Health Assessment Exam 1

Health Assessment

The collection of information, clinical judgment, and evaluation of obtained data to deliver care

What does a health assessment identify?

The client needs through the collection of subjective and objective information

Comprehensive Assessment

A full head to toe exam

Focused Assessment

Focuses on a body system or body part

Subjective Assessment

Review chief complaint and any previous or chronic health conditions that may assisst to direct the approach of the current assessment and is completed by asking appropriate health history questions

Objective Assessment

Hands-on approach of seeing, feeling/touching, hearing, or smelling to obtain a complete assessment together with subjective information

IPPA

Inspection, Palpation, Percussion, and Auscultation

Nursing Process

A structured course of action which includes the process to develop, implement, and evaluate the care of the client. This provides a blueprint for delivering patient centered care that is holistic and enhances patient outcome

Assessment

The information gathering phase through interview, physical exam, and observation using assessment techniques and best practices

Analysis

The RN analyzes the collected data, then collaborates with the client to develop a plan of care. Nursing interventions are determined at this point

Planning

The nurse uses problem solving and decision making skills to prioritize care with outcomes and goals in mind using evidence-based practice and current nursing standards

Implementation

The RN will carry out established interventions while using clinical judgement to monitor the client’s progress toward their goals

Evaluation

Ongoing part of each step to evaluate the effectiveness and achievability of each goal. This will also determine the need for interventions to be adjusted to improve patient outcomes.

Contextual awareness

Understanding the status of the client and the events that have led to their interactions with the health care team

Analyzing assumptions

Involves evaluating the client’s clinical situation and the use or modification of standard approaches to meet the healthcare needs and concerns of the client

Exploring Alternatives

The use of holistic approaches in treating the whole person. The health needs of each client are unique and are a culmination of physical health, lifestyle choices, culture, living environment, and life experiences

Using credible sources

Involves using institutional standards, local, state, and federal standards, accreditation standards, and scholarly sources to determine evidence-based practice

Non-Maleficence

First and foremost- do no harm

Beneficence

Promote the good of the client, with a return torward health and homeostasis

Autonomy

Clients right to make decisions; the client can refuse treatment if they so desire

Justice

Treat everyone regardless of their ability to pay for treatment, social status, cultural or relgious background

Confidentiality

Respecting the rights of the client to maintain privacy (HIPAA)

Communication Skills: Personal Factors

Maintain professionalism with all communications which includes reflecting on our own biases, thoughts, and feelings regarding the patient

Therapeutic communication

An approach to communicate that is verbal and nonverbal. Introducing yourself, your title, and making sure your badge is visible

What should you avoid when communicating to a client?

Inappropriate pronouns, non relveant personal questions, assuming the client knows about the health interview or physical, personal opinions, automatic responses or false reassurances, or relaying disapproval of client statements or health practices

ISBARR

Identify, Situation, Background, Assessment, Recommendations, Read back orders

Palpation

Use your hands and fingertips to feel areas of the body for various findings such as temperature, moisture, and ab

Percussion

Striking or tapping a body part used as a diagnostic technique by listening to the sound produced

Auscultation

Listening to the sounds of the heart, lungs, abdomen, and arteries

What is the diaphram of a stethoscope used to listen for?

High pitch noises (breath sounds, bowel sounds, heart sounds)

What is the bell of a stethoscope used to listen for?

Cardiac sounds or soft, low pitch sounds lik eextra heart sounds or murmurs

Documentation

A legal document that records the action of the healthcare provider, and it’s a part of the permanent record. Clar and accurate documentation is considered a precise and factual account of the status of the client in chronological order

Health History

The structured conversation to allow the nurse to gather pertinent details about the background and current medical status of the client

Directive Interview

Highly structured; the nurse controls the elements of the interview and asks essentail questions for the nurse to gain precise details about the clients reported condition

Nondirective Interview

The client controls the pace and theinformation seeking route.

Closed ended questions

Direct, noncomplex questions that require simple answers such as yes or no

Open ended questions

Allow the client to elaborate on their answer which results in a more thorough and detailed response

Biographic Data

Document clients name, address, and phone number; age date of birth; illnesses or medical disability

Childhood illnesses

Illness that is experienced and any complication or have lasting effect

Injuries

Significant injuries such as auto accidents, fractures, head injuries, penetrating wounds, or serious burns

Chronic Illnesses

Not any serious or chronic illness such as asthma, diabetes, or seizures

Health maintenance exams and screenings

Doocument when the client last had a medical visit for physical, dental or vision assessment

Allergies

Reactions to food, medications, environmental or contract triggers

GTPAL: G- Gravida

Total number of pregnancies

GTPAL: T-Term

Number of pregnancies carried to within two weeks of client due date

GTPAL: P-Preterm

Number of pregnancies delivered more than 2 weeks before client’s due date

GTPAL: A-Abortion

Spontaneous (Miscarriage) or Induced (Therapeutic)

