Health Assessment

Types of histories

• Focused or Problem-Oriented History

• Follow-Up History

• Emergency History

• Comprehensive Health History

Focused or Problem-Oriented History

• Focus on current problem

• Smaller in scope than comprehensive assessment

Follow-Up History

• Returning client to have problem evaluated after treatment

• Second-shift nurse may be following up on a problem identified by a nurse on an earlier shift

• Gather info to evaluate if treatment was successful

Emergency History

• Focused on the patient’s emergent problem w/ a systemic prioritization of need based on pt’s presentation

• Rapid assessment is performed in life-threatening situations

Comprehensive History

• New admit to hospital, rehab, facility

  • Prior to elective surgery

• Provides basis for assessing concerns, health status, risk factors, health promotion, fundamental and personalized knowledge

• Strengthens relationship w/ pt

• Provides baselines for future reference

• Creates platform for health promotion/counseling/education

Components of comprehensive health history

• Identifying data

• Chief complaint(a)

• History of present illness

• Past history

• Family history

• Review of systems

• Health patterns

Identifying Data

• Age

• DOB

• Gender

• Occupation

• Marital Status

• Primary language

Chief complaint

• Determine one or more symptoms causing the patient to seek care

History of Present Illness

• Elaborate on chief complaint

  • Describes how each symptom developed

• Include pt’s thoughts/feelings about illness

• Can include allergies, medications, habits (social) that frequently relate to present illness

• Self treatment

• Past Occurrences of symptom

• Pertinent positives and/or negatives

• Risk Factors or other pertinent info

Past history

• Childhood illness (no matter how old they are)

• Adult illnesses (include dates)

  • Medical, surgical, psychiatric

• Health maintenance practices

  • Immunizations, screenings, lifestyle issues, home safety

• Risk factors

• Allergies

• Medications

• Alcohol + Drug Use

What should you ask when a pt says they have an allergy?

• “What is your reaction?”

Family History

• Diagram/ outline age, health, cause of death

• Includes siblings, parents, grandparents, and children

• Documents presence or absence of specific illness (HTN, CAD)

Genogram

• diagram for family history (similar to concept map)

• Helps with pattern recognition

Review of systems

• Presence or absence of common symptoms related to each major body system

List of head to toe assessment

• skin, hair, head

• eyes, ears

• nose, sinuses, mouth, throat, neck

• breast, axilla

• respiratory

• cardiovascular

• peripheral vascular

• gastrointestinal

• urinary system

• male/female genital system

• sexual history

• musculoskeletal

• neurologic

• hematologic

• endocrine

Health Patterns

• Sleep/rest

• Nutritional Data

• Role/Relationships

• Coping/ Stress tolerance

• Activity/ Exercise

Tools and techniques when discussing sensitive topics

• nonjudgmental

• explain why you need to know info

• Find opening questions for sensitive topics

• Consciously acknowledge discomfort that you are feeling

Seven dimensions of pain

• Physical

• Sensory

• Behavioral

• Sociocultural

• Cognitive

• Affective

• Spiritual

Sites of pain for heart

• neck

• Mid back

• Elf chest

• Arm

• Jaw

Site of pain for liver

• right shoulder

• Lower right back

• Abdomen

Site of pain for stomach

• abdomen

• Mid back

Site of pain for appendix

• right lower quadrant

Site of pain for ureters

• close to genitals

Site of pain for colon

• lower abdomen

Site of pain for ovaries

• both sides of lower abdomen

Site of pain of small intestine

• abdomen

Pain from pancreas

• abdomen (next to stomach and liver pain)

• Indicative of pancreatitis

Site of pain for lung and diaphragm

• central to posterior

• Anterior shoulders

• Lower neck

Site of pain for kidney

• covers largest area of human body

• Stretch from abdomen and mid-back → mid- thigh

Site of pain for bladder

• close to genitals

  • May be in anterior and posterior positions

Pulse Ox

• how saturated blood cells are w/ O2

OLDCARTS

• Onset

• Location

• Duration

• Characteristic

• Aggravating factors

• Relieving factors/ Radiation

• Treatment

• Severity

When can you start to analyze patient?

• As soon as you walk in the room

Analyzing data from patient

• Pattern recognition (cluster)

• Development of schema

• Application of relevant basic + clinical science

What type of questions should you ask patient throughout assessment?

• Open ended → specific

Before beginning any assessment, standard procedures are…

• wash hands

• Identify patient correctly (with two forms)

• Provide patient privacy

• Ensure patient comfort and safety

• Ensure adequate lighting

• Check for appropriate room temperature

• Make sure relevant equipment is assembled

Dimensions of pain

• Physical

• Sensory

• Behavioral

• Sociocultural

• Cognitive

• Emotional (Affective)

• Spiritual

Gate Control Theory

• painful stimulus on peripheral neuron

• “Gate” opens because of depolarization or nerve

• Stimulus goes through PNS @ synaptic junction to CNS up aferente nerve pathways

• Stimulus passes through distal horn of spine structures of límbico system and cerebral Cortex

• Stimulus identified as pain and response created

Acute Pain

• Visceral

• Somatic

• Cutaneous

• Referred

• Phantom

What is used for substance abuse issues?

