Health Assessment Theory

Inspection

Concentrated watching

Palpation

Applies your sense of touch to assess factors noted during inspection (texture, temperature, moisture, vibration, etc.)

Percussion

Tapping the person’s skin with short, sharp strokes to assess underlying structures.

Amplitude (intensity)

A loud or soft sound

Pitch (frequency)

the number of vibrations per second

Quality (timbre)

A subjective difference caused by the distinctive overtones of a sound

Duration

the length of time the note lingers

Auscultation

Listening to sounds produced by the body

Diaphragm (Stethoscope)

Flat edge that is best for high-pitched sounds.

Bell (Stethoscope)

Deep, hollow, cuplike shape. Best for low-pitch sounds.

Otoscope

Funnels light into the ear canal and onto the tympanic membrane

Ophthalmoscope

Illuminates the internal eye structures

Physical Appearance

Age, sex, skin color

Body structure

Stature, nutrition, symmetry, posture, position, physical deformities

Mobility

Gait and range of motion

Oral temperature

Most convenient and accurate site

Rectal temperature

Most accurate route, but more invasive

Tympanic Membrane Thermometer (TMT)

Senses infrared emissions of the tympanic membrane (eardrum), noninvasive and quick

Stroke volume

With every beat, the heart pumps a certain amount of blood into the aorta

Pulse

Arterial walls flaring due to beat of heart that creates a pressure wave, felt in the periphery

Bradycardia

A resting heart rate in adults less than 50 beats/min

Tachycardia

A heart rate in adults more than 95 beats/min

Sinus Arrhythmia

The heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. Commonly found in children and young adults.

Pulse Pressure

The difference between the systolic and diastolic pressures and reflects the stroke volume

Mean Arterial Pressure (MAP)

The pressure forcing blood into the tissues averaged over the cardiac cycle

The level of blood pressure is determined by five factors:

Cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of vessel walls

Auscultatory Gap

A period when Korotkoff sounds disappear during auscultation

Systolic pressure

Clear tapping sound

Diastolic pressure

The last audible sound

Korotkoff sounds

The components of a BP reading

Hypotension

Abnormally low BP

Hypertension

Abnormally high BP

Orthostatic hypotension

A sudden drop in systolic pressure when going from sitting to standing

Coarctation of the aorta

A congenital form of narrowing, arm pressures are high, thigh pressure is lower because the blood supply to the thigh is below the constriction

Pulse oximeter

A noninvasive method to assess arterial oxygen saturation

Nociceptors

Specialized nerve endings that are designed to detect painful sensations from the periphery and transmit them to the CNS

Aδ fibers

A primary sensory (afferent) fiber that is myelinated and larger, transmitting pain signals rapidly to the CNS

C fibers

A primary sensory (afferent) fiber that is unmyelinated and smaller, transmitting the signal to the CNS slower

Interneurons

Aδ and C fibers synapse with these interneurons located within a specific area of the cord

Substantia gelatinosa

the specified area of the cord that Aδ and C fibers synapse with interneurons in

Anterolateral spinothalamic tract

By which pain signals cross over to the other side of the spinal cord and ascend to the brain

Transduction (first phase)

Occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery

Transmission (second phase)

The pain impulse moves from the level of the spinal cord to the brain.

Perception (third stage)

Signifies the conscious awareness of a painful sensation

Modulation (fourth stage)

Pain message is inhibited/slowed down

Somatic pain

Originates from musculoskeletal tissues or the body surface

Deep Somatic Pain

Comes from sources such as the blood vessels, joints, tendons, muscles, and bone.

Cutaneous Pain

Derived from skin surface and subcutaneous tissues.

Referred pain

Pain that is felt at a particular site but originates from another location

Acute pain

Short term and dissipates after an injury heals

Chronic (persistent) pain

Diagnosed when the pain continues for 6 months or longer

Malignant pain

Parallels the pathology created by tumor cells

Nonmalignant pain

Associated with musculoskeletal conditions such as arthritis, low back pain, or fibromyalgia

Breakthrough pain

Transient spike in pain level, moderate to severe in intensity

Initial Pain Assessment

asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors

Brief Pain Inventory

asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability and sleep

Short-form McGill Pain Questionnaire

asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain

Verbal Descriptor Scale

uses words to describe the patient’s feelings

Numeric rating scales

asks the patient to choose a number that rates the level of pain for each painful site

