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Chapter 2:
Interviewing phases
Introduction:
Purpose; who you are, what is occurring, what is your role; INTRO; let pt know you will be
taking notes
Confidentiality; make pt comfortable; environment private
Develop trust and rapport
Working SUBJECTIVE DATA
Getting the information from the actual interview
Documentation: health insurance, beliefs, understandings, family contact
Reason for seeking care; Hx of present health concern
PH, FH, ROS, Lifestyles/health practices
Summary/Closing
Summarize info: this is what you told me
Validates problems and goals; ID possible plans
Q&A; agreement to information, plan, objectives
Communication/Interview skills verbal and nonverbal effective and ineffective
Effective: - one question at a time
Active listener: pay attention, face the patient, sit during interview, maintain eye contact; look
interested
Guided questioning
Open ended questions
Graded questions: how many/how much-range of amount
Multiple choice questions: is the pain sharp or dull; is it constant or intermediate (this may
min. the pt responses/ max distorted information)
Clarify: ask pt to clarify something you may be unsure about
Encouragement: uh huh: look at them when they are speaking- take notes of importance
Reflection: pt responds: pain got worse and spreading now
Nurse responds: spread? --> use the pts language; what do you mean by.
Health Assessment
Nonverbal communication: posture, facial expressions; your behavior during the interview
Empathetic responses: NOT: I am sorry about your moms death; YES: It must be very
heartbreaking for you.
Validation: acknowledge what is occurring; ask about how the patient feels
Reassurance: it is okay to feel like this when a patient feels angry or in denial
Summarization: this is what the pt told the nurse; how the nurse interprets it; pt should correct the
nurse if needed
Transitions: now I am going to ask you questions about...
Empowering the patient: nurse encourages pt to feel in control; help pt deal w/ situation; EXPLAIN
everything
Ineffective:
Do not use LEADING questions: it did happen to you yesterday, right?
False assurance: everything will be okay
Unwanted advice: do not give advice
Using authority: sounding like you are demanding the pt
Use of Avoidance lang.:
Engaging in distancing:
Professional jargon: explain in laymen terms unless pt is capable of understanding
Talking too much/interrupting
Using why questions
How/when to use different types of questions
Open-ended: What happened today; tell me what the problem is
Closed-ended: did this happen to you yesterday?
Laundry list: choice of words to choose from
Rephrasing: clarify the information the client is providing
Well-places phrases--> encouragement skill: yes, I see; I agree
Inferring: do not lead rather get more information: it seems you have more difficulty w/ your ;
use the pts words
Providing information: answer every question the pt; be honest if do not know the answer
Focus question: more specific toward the problem: So you woke up short of breath; has this
happened before?
How to deal with anxious, angry, depressed, manipulative patient
Anxious
Structure info
Explain who you are, your role, and purpose of visit
Questions = simple/concise
Nurse needs to stay Relax
Do not hurry; decrease external stimuli
Angry
Calm, in-control mannerisms and tone
o Let patient vent
o If excessive, do not touch or argue back
Obtain info from other health professionals as much as needed
Do not argue back; provide personal space
Depressed
Show interest and understanding to client and situation
Do not be upbeat or encouraging
Manipulative
Provide structure and limitations
Fine line b/w manipulative and reasonable requests
What constitutes as subjective data
ANYTHING elicited by the patient; must be verified by the patient
Health Assessment
ROS for current health problem: need to ask about the specific systems
Lifestyle and Health practices:
o Nutrition/ weight management: meals of the past 24 hrs --Self-concept/self
care/relationships
o Activity level/exercise/ social activities -- values and beliefs
o Sleep and rest: naps? -- edu/work; stress
levels/coping
o Medication and substance use/ herbal preps
Complete Health History
Biographical data --FH
Reasons for seeking health care --ROS
Hx of present health concern --Lifestyle and health practices
PH --Developmental level
COLDSPA
Character: description -- Severity
Onset -- Pattern: what makes it better/worse
Location -- Associated Factors: other symptoms