• Cut down

• Annoyed

• Guilty

• Eye-Opener

Blood Pressure

• Arm at heart level

• Legs uncrossed

• Brachial artery

• Cuff 2 in above artery

• Systolic first when you begin to hear artery

• Keep going 30 units after stop hearing artery

• Don’t fully compress w/ stethoscope

• Release air pressure by 2 units

• Record diastolic when you can no longer hear artery

Nursing Process

• Assessment

• Diagnosis

• Planning

• Implementation

• Evaluation

Purpose of interview

• Obtain accurate info

• Build rapport/ trust

• Create safe space

Subjective Data

• “Saying”

• Collected during interview

Objected Data

• can be measured or observed

• collected during physical exam

Phases of Interview

• Pre- Interview

• Introduction

• Working Phase

• Termination

Pre- Interview

• Prepare

• Review records

• Set goals

• Reflect on approach

• Check appearance

Introduction

• Connect

• Introduce self and role

• Confirm patient’s preferred name

• Explain purpose

• Review agenda

Why is introduction phase of interview important?

• First few minutes set tone for entire interview

How to provide patient with privacy?

• close door or curtain

Working Phase

• Collect most of history

• Chief complaint

• Listen for cues

• Symptoms

• Health History

• Learn patient’s priorities

• Open-ended questions first → focused questions for more details

Termination Phase

• Close

• Summarize what was learned

• Ask what was missed

• Clarify unclear data

• Explain what happens next

What affects communication?

• language barriers

• Age

• Active listening

• Nonverbal

• Literacy

• Tone

When does acute pain occur?

• Suddenly

• Associated w/ recent injury/ illness

Duration of acute pain

• short term

• often self limiting

• decreases as healing occurs

Common examples of acute pain

• surgery

• trauma

• kidney stones

When does chronic pain occur?

• goes beyond healing period

• continues after original injury has healed

Duration of chronic pain

• usually longer than 3 months

• may continue for months or years

Key different between acute and chronic pain

• continues after original injury has healed

• may not improve as healing happens

Where does deep somatic pain start?

• joints

• tendons

• muscles

• bones

• blood vessels

Common causes of deep somatic pain?

• pressure

• trauma

• ischemia

What does deep somatic pain feel like?

• aching

• throbbing

• localized

• Pt can pint to area

Chronic malignant pain

• cancer-related

Chronic nonmalignant pain

• NOT cancer-related

• associated w/ musculoskeletal conditions

  • Arthritis

  • Chronic low back pain'

  • Fibromyalgia

Where does visceral pain start?

• Internal organs

• Stomach/intestines

• bladder

• kidneys

• other abdominal/ thoracic organs

What does visceral pain feel like

• deep aching

• cramping

• pressure

• poorly localized

• pt has hard time pointing to painful area

Common causes of visceral pain

• stretching or distension of organ

• inflammation

• ischemia

Where does cutaneous pain start?

• skin

• subcutaneous layer

What does cutaneous pain feel like?

• superficial

• well localized

• sharp, burning, stinging

Common examples of cutaneous burns

• cut

• abrasion'

• minor burn

• injection/ needle stick

PQRST (used for quicker emergent history)

• Provokes

• Quality

• Radiation

• Severity

• Time

ADPIE

• Assess

• Diagnose

• Plan

• Implement

• Evaluate

Four A’s of Pain Management

• Analgesia

• Activities of daily living

• Adverse effects

• Aberrant behaviors

Analgesia

• measures how treatment relieves the pain

Activities of Daily Living

• Should be considered during pain management

  • How well does pt function and perform everyday tasks

Adverse Effects

• Should track negative side effects of medication when assessing pain management

Aberrant behaviors

• looks for warning signs of misuse, abuse, or addiction

CRIES

• Crying

• Requires Oxygen

• Increased vital signs

• Expression

• Sleeplessness

2SNOOP

• Systemic

• Secondary Risk Factors

• Neurologic

• Onset

• Other conditions

• Positional/ Prior/ Papilledema

When to use 2SNOOP?

• assessing red flags of headaches

What is pain?

• subjective sensory and emotional experience

What does Health Assessment consists of?

• Health History

• Physical Examination

What are health examination techniques?

• Inspection

• Palpation

• Percussion

• Auscultation

Inspection

• First

• Look

Palpation

• Second

• Touch

What to check for when palpating?

• texture

• temperature

• moisture

• swelling

• pulsations

• masses

• pain

• tenderness

What should you use when palpating?

• Back of hand for temperature

• compare both sides

Percussion

• Third

• Tap the skin to possible organ location

What are you looking for when percussing?

• air

• fluid

• solid tissue

Auscultation

• Fourth

• Hearing

What should you listen for during auscultation?

• lung sounds

• heart sounds

• bowel sounds

Percussion sounds

• Resonant

• Hyperresonant

• Tympany

• Dull

• Flat

Nursing diagnosis

• Based on real or potential health problems or human responses to health problems

• change as client’s response and health problem change

Medical diagnosis

• based on illness, injury, or disease process and is the same until it is cured

Reliability

• Repeat measurements give same results

Validity

• Given observation agrees with the best possible measure of reality

How is emergency health assessment organized when cardiac arrest is suspected?

• Circulation, airway, and breathing (CAB)

AUDIT-C

• Alcohol Use Disorder Identification Test

What is considered positive in AUDIT-C for men?

• 4

What is considered positive in AUDIT-C for women?

• 3