, below the inguinal ligament.
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Located on the dorsum of the foot with the foot plantar flexed.
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Located behind the knee in the popliteal fossa with the patient’s knee flexed
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Located on the inner side of the ankle slightly below
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
May be a random, irregular beats or predictable pattern of irregular beats
Dysrhythmia or arrhythmia
Erythema
Cardicthmia
Describes as breaths per minute. (slow respiration)
Eupnea
Bradypnea
Tachypnea
Apnea
Describes as breaths per minute. (normal)
Eupnea
Bradypnea
Tachypnea
Apnea
Describes as breaths per minute. (absence of breathing)
Eupnea
Bradypnea
Tachypnea
Apnea
Describes as breaths per minute. (fast / rapid respiration)
Eupnea
Bradypnea
Tachypnea
Apnea
Increased amount of air in the lungs characterized by prolonged deep breaths. o It is a condition in which you start to breathe very fast
Hyperventilation
Hypoventilation
Decreased in amount of air in lungs caused by shallow breaths (hypopnea) or too slow (bradypnea) or may be caused by diminished lung function
Hyperventilation
Hypoventilation
To document the responses of the client and actual and potential concerns. • To obtain information about the client’s health.
Health history
Purpose
Interviewing
Focuses of Interview
Obtaining a valid nursing health history requires professional, interpersonal and interviewing skills
Health history
Purpose
Interviewing
Focuses of Interview
A comprehensive record of the client’s past and current health. • This is gathered during the initial assessment interview.
Health history
Purpose
Interviewing
Focuses of Interview
Establishing rapport and trusting relationship • Client’s response to the health concern as a whole person
Health history
Purpose
Interviewing
Focuses of Interview
What are the abbre of TP SA DL. This is important during interview
Technology, preparation, seating arrangement, duration, language
Time, place, seating arrangement, distance, language
Time, preparation, seating arrangement, date, life
Time, preparation, seating arrangement, duration, language
Arab (Interview distance)
8-12 inches (1 ft)
18 inches (1'6 ft)
24 inches (2ft)
36 inches (3ft)
Britain (Interview distance)
8-12 inches (1 ft)
18 inches (1'6 ft)
24 inches (2ft)
36 inches (3ft)
US (Interview distance)
8-12 inches (1 ft)
18 inches (1'6 ft)
24 inches (2ft)
36 inches (3ft)
Japan (Interview distance)
8-12 inches (1 ft)
18 inches (1'6 ft)
24 inches (2ft)
36 inches (3ft)
It can be dull, achy, sharp, burning. ® It can be constant, intermittent, mild, moderate, severe
Acute pain
Chronic pain
Cancer pain
Lasts only through the expected recovery period o Does not last longer than six months
Acute pain
Chronic pain
Cancer pain
Ongoing pain and last longer than 6 months
Acute pain
Chronic pain
Cancer pain
A systematic way of collecting objective data from a client using the four examination techniques.
Physical assessment
Mental Assessment
Holistic Assessment
Physiological Assessment
Seated position, back unsupported and legs hanging freely
Standing / Erect
Sitting
Dorsal Recumbent
Sim’s
Assessment of posture, gait & balance
Standing / Erect
Sitting
Dorsal Recumbent
Sim’s
The client is lying on the side with the body turned at 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45 to 90 degree angle.
Standing / Erect
Sitting
Dorsal Recumbent
Sim’s
Back lying position with knees flexed and hips externally rotated; small pillow under the head; soles of the feet on the surface
Standing / Erect
Sitting
Dorsal Recumbent
Sim’s
The client is lying on the abdomen with head turned to the side.
Prone
Lithotomy
Knee-chest
The client is lying on the back with the hips and knees flexed at right angles and feet in stirrups.
Prone
Lithotomy
Knee-chest
Assessment of rectal area (for a brief period only)
Prone
Lithotomy
Knee-chest
Observing the patient holistically
Inspection
Palpation
Percussion
Auscultation
Assessing the physical status of the body of client using the sense of touch
Inspection
Palpation
Percussion
Auscultation
Striking of the body surface with short, sharp strokes. To detect the presence of air or fluid in a body space
Inspection
Palpation
Percussion
Auscultation
Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds.
Inspection
Palpation
Percussion
Auscultation
Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Depress the skin (1cm) with your finger pads, using the lightest touch possible.
Light palpation
Deep palpation
Bimanual deep palpitation
Moderate Palpation
Used to assess most of the other structures of the body. Depress the skin surface 1 to 2 cm with your dominant hand, and use a circular motion
Light palpation
Deep palpation
Bimanual deep palpitation
Moderate Palpation
This allows you to feel very deep organs or structures that are covered by thick muscle. This technique provides extra support and pressure and allows the nurse to palpate at a deeper level from 2 to 4cm
Light palpation
Deep palpation
Bimanual deep palpitation
Moderate Palpation
Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated. Use one hand to apply pressure and the other hand to feel the structure.
Light palpation
Deep palpation
Bimanual deep palpitation
Moderate Palpation
Is used to detect tenderness over organs, by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface
DIRECT PERCUSSION
BLUNT PERCUSSION
INDIRECT PERCUSSION
Is the technique of tapping the body with the fingertips of the dominant hand. -is the direct tapping of a body part with one or two fingertips to elicit possible tenderness
DIRECT PERCUSSION
BLUNT PERCUSSION
INDIRECT PERCUSSION
Two hands are used and the plexor strikes the finger of the examiner’s other hand which is in contact with the body surface being percussed
DIRECT PERCUSSION
BLUNT PERCUSSION
INDIRECT PERCUSSION
Is an abnormally loud, low tone of longer duration than resonance. (it is heard when air is trapped in the lungs
TYMPANY
RESONANCE
HYPERRESONANCE
DULLNESS
FLATNESS
Is a high-pitched tone, very soft and very short duration. (It occurs over solid tissue such as muscle or bone)
TYMPANY
RESONANCE
HYPERRESONANCE
DULLNESS
FLATNESS
- is a high-pitched tone that is soft and of short duration (Usually heard over solid body organs such as the liver or stool-filled colon)
TYMPANY
RESONANCE
HYPERRESONANCE
DULLNESS
FLATNESS
S a loud, low-pitched, hollow tone of long duration. (Normal finding over the lungs
TYMPANY
RESONANCE
HYPERRESONANCE
DULLNESS
FLATNESS
Is a loud, high-pitched, drumlike tone of medium duration characteristic of an organ that is filled with air. (Stomach, over air-filled intestines)
TYMPANY
RESONANCE
HYPERRESONANCE
DULLNESS
FLATNESS
Subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure.
Cues
Inferences
The nurse’s interpretation or conclusions made
Cues
Inferences
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