Health Assessment Exam 1

Nurse’s role in heath assessment

To perform assessment as a foundation for the nursing process.

What happens step 1 of the nursing process

Assessment: nurse gathers, analyzes, and synthesizes data.

Initial comprehensive assessment.

Done when a patient is first admitted. Collects data subjective about heath history, family history, and lifestyle. Collects objective data from physical exam.

Ongoing/partial assessment

Occurs after a comprehensive database is established. Is a follow-up on a patient’s heath status, usually done whenever nurse interacts with patient, can change frequency based on patient needs.

Focused or Problem-Oriented Assessment

Assessment of a specific health concern only. Does NOT replace comprehensive assessment.

Emergency Assessment

Performed in life-threating situations that don’t allow time for comprehensive assessment. Focuses on stabilization.

Steps of health assessment

Collection of subjective data from patient interview, collection of objective data from nursing assessment, validation of data, and documentation of data.

Purpose of validating data

Nurse clarifies information with patient to prevent incorrect data being recorded. Data can also be verified by asking a college for a second opinion.

Importance of accurate documentation in EHR

Provides information about a patient for their accurate care. Allows the entire healthcare team to access the information easily. Serves as a legal record as well.

S of SBAR

Situation - who are you, where are you, what is going on with the patient

B of SBAR

Background - what is the clinical context of the patient

A of SBAR

Assessment - what do I think the problem is

R of SBAR

Recommendation/Request - what would I do to correct the issue

How to verbally communicate with other heath care workers

Use SBAR to be concise and accurate.

What is subjective data?

In heath assessment, subjective data is reported by the patient. It is symptoms that the patient tells you they are experiencing.

Pre-introductory phase of patient interview

Before you see the patient review EHR to obtain PMH and reason for seeking care. Look for language and cultural barriers.

Introductory phase of patient interview

Introduce yourself to the client, explain the interview process and that it will involve many questions, explain that you may be taking notes, assure pt of confidentiality and privacy.

Working phase of patient interview

Nurse will use listening, critical thinking, and intuition skills to ask questions to gather a heath history and review of systems from the patient.

Summary + closing phase of patient interview

Summarize the information obtained, validate problems and goals with the patient, ask follow up questions to fill any gaps in data.

How to listen

Be present and engaged, keep an open mind, empathize and clarify, listen and learn

Opened ended questions

Allows patient to elaborate and express in their own words. Typically begins with words like “how” or “what”.

Closed ended questions

Require one word answers or yes/no.

Adapting interview for older patients.

Don’t assume hearing status, speak clearly, use straightforward language, show respect.

Adapting interview for depression

Express understanding, don’t be inappropriately cheery, respond neutrally

Adapting interview for anxious client

Be calm, simple, and concise

Adapting interview for patient with cultural differences

May need an interpreter, be aware of cultural practices and variations in communication

The 8 sections of a complete health history

Biographical, reason for seeking care, history of present health concern, personal health history, family health history, review of systems, lifestyle + health promotion, and developmental level

COLDSPA

Character, Onset, Location, Duration, Severity, Pattern, Associated factors

Interview for newborns

Dependent on health records and parents

Interview techniques for older adults

Be aware of potential reluctance to share information

Interviewing older children and adolescents

Allow for privacy from parents, talk to as an equal, avoid close ended questions

Equipment for physical exam

Thermometer, stethoscope, watch with second hand, pulse ox, pen light, gloves, charting system. Sometimes reflex hammer.

How to prepare environment for physical environment

Comfortable temp, private area, quite area, adequate lighting, firm exam table/bed, and bedside table/tray to hold equipment.

How to prepare yourself for physical exam of a patient

Practice makes perfect, try your best to not be anxious as pt will sense it, take precautions to prevent infections

Standard precautions

Hand hygiene, gloves, clean equipment, proper pt placement based on precautions, and occupation health on blood-borne pathogens

Contact precaution

Gown and gloves

Droplet precaution

Gown, gloves, surgical mask

Airborne precautions

Gown, gloves, and fitted N-95 mask

How to approach newborns/infants for physical exam

Explain process to parent, listen to lungs + heart while infant is quiet, keep infant in diaper until needed off (keep infant comfortable).

How to approach children for physical exam

Allow children to play with equipment to mitigate fear, use age appropriate distractions, complete least invasive procedures first

How to approach older adults for physical exam

You may need to limit time if pt tires easily, be respectful and don’t assume status, simplify or rephrase questions if needed.

When do we use sitting position?

Taking vitals, listening to heart and lungs

What is this position and when do we use it?

Supine, for abdominal assessment

What is this position and when do we use it?

Dorsal recumbent, vaginal exam

What is this position and when do we use it?

Sim’s Position, access to vaginal and rectal areas

What do we use standing position for

Assessing posture, gait, or male genitalia

What is this position?