Duration
Chapter 3:
How to prepare for a physical exam examiner, patient
Prepare physical setting: get equipment, room is comfortable and warm, private and quiet, firm
exam bed/table
Prepare self: be calm, confident, practice clean/sterile technique, wash hands, use protective
gear
Approach/prepare pt: est. rapport, respect clients requests and desires, get consent, and
explain everything
Positioning Client
1. Sitting
a. Can evaluate head, neck, lungs, chest, back, breasts, armpits, heart, vital sign, arms
2. Supine
a. Flat on back, Legs together
b. Evaluate head, neck, chest, breast, armpits, abdomen, heart, lungs, limbs, peripheral pulses
3. Doral recumbent
a. On back, knees bent, legs separated, feet flat
b. Most comfortable for people with back or abdomen pain
c. Assess: head, neck, chest, armpits, lungs, heart, limbs, breasts, peripheral pulses
4. SIMs position
a. Lay on side; Lower leg behind body and flexed; Upper leg flexed at sharp angle; forward
b. Upper arm bent
c. Assess: rectal and vaginal areas
5. Standing
a. Assess: posture, balance, gait, males genitalia
6. Prone
a. Flat on stomach, head to one side
b. Assess: hip joint, back
c. If cardiac or respiratory problems = do not use position
7. Knee-chest
a. Kneeling, 90-degree angle b/w body and hips; Arms above head; head to one side
b. Assess: rectum
c. Do not use with elderly or pt. with respiratory or cardiac problems
8. Lithotomy
a. Lays on back, hips at end of table, feet in strirrups (at the gyno)
b. Assess: female genitalia, reproductive tracts, rectum
What is objective data
Anything that can be measured: physical characteristics, body functions, appearance/behavior,
measurements
Health Assessment
Chapter 4:
Purpose of Validation
Confirm/ verify subjective and objective data
Need to make sure information is correct to cont. with nursing process
Data requiring validation
Health Assessment
Gaps b/w subjective/objective data, what the person says at different points of the
conversation
Findings that are abnormal/ inconsistent w/ other findings
Methods of validation
Repeat assessment
Clarify data w/ client- additional questions
Verify data w/ another healthcare professional
Compare objective findings w/ subjective findings
Missing information
ID areas where more data is needed
o Ex) pt weighs 98lbs: want to know if pt has lost weight or this has been normal for
some time
o Ex) pt tells you he lives alone: want to know if he has a support group, ability to
function alone
Documentation
Purpose:
Chronological source, prevents repetition, helps w/ dx,, determines edu. & teachings,
eligibility for reimbursement, legal record
What do you document:
Subjective/ Objective data: sub- if there is nothing write DENIED
Present health concern via COLDSPA
Follow health hx: PH, FH, lifestyle/health practices
Guidelines:
Legible w/ non-erasable ink or print; correct grammar/spelling; Abbreviations approved by
institution
Wordiness will create redundancy
Phrases not sentences
Record findings not method of obtaining; what you see; judgment free
Record pts understanding and response to info/tx
Do not use normal
Chapter 5:
Analyze data
Critical thinking
o ID abnormal data and strengths of pt
o Cluster data
o Draw inferences
o Purpose possible nursing dx check for defining characteristics; confirm/rule out dx
o Document conclusions
Similar to ADPIE
o Assess areas of concern and strengths
o Dx based on abnormal findings and pts abilities
o Plan what outcomes and expectations via the dx; implement plan
Interventions come from the problem
o Evaluate and document
Health Assessment
Chapter 6:
Mental status
Ones orientation and consciousness
o Orientation: person, place, time, situation looking for cognitive consciousness
Orientation to time is the 1st to be lost
Orientation to person is the 2nd to be lost
Mental Health assessment
o Observe the pt; ask them questions
How to assess dementia, delirium
Looking for Dementia
Alzheimers Guide
All Alzheimer is dementia; not all dementia is Alzheimer
Lose executive functioning
Repeatedly ask the same questions
o Pt consistently asks the same questions about the same topic/situation
o Caregiver/families need to constantly remind pt how and what to do
lost/disoriented to places and of time; cannot follow directions
Do not recognize family
Difficulty performing routine tasks
Neglects personal hygiene
CANT RECALL RECENT EVENTS; remembers remote events
Chapter 7:
General Survey
Apparent state of health: general observation for acute (focused assess.) or chronic illness (full
assess.)