GTPAL: L-Living

Current number of living children

Emotional and psychological history

Ask client about current stress and coping strategies and effectiveness. History of previous counseling or mental healthcare, recent losses and if grief is playing a part in the client’s current emotional state

Family History

Within 3 generations of blood relatives. Document age and cause of death for deceased family members

True or False: Painful symptoms are always a priority

True

Functional Assessment

Determines the client’s ability to care for themselves when they are not experiencing illness. This includes lifestyle, living environment, and ability to perform ADL’s

Self Esteem

How the client views themself and their self worth

Body image

The clients attitude toward their physical apperance, health, strength, and sexuality

Role Performance

The client’s ability to meet their responsibilities at work and at home as well as in personal and family relationships

Personal Identity

Involves a client’s ability to be authentic with self and others

Health Literacy

Ability to navigate, understand, and use health information with the intent of maintaining health

Sleep

Describe the pattern of their sleep habits along with use, frequency, and effectivenss of sleep aids

FICA: F-Faith

Do you have any spiritual traditions that you follow or you would like us to be aware of?

FICA: I-Influence

How does your religious fatih or spirituality guide your health choices and practices?

FICA: C-community

Do you participate in a religious or spiritual community?

FICA: A-address

Do you ahve any spiritual or religious preferences that we need to address?

Alcohol Consumption

How often they consume alcohol, how much they consume, and when their last drink was

Tobacco/Nicotine

Determine the type of tobacco used, amount smoked in a day and last time a client smoked, vaped, or chewed. If a former smoker, record how long ago they quit

Recreational drug use

Ask if the client has used illicit drugs or prescription medication for a nontherapeutic use and determine the type of substance used and the frequency

Relationships

Ask clients to characterize their interactions with family and friends including social relationships with positive and negative influences to a client’s health

Occupational Health

Ask client about their occupation, exposure to health hazards, risk for injury with moving machinery or heavy lifting, use of PPE, stressful job responsibilities

Verbal Communication

Involves active listening, expressing empathy, being respectful, and showing acceptance of the patient and their situation

Nonverbal communication

Communicates warmth, interest, and availabiltiy

Miscommunication

May occur due to cultural or personal resasons, past experiences or current emotional/physical state

Abuse

Observe the client’s appearance, behavior, body structure, and mobility; note anything that the client may be experiencing abuse, neglect or human trafficking

Signs of abuse, neglect, or trafficking

Unkempt or inappropriate dirty clothing, appears malnourished, difficulty walking or sitting due to perineal or rectal pain

General Appearance

Quick overall assessment of the client’s general appearance noting any signs of acute distress

Mood

State of emotion

Affect

Physical expression of the client mood or how the client’s mood appears to others

Body structure

Observe the client’s posture and positioning- any observable body alterations, body parts symmetrical and proportionate

Mobility

Focuses on gait and range of motion- note ability to move each joint and ambulate

Measurement obtain client height and weight

Note the anthropometric measurement in relationship to stated age

PQRST: Provocation

What causes the pain?

PQRST: Quality

What does the pain feel like?

PQRST: Region

Where is the pain located?

PQRST: Severity

How severe is the pain?

PQRST: Timing

When did the pain start?

Eye contact

Assess patients amount of eye contact while considering client cultural background, especially when eye contact is established then lost due to changes in questions and answers

Alert

Awake, opens their eyes spontaneously

Delirium

Has acute confusion that comes and goes

Dementia

Has chronic, progressive confusion

Lethargic

Is not fully awake- will drift off to sleep with lack of interaction or stimulation and are easily awakend with calling of name or verbal stimulation

Obtunded

Asleep and only arouses with loud auditory or physical stimulation. Confused and speaks in one word sentences when awake and falls back asleep without contant stimulation

Stupor

Unconsciousness but will respond to physical stimuli or pain with movement or incoherent vocalizations

Comatose

Completely unconscious and has no response to physical or painful stimuli

Skin

Ensure skin is warm to touch, dry, and intact with even skin tones

Personal Hygiene

Observe client’s grooming, noting body and breath odors noting dental hygiene

What is important for an oral temperature reading?

Ensure the client has not smoked or had oral intake recently

What is the most accurate reading of core temperatures?

Rectal

Temporal temperature reading

The probe should be held at the center of the forehead then moved across the forehead than behind the ear to obtain and accurate temperature

Axillary Temp reading

Least considered less accurate and is used less often in adults but is easily tolerated in patient populations of toddler and older

Tympanic Temp reading

Quick, easily accessed, and reflects a core temperature

Pulse oximetry

A device that uses a light wavelength to detect the amount of oxygen that is bound to hemoglobin

Factors that affect O2 readings?

Carbon monoxide poisoning, jaundice, painted nails, recent injection of dyes