Visual Analogue Scale

lets the patient make a mark on a line from no pain to worst pain imaginable

Peripheral neuropathy (PN)

symmetric damage to peripheral nerves, resulting in pain without nerve stimulation

Chemotherapy-induced PN (CIPN)

occurs after chemotherapy, numbness or burning, shooting pain

Optimal nutritional status

Achieved when sufficient nutrients are consumed to support body needs

Metabolic syndrome

Increased cardiac risk and is when a person has 3 of the following 5: elevated BP, increased fasting plasma glucose, elevated triglycerides, increased waist circumference, and low high0density lipoprotein cholesterol

Sarcopenia

Age-related loss of muscle mass

Sarcopenic obesity

Sarcopenia combined with an increase in body fat

Holistic health

The mind, body, and spirit all being in balance

Subjective

What the patient says, what caregiver says (pain, medical history, family history)

Objective

What the healthcare provider sees, hears, feels, smells, or tastes (heart murmur, warm skin, foul odor)

What are the five steps to evidence based practice (nursing process)?

Assessment, diagnosis, planning, implementation, evaluate

Assessment

the collection of data about the individual’s health

Diagnosis

Analyzing data to identify diagnoses

Diagnostic Reasoning

Analyzing health data and drawing conclusions, validate data and look for gaps

NANDA

guidelines that must be followed

Critical thinking

Intuition/recognition of patterns, learn to assess and modify before acting, sort through unpredictable situations, think outside the box, avoid assumptions

Planning

Develop a care plan, establish priorities, develop outcomes, set timelines for outcomes, identify interventions, integrate evidence-based trends, document the plan of care

Implementation

Outcomes are SMART (specific, measurable, appropriate, realistic, timely)

Evaluate

Progress toward outcomes, conduct systematic evaluation, include patient, use ongoing assessment to revise diagnosis and plan, disseminate results to patient and family

Social Determinants of Health Care

Factors that influence a person’s health (education access and quality, health care access and quality, neighborhood and environment, community, economic stability)

Linguistic Competence

understand differing languages, relationships, values, practices, etc.

Socialization or enculturation

the process of being raised within a culture and acquiring the norms, values, and behaviors of that group

Four characteristics of culture

1. Learned from birth through language acquisition and socialization

2. Shared by all members of the same cultural group

3. Adapted to specific conditions related to environmental and technical factors

4. Dynamic and ever changing

Ethnicity

Shared traits such as geography, language, or religion

Acculturation

Adopting the culture of the majority culture

Religion

refers to an organized system of belief

Spirituality

a broader connection with a belief

Beliefs about causes of illness

Biomedical/scientific (assumes cause and effect, embraced by healthcare), naturalistic (forces of nature must be kept in balance), magicoreligious

Dimensions of Acculturative Stress

Instrumental/Environmental (financial, language barriers, lack of access to healthcare, unemployment, lack of education), Social/interpersonal (loss of social network or status, family conflict, changing gender roles), Societal (discrimination, level of acculturation, political forces, legal status)

Spiritual Assessment

FICA Spiritual History Tool (faith, importance, community, and action)

Cultural Assessment

Heritage, health practices, communication, family roles, nutrition, childbirth, spirituality, death, health providers

Communication during the Interview

Exchanging information so that each person clearly understands the other, consist of internal factors (liking other, empathy, ability to listen, self-awareness) and external factors (privacy, interruptions, physical environment, dress)

Electronic Health Record (EHR)

Mandated by the federal government, improves documentation, failure to capture psychosocial and emotional info, do not let the computer become a barrier, explain charting to the patient

Communication techniques

Introducing the interview, open-ended questions, closed questions, verbal response

Interview traps to avoid

False assurance, unwanted advice, using authority, avoidance language, distancing, biased questioning, talking too much, interrupting, using “why” questions

What is the purpose of the health history?

To collect subjective data

Biographic data

Name, address, phone number, age, birth date, gender, etc.

How to communicate in the healthcare field when transferring or inquiring info?

SBAR (situation, background, assessment, recommendation)

Symptom

subjective sensation that the person feels

Sign

objective abnormality that you as the examiner could detect on a physical examination

What does the complete health history include?

Biographic data, source of history, reason for seeking care, history of present illness, past health, family history, review of system, functional assessment, and perception of heath