Health Assessment Week 1

Chapters 1,8,9,10

What is assessment in nursing?

Point of entry in an ongoing process of patient care

What forms the patient database?

subjective + objective + patient record + laboratory studies

Why is the database important?

It allows the nurse to make a clinical judgement or diagnosis about the patient’s health status

What is the key to a good assessment?

organization of assessment based on complete, factually based data

What is subjective data?

What the patient tell you is wrong with them

Examples of subjective data

patient says they feel cold or itchy

What is objective data?

what the nurse observes about the patient

What is diagnostic reasoning?

process of analyzing health data and drawing conclusions to identify diagnoses

What does it mean to cluster data?

putting related data into groups

What types of reasoning are combined in diagnostic reasoning?

Deductive, inductive, and abductive reasoning

What type of reasoning is used first and why?

deductive reasoning - applying physiology and pathophysiology

What type of reasoning is used after deductive reasoning?

Inductive reasoning - using signs and symptoms of disease

What is the clinical judgement model?

a framework used in nursing education to improve clinical judgement skills, especially for novice nurses

What is the nursing process?

A 5-step method nurses use to provide care

What are the 5 steps of the nursing process?

Assessment, diagnosis, planning, implementation, evaluation

What does ADPIE stand for?

Assessment, diagnosis, planning, implementation, evaluation (abbreviation)

What is the goal of the clinical judgement model for nurses?

To help nurses transition from novice to expert

Why is an interdisciplinary approach important?

it improves patient outcomes by involving multiple healthcare professionals

What does “level of experience” meaning in nursing?

all nurses start as novices and improve through experience

What is critical thinking in nursing?

the process used to assess and modify thinking to achieve clinical judgement

What methods help develop clinical judgement?

case studies and simulation

Why are case studies and simulations used?

they help cluster and organize data sets

What does decision-making in nursing require?

a nonjudgmental approach and double-checking data for accuracy

What is a first-level priority problem?

Emergent, life-threatening, and requires immediate attention

What framework is used for first-level priorities?

ABCs: airway, breathing, circulation (pulse)

What is a second-level priority problem?

next in urgency - needs attention to prevent further deterioration

Examples of second-level priority problems

mental status change, abnormal lab work, risk of infection, safety issues

What is a third-level priority problem?

important to health but can be treated after urgent problems

Example of a third-level priority problem

chronic issues that take a long time to resolve

What is an interdisciplinary approach?

working with other healthcare professionals to improve outcomes for complex patients

Example of an interdisciplinary approach

involving occupational therapist and other care teams

What is evidence-based assessment?

using the best research evidence combined with clinical expertise and patient preferences to make care decisions

What happened in the 1850s related to evidence based practice?

Florence Nightingale began the use of research evidence in nursing

Why is Florence Nightingale important to nursing?

she is the mother of nursing and started using data and research to improve care

What happened in the 1970s regarding evidence-based medicine?

the term was defined in context of clinical research methods

What was the focus from 1970-1980?

research utilization, now called evidence-based practice (EBP)

What is evidence-based practice (EBP)?

Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences

What is clinical decision-making based on in EBP?

Best evidence from literature + patient’s preferences + clinician’s experience/expertise + physical exam

Why do nurses look for gaps in literature?

to identify areas needing more research and improvement

Why is fostering a culture of EBP important?

it promotes consistent use of best evidence in practice

What is a complete total health databse?

a full picture of past and present health that forms a baseline for future changes

What is a focused or problem-centered database?

a smaller, more specific “mini” database focused on a current problem

• common in hospitals

What is a follow-up database?

reevaluation of known problems at regular and appropriate intervals

What is an emergency database?

rapid data collection during urgent situations, often done while lifesaving care is provided (ER, EMS)

What is the holistic model of care?

care that addresses mind, body, spirit as interconnected parts of health

Why must nurses respect patient wishes in holistic care?