Level of consciousness: stages of consciousness
o Alertness: speaking to pt in normal tone
eyes are open, pt looking at you, responds fully and appropriately
o Lethargy: Speaking to pt in loud voice-call pts name; how are you
Pt= drowsy; eyes open; looks at you; responds to questions but then falls asleep
after
o Obtundation: (dull) speak in loud voice; shake pt gently
Pt opens eyes and looks at you; responds slowly; somewhat confused
Alertness and interest in environment = decreased
o Stupor: (dazed state; unconscious) Apply painful stimuli
Arouses ONLY from PAINFUL stimuli
Verbal responses are slow/absent
Lapses into an unresponsive state when stimulus stops
Minimal awareness of self or environment
o Coma: Apply repeated painful stimuli
Remain unaroused w/ eyes closed; no evident response to inner need or external
stimuli
1. Decorticate rigidity: arms flexed tight to body; legs extended; rotated
inward- corticospinal issue
2. Hemiplegia: sudden unilateral brain damage; one side is paralyzed
3. Decerebrate rigidity: jaw clenched; neck extended; arms adducted stiff;
wrist flex diencephalon, midbrain, pons
Facial expressions: eye contact, facial movements
o Parkinsons Disease- pt has a masklike facial expression
Odors of the body or breath
o Fruity scent = diabetes is out of control
o Alcohol?/ Marijuana?
Personal hygiene/dress: appropriate? Clues to weight loss; cleanliness?
o Can get cold easier as you age- less body muscle
Posture, gait, motor activity
o Stooped over posture (-); straight/upright posture (+)
o Walking heals to toes and swinging arms? (+)
o Facial muscles appropriate? Abnormal = twitches, muscle spasms; observe overall
muscle control
Weakness = difficulty in moving muscle; loss of muscle power
Fatigue = you dont feel like doing anything/something; has normal muscle
function
Speech: articulating appropriately; no slurred words/ awkward pauses
Voice and speech problems
o Aphonia: no, voice; loss of voice; from disease affecting larynx (voicebox)
o Dysphonia: faulty, voice; speak in a whisper/ hoarse
can be disease oriented; something affecting larynx or vocal cords = cancer?
1. Laryngitis, laryngeal tumors, unilateral vocal cord paralysis
2. Vagus nerve
o Dysarthria: defect in muscular control; slurred speech MS/ Parkinsons
o Aphasia: disorder of producing or understanding lang.; pathological component/cause-
lesion
Wernickes: can produce language but cannot understand language; cant
process
Health Assessment
1. Production of speech is intact
2. Cannot comprehend, name (temporal lobe)
Brocas: production of lang. impaired; can understand lang.
1. FRUSTRATION enhances problem
2. Not fluent; production of speech highly impaired
3. Comprehension is intact
4. cannot name (although the pt knows what the object is)
5. Frontal lobe
Both cannot repeat or write
Mood and affect: answers and mood are appropriate
o Ex) appropriate: in so much pain and pt is wincing, grimacing, low demeanor
o Ex) inappropriate: in so much pain and pt is laughing
Check vital signs
Height and weight
BMI
Ex) Female 411 95lbs (subtract 5lbs from the 5ft total (100))
Male: 106lbs for 5 feet + 6lbs for each inch over 5ft --> medium frame
Subtract 10% for small frame
Add 10% for large frame
Ex) Male: 5ft 6in 5ft= 106lbs + 6in=36in (6*6)
142lbs for a 56 male, medium frame
127lbs for a 56 male, small frame
156.2lbs for a 56 male, large frame
Percentage of ideal body weight
Actual weight Ex) Actual weight: 130lbs
o 100= of IBW Ideal body weight: 100+5=
ideal body weight
105lbs
Ideally you want to get close to 100%
o 100-110% = normal
o > 120% = obese
o >110% = overweight
o 80-90% = lean and potentially malnourished
o 80-70%= moderate malnourished
o <70% = severely malnourished
Overweight people:
o Higher Triglycerides
o Higher blood sugar
o What is activity level? Smoker?