Prone

What is this position and when do we use it?

Knee-chest, rectal exam

What is this position and when do we use it?

Lithotomy, vaginal exam

What is inspection?

Assessing the patient by simply viewing/smelling. Should be done first as other parts of the exam may alter the state of the pt.

What is palpation

Using parts of the hand to touch and feel for texture, temp, moisture, pulse, size, shape, tenderness, consistency, and mass mobility

What are the finger pads used for in palpation?

Pulse, texture, air under skin

What is the ulnar side of the hand used for in palpation?

Feeling vibration

What is the dorsal side of the hand used for in palpation?

Temperature

What is percussion?

Tapping various parts of the body to produce sound waves

Resonance

Loud, low, hollow sound. Should come from hollow organs like the lungs.

Hyperresonance

Very loud, low, booming sound. Comes from conditions like over-inflated lungs.

Tympany

Loud, high, drum-like sound. Comes from stomach and intestines.

Dullness (sound)

Medium volume, medium pitch, thud-like sound. Comes from solid organ like the liver.

Flatness (sound)

Soft, high pitch, flat sound. Comes from bone and muscle.

Auscultation

Listening - requires use of stethoscope

Diaphragm of stethoscope

Larger side. Used to detect high-pitched sounds like heart, lungs, and bowels.

Bell of stethoscope

Smaller side. Used to detect low-pitched sounds such as abnormal heart sounds or the carotid artery.

Components of a general survey

Begins the moment the nurse sees the pt. Nurse observes skin color, dress, hygiene, grooming, posture, gait, apparent age, LOC, facial affect, speech, and behaviors.

Sites you can take temperature

Oral, tympanic, axillary (armpit), temporal, rectal.

Normal temperature

35.9-38 degrees C

Normal pulse

60-100 BPM

Normal respiratory rate

12-20 breaths per min

Regular pulse oximetry

95-100% (90-100% good in acute care settings)

Orthostatic Hypotension

Drop of more that 20 mmHg systolic or 10 mmHg diastolic WITH 10-20% increase in HR

Normal blood pressure

Less than 120/80

Hypotensive

Less than 90/60

Elevated BP

120-129 and >80 mmHg

Stage 1 hypertension

130-139 or 80-89 mmHg

Stage 2 hypertension

>140 or >90

Hypertensive crisis

>180 and/or diastolic >120

Pulse pressure

Difference between systolic and diastolic. Normal range is 30-50 mmHg.

Differences in vitals for childbearing women

BP may be increased slightly, pulse may increase 10-15 BPM, temp should be stable, weight gain normal.

Differences in vitals for infants (28 days - 1 yr)

HR: 120-160

RR: 30-60

Differences in HR for children (2-11)

HR for 2-10 yrs: 70-110

HR for 10+: 55-90

Differences in RR for children

3-5 yrs: 20-28

6-11 yrs: 18-25

12-15 yrs: 12-20

Differences in vitals for adolescents

Vitals begin to normalize to adult numbers at 11-15

Differences in vitals for geriatrics

Temp: 35-36.4 degrees C

Pulse: may feel more rigid

BP: My be higher

Early warning scoring systems

In hospital EHRs, automatically calculates changes in vitals to assess risk of deterioration. There is low, moderate, and high risk.

Analyzing data signs

Identify abnormal findings, compile pt data to reveal patterns, assess for opportunities for pt improvement, risks, actual instabilities, and medical problems (provider diagnosis).

Frontal lobe function

Voluntary movement, emotions, behavior

Parietal lobe function

General touch, pain, temperature sensation

Temporal lobe function

Hearing

Occipital lobe function

Sight

Cerebellum function

Coordination, balance

What is a dermatome

An area of skin supplied by a singe nerve.

Subjective data questions in neuro assessment about current health concern

Ask about any headaches, seizures, dizziness, numbness/tingling, change in senses, difficulty speaking or swallowing, muscle control, or memory loss.

Subjective data questions in neuro assessment about past heath history

History of head injury, meningitis, encephalitis, spinal cord injury, or stroke

Subjective data questions in neuro assessment about family history

Hypertension, stroke, dementia, seizers

Subjective data questions in neuro assessment about lifestyle

Alcohol, drug use, smoking, medication, seatbelt/helmet use, diet, ADLs, stress, chemical exposure.

When is a brief neurological screening used?

When pt is not complaining of any neuro symptoms.

What does a brief neurological screening entail?

LOC, pupils, movement/strength, sensation, vitals.

Alert and oriented

Pt knows who they are, where they are, when they are, and what’s happing (to be A&O x4).

Lethargic

Drowsy, slow to answer questions or is inattentive

Obtunded

Difficult to arouse, requires constant stimulation to follow commands