some patients prefer this approach and their values must be honored

What are social determinants of health?

factors that influence overall well-being

Examples of social determinants of health

environment, access to healthcare, community, education, economic stability

Why are social determinants important in nursing care?

they can create barriers that affect health outcomes

What does physical examination require?

use of technical skills through senses: sight, smell, touch, and hearing to obtain data

How are physical exam skills usually performed?

one at a time in a specific order

What are the four physical examination techniques in order?

inspection, palpation, percussion, ausculation

Which assessment technique is always done first?

inspection

What is inspection?

close, careful observation of the patient

How is inspection performed?

first observe the patient as a whole, then each body system

When does inspection begin?

the moment you first meet the patient during the general survey

How is inspection used during the exam?

each body system assessment starts with inspection

What does inspection require to be effective?

good lighting and adequate exposure

What instruments may be used during inspection?

otoscope, ophthalmoscope, penlight, nasal and vaginal specula

What is palpation?

using the sense of touch to examine the patient

What does palpation assess?

texture, temperature, moisture

What structural features are assessed by palpation?

organ location and size

What abnormal findings can be felt with palpation?

swelling, vibration, pulsation, crepitation

What muscle findings are assessed by palpation?

rigidity or spasticity

What mass findings are assessed by palpation?

presence of lumps or masses

What pain-related findings are assessed by palpation?

tenderness or pain

How should palpation be performed?

slowly and systematically

what is the correct pressure order for palpation?

start light, then proceed deep

What is bimanual palpation?

using two hands to examine certain organs or body parts

What is ausculation?

listening to internal body sounds using a stethoscope

Why are different parts of the hands used in palpation?

it is better for assessing different types of findings

What are fingertips best used for?

Fine tactile discrimination of skin texture, swelling, pulsation, and detecting lumps

What are fingers and thumbs best used for?

detecting position, shape, and consistency of an organ or mass

what is the dorsum (back) of hand best used for?

assessing temperature because the skin is thinner than the palms

What is the base of fingers or ulnar surface of the hand best used for?

detecting vibration

What is percussion?

tapping the patient’s skin with short, sharp strokes to assess underlying structures

Why is percussion used in physical assessment?

to evaluate structures beneath the surface of the body

How does percussion help determine tissue density?

by producing characteristic sounds based on structure density

How does percussion help detect abnormal masses?

It can detect superficial abnormal masses

How deep do percussion vibrations penetrate?

about 5 cm deep

Why might deeper masses not change percussion sounds?

because percussion does not reach deep enough to detect them

How does percussion help identify inflammation

it can elicit pain over inflamed underlying structures

How is percussion used for neurological testing?

to elicit deep tendon reflexes using a percussion hammer

Why must percussion techniques be practiced?

to achieve competence and accuracy

What is the stationary hand in percussion?

the pleximeter hand (middle finger is hyperextended)

What is the striking hand in percussion called?

the plexor hand (the finger that strikes)

What finger is used as the pleximeter?

the middle finger of the stationary hand

How does the pleximeter finger be positioned?

hyperextended

Where should the pleximeter finer be placed?

distal joint and tip firmly against the patient’s skin

What part of the finger should touch the skin during percussion?

only the distal joint and tip of the middle finger

Which finger is used as the striking finger (plexor)?

the middle finger of the dominant hand

How should the forearm be positioned during percussion?

held close to the skin surface, steady but not rigid

How should the striking finer make contact?

Flex the finger so the tip makes contact

What determines the characteristics of percussion sounds?

amplitude, pitch, quality, and duration

What is amplitude in sound?

the intensity - how loud or soft the sound is

What is pitch in sound?

The frequency - number of vibrations per second

What is quality (timbre) in sound?

The subjective difference in sound

What is duration in sound?

how long the sound lingers

How does air content affect sound?

structures with more air produce louder, deeper sounds than dense structures

Why do percussion sounds vary among patients?

because of individual anatomical differences