o Increase weight, increase risk for osteoarthritis, respiratory problems, sleep apnea,
stroke
Health Assessment
BMI + categories
BMI < 18.5 (underweight)~18 or less
BMI = 18.5 to 24.9 (normal) ~ 18 to about 25
BMI = 25-29.9 (overweight) ~ 25 to about 30
BMI > 30 = obese ~ 30s
BMI: 40+ extreme obesity ~ 40 +
Waist circumference
Pt stands straight feet together, arms at side; measure snugly around waist at belly button
Pt should be relaxed, taking normal breaths
Record on exhalation
Female normal waist circumference = < 35 inches; over 35 = overweight
Male normal waist circumference = < 40 inches; over 40 = overweight
Chapter 13:
Subjective data of skin, hair, nails: Symptoms, PH, FH, Lifestyles/Habits
Skin:
Skin problems, swelling, color change; birthmarks/moles; change in pain, pressure, touch, temp.,
body odor
Shots, hx of lesions, tattoos piercings, past treatments on skin, allergic reactions
Cancer: eczema, psoriasis, melanoma; keloids
Bathing patterns, type of soap, how often; sunbathe; environmental exposure; sedentary life; self
exam?
Color Influenced by illness, body temp, pregnancy, genes, arterial blood flow, O2, liver function,
melanin
Hair:
Hair loss, change in condition of hair
Hair loss in past, lacerations to the scalp
Hair care routine, products, color treatment
Nails
Change in condition and appearance of nails
Infections of nails
Who cleans them; how are they cleaned; salon use sterile procedure
8. Lesions: Size, Shape, Color, Texture, surface relationship, exudate, tenderness, body
location
(Sam Sells Coats to SET B)
a. Normal: smooth- no lesions; stretch marks, healed scars, freckles, moles, birthmarks
i. Look around skin folds
ii. Older people: common skin lesions- senile keratoses (small, raised, dark sun
exposed area)/lentigines (flat ?,darker sun exposed skin), cherry angiomas,
purpura, cutaneous tags
b. Abnormal
i. Local or systemic lesions
1. Primary: arise from normal skin due to irritation or disease
Size: less than 0.5 cm - usually
Shape: Macules/ Patch- flat (</> 1 cm); Wheal- elevated, red (2cm)
Vesicle/ bulla- blister/fluid filled (</> .05)
Color: Pustules- white/yellow-white & pus filled
Petechia: red, round, macule (flat <1cm); flat; bleeding from superficial capillaries
Purpura: red to purplish
Texture: macules- smooth; warts- rough; psoriasis- scaly
Surface location: flat nonpalpable macules/patches, purpura, ecchymoses (>petechia), spider
angioma
Raised palpable solid- papule/plaque (</>.5), nodules/tumor (.5-2/>2 cm), wheals
Raised palpable cystic- vesicles/bullea, pustuale, cyst
Depressed: atrophy, erosion, ulcer, fissures
Pedunculated (having a stalk): skin tags
Exudate: Serous: clear/white/pale (GOOD)--> vesicles/bullea (blister)
Purulent: gross, infected, a lot, colorful; Pus: yellow --> acne, impetigo
Tenderness: bullae or bruise- underlying cause/ pain
Body Location: where is it on the body
Configuration of lesion:
Annular/circular: in a ring shape--> ringworm
Round/oval: coin shaped --> eczema
Confluent: runs together --> rubella
Discrete: separate; apart; isolation; no association w/ another --> moles
Grouped: cluster; individual entities but grouped together --> herpes
Gyrate: twisted/coiled; worm like --> gyrate erythema (twisted red skin)
Target/iris: concentrated rings of color; bulls eye like --> lyme disease
Linear: line, streak, stripe --> poison ivy/ herpes zoster (shingles)
Polycyclic: annular lesions growing together; slowly growing into one nearby; distinct w/ little
grouping
Zosteriform: linear growing on nerve root; never crosses midline
always stays on one side; can cross front to back but not left to right
Distribution of lesions:
Diffuse/generalized: occurring all over --> full body rash; urticaria (skin rash) from allergic
reaction
Scattered: sparsly distributed --> seborrheic keratosis (warts, moles)
Localized: one area of body; discrete area; usually unilateral
Regional: bilateral; one body area --> tinea capitis (skin fungus)
Torso: just on the torso (below neck to below belly button)--> pityriasis rosea (flaky dry skin)
Health Assessment
Extensor surfaces: posterior elbows; anterior knee
