Health Assessment Exam 1

Subjective vs. Objective Data

Subjective: What the patient says

Objective: Physical exams, diagnostics, observations

Nursing Process (ADPIE)

Assessment: Subjective & Objective data

Diagnosis: Clinical judgment

Planning: Goals

Implementation: Interventions

Evaluation: Reassess

Clinical judgement model

Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes

Maslow's Hierarchy of Needs

1. Physiological Needs

2. Safety and Security

3. Relationships, Love and Affection

4. Self-Esteem

5. Self-Actualization

Maslow's hierarchy of needs priority levels

Level 1: Emergent, Immediate, and Life-Threatening (ABCs)

Level 2: Acute, non-life-threatening issues that require prompt attention (Mental status changes, acute pain, abnormal vitals/labs, risks of infection, safety issues).

Level 3: Non-urgent interventions focused on education, long-term rehabilitation, and higher-level psychosocial needs (Belonging, Self-Esteem, Self-Actualization).

Examples of priority level problems (First, second, third)

High fever: Second level

Client choking: First level

Contaminated wound: Second level

Cardiac arrest: First level

Physical therapy after injury: Third level

Diabetes management education: Third level

Decreased alertness: Second level

Respiratory distress: First level

Community support group: Third level

Patient data types

1. Complete (Total Health) database

2. Focused or problem-centered database

3. Follow-up database

4. Emergency database

Complete (total health) database

Baseline collection of full health history and head-to-toe physical examination is conducted during initial hospital admission or entry into a primary care setting.

Focused database

Used for a limited or short-term problem. A targeted assessment focused on a single, acute health complaint or a specific body system

Ex: assessing ear pain in urgent care.

Follow-up database

Scheduled re-assessments to monitor an already identified problem over time and evaluate treatment effectiveness

Ex: Rechecking blood pressure weeks after starting a new medication.

Emergency database

Rapid, vital data collection performed concurrently with lifesaving interventions during acute, life-threatening crises

Ex: cardiac arrest or severe trauma.

Social Determinants of Health (SDOH)

Economic stability: Financial capability, employment, housing stability, etc.

Education access and quality: Early childhood education, health literacy, and language skills

Health care access and quality: Insurance coverage, proximity to primary care clinics, and access to medical interpreters

Neighborhood and built environment: Housing safety, clean air/water, transportation options, and absence of food or violence

Social and community context: Family/community support networks, and workplace stress

Diagnostic Reasoning

Cognitive, critical-thinking process used by nurses and clinicians to analyze patient cues, recognize clinical patterns, test hypotheses, and formulate an accurate diagnosis or care plan.

Enculturation

The process of learning and absorbing one's native culture from birth (Born into that culture)

Acculturation

The process of adapting to and adopting traits from a new or second culture.

Ex: Immigrant who learns a different culture of language

Cultural Assessment questions

Health practices: "When someone in your family is ill, who cares for them, and what home remedies do you use?"

Family role: "Who makes the primary health and family decisions in your household?"

Religion/spirituality: "What are your religious or spiritual beliefs?"

Death: "What traditions, rituals, or comforting actions are important to your family around death and dying?"

A culturally sensitive nurse shows what four things?

Cultural awareness, cultural knowledge, cultural skills, cultural humility

Communication with professionals (SBAR)

Communication with other healthcare professionals is going to include the patients: Situation, Background, Assessment, and Recommendations

Health literacy includes

Oral teachings, written materials, and teach-back

The nurse's verbal responses in an interview includes

Silence, Reflection, Empathy, Explanation, and Summary

External interview factors include

Ensuring privacy

Note taking

Limiting interruptions

Physical environment

Dressing profesional

Electronic health record (EHR)

Internal interview factors include

Liking others

Empathy

Ability to listen

Self-awareness

Health History includes

Identifying data

Chief complaint

History of present illness

Past medical history

Medications

Allergies

Family history

Social history

Review of body systems

Head-to-toe assessment

PQRSTU mnemonic stands for...

P: Provocative/Palliation

Q: Quality or quantity

R: Region or radiation

S: Severity scale

T: Timing (onset, duration, and frequency)

U: Understanding of the patient's perception

Provocative/palliation questions to ask...

What makes the pain worse or better?

What were you doing when it started?

Quality/quantity questions to ask

What does the pain feel like? Is it throbbing, burning, sharp, dull etc...

Radiation/region questions to ask

Where exactly do you feel the pain?

Does it radiate to other parts of your body?

Can you point to where it hurts?

Severity question to ask

Rate the pain on a scale of 0-10, with 0 being no pain and 10 being the worst pain you've ever felt

Timing/treatment questions to ask

When did the pain begin, and is it constant?

Have you taken any medication for it?

Mental status examination (MSE)

Focuses on the patient's appearance, behavior, cognition, and thought processes

When conducting an MSE, what traits do you look for in a patient's appearance?

Posture, body movements, dress, grooming, hygiene, pupils

When conducting an MSE, what traits do you look for in a patient's behavior?

Level of consciousness, facial expressions, speech, mood and affect

When conducting an MSE, what traits do you look for in a patient's cognitive function?

Orientation: are they alert, do they know what day it is, attention span, memory (ask them to memorize three things and have them repeat at the end of the examination.

When conducting an MSE, what traits do you look for in a patient's thought processes and perceptions?

Thought content, screen for suicidal thoughts, judgment (are they able to manage their care independently?)

Assessment techniques include

Inspection: Assess for skin changes, labored breathing, etc.

Palpation: Touch the skin (Lightly feel, and if no pain, palpate a little deeper in the 4 quadrants of the abdomen)

Percussion: Tapping of the skin; listen for dullness, flatness, tympany (high-pitched and longer sound in the abdomen)

Auscultation: Heart and lungs; listen for abnormal lung sounds (crackles, wheezes, friction, etc...)

General survey

Looking at the patient's age, gender, skin color, level of consciousness, facial features, and overall appearance

When looking at the patient's body structure, what do you look for?

Stature, posture, nutrition, symmetry, position, body build/contour

When assessing a patient's mobility, what do you look for?

Does the patient have any limited ROM

When assessing a patient's Behavior, what do you look for?

Focus on facial expressions (can indicate any pain), mood/affect, speech (can indicate a previous stroke or speech impediment), dress, and personal hygiene

Measurements

Underweight: below 18.5kg

Healthy weight: 18.5 - 24.9 kg

Overweight: 25.0-29/9kg

Obesity: 30.0kg and above

BMI calculation: Weight in lbs divided by height squared, times 703

Vital signs

Body's most basic functions

Detect medical problems

Monitor medical problems

Temperature ranges

Stable = 37*C or 97.0-99.0*F

Hyperpyrexia/Hyporthermia/Pyrexia

Hyperpyrexia: > 104.4*F

Hypothermia: < 95.0*F

Pyrexia: >/= 100.4*F

Where is the control center for temperature

Hypothalamus

Hypertension

Abnormally high blood pressure (overheating)

>140/90

Ways to obtain a clients temperature include

Oral, axillary, rectum, temporal artery, tympanic membrane

Pulse ranges

Expected adult: 60-100 bpm

Bradycardia: < 60 bpm

Tachycardia: >100 bpm

Respiration ranges

Normal adult: 12- 20 breaths/min

Bradypnea:

ABG (arterial blood gas)

A lab that tells us a specific amount of oxygen and carbon dioxide

Peripheral Oxygen Saturation (SPO2) ranges

Expected adults: 95-100%

Hypoxemia =

Blood pressure ranges

Normal adult: 120/80

Hypotension: < 90

Hypertension Elevated: 120-129 SBP,

Orthostatic BP

Measurement BP as patient goes from standing to lying down and from lying down to standing

Initial pain assessment questions

Do you have pain?

Where is the pain?

When did it start?

Rate the pain

What makes the pain worse or better?

What does your pain feel like?

Types of pain

Acute: Does not last long

Chronic: Lasting more than 6 months

Break through pain: Taking medication