Dermatome lines: zosteriform (configuration)- along a nerve root --> herpes zoster (shingles)
Hairy areas: where people grow hair- not scalp --> herpes II (sexual), lice
Nails
Inspection
1. Grooming and cleanliness
a. Normal: nails are clean and manicured
b. Abnormal:
i. Dirty, broken, jagged nails poor hygiene
1. Could be a hobby biting nails
2. Occupation electrician
2. Color and Marking
a. Normal: pink tones; longitudinal ridging
i. Dark skinned people: freckles or pigmented streaks normal
b. Abnormal:
i. Pale or cyanotic nails hypoxia or anemia
ii. Splinter hemorrhages- trauma
iii. Beaus lines: occur after acute illness/trauma; eventually grow out ridges
iv. Yellow discoloration fungal infections
3. Shape
a. Abnormal
i. Early clubbing- spongy sensation 02 deficiency
ii. Late clubbing- hypoxia- perfectly straight- no normal slant into cuticle
iii. Spoon nails- concave iron deficiency anemia (indentation)
Palpation
1. Texture and consistency
a. Normal: hard; immobile
i. Dark skinned pt: thicker
ii. Older people: appear thickened, yellow, brittle- decreased circulation
b. Abnormal:
i. Thickened especially toenails --> decreased circulation
c. Note if nailplate is attached to nailbed
Health Assessment
i. Normal: smooth and firm; nailplate firmly attached to nailbed
d. Abnormal:
i. paronychia (abnormal nail condition- inflammation) local infection
ii. detachment of plate from bed (onycholysis- nail breakage)
infection/trauma
2. Test capillary refill
a. Press the nail tip briefly and watch for color change
i. Normal: pink tone returns immediately after release of pressure
ii. Abnormal: slow refill respiratory or cardiovascular diseases hypoxia
Health Assessment
Chapter 14:
Subjective data for head and neck: Symptoms, PH, FH, Lifestyle/Health Practices
Frequent headaches: type of headache pain + location, intensity, duration
Dizziness, spinning (vertigo), lightheadedness, loss of consciousness
Neck pain, face pain, limited movement, lumps, bumps, or lesions, changes w/ hair
Skull fractures, surgeries on head or neck, Traumatic Brain Injury, head injuries
Hx of headaches, neck or head cancer in family
Helmet, seatbelt use; stress/tension; level of exercise/energy, sleeping patterns; smoker?; typical
posture?
Head/neck pain interfere w/ work, relationships, daily living?
Inspection of neck
1. Inspect the neck slightly extended neck for symmetry, lumps or masses Side lighting
a. Abnormal:
i. Swelling, enlarged masses/nodules enlarged thyroid gland (huge bulge on
anterior neck)
ii. Inflammation of lymph nodes tumor/ infection
2. Inspect movement of neck structures
a. Pt swallows small sip of water; observe movement of thyroid cartilage/thyroid gland
i. Normal: thyroid cartilage, cricoids cartilage, thyroid gland move up and down
ii. Abnormal: asymmetric movement or generalized enlargement of thyroid
gland
3. Inspect cervical vertebra
a. Pt flex neck- move neck in different directions
i. Normal: C7 visible and palpable; sometimes T1
Older people: cervical curvature- increase b/c of kyphosis (hunchback)
a. Dowagers hump- in older women
ii. Abnormal: prominence or swellings other than the C7 vertebrae
4. Inspect ROM- move head around
a. Normal: movement is smooth and controlled
i. Older people: somewhat decreased ROM- arthritis
b. Abnormal:
i. Stiffness, rigidity, limited mobility Muscle spasm, inflamed, cervical
arthritis
affects daily functioning
Palpate
1. Trachea: fingers on sterna notch; feel each side of the notch
a. Abnormal:
i. Not midline tumor, thyroid gland enlargement, aortic aneurysm,
pneumothorax (air or gas in pleural cavity), atelectasis (collapse of lung),
fibrosis
2. Thyroid gland
a. Hyoid bone- bone that does not articulate with any other bone; high anterior neck
b. Thyroid cartilage adams apple
c. Cricoid cartilage- above sterna notch
i. Abnormal: not midlined; obscured masses; abnormal growth
Palpable thyroid if enlarged hyperthyroidism (Graves disease)
o Edemic goiter, thyroiditis caused by Graves disease
o Rapid enlargement of a single nodule malignancy
Thyroid Auscultation
1. Only if enlarged - Bell on lateral lobes; pt holds breath & blood work
i. Abnormal: soft, blowing, swishing hyperthyroidism- increase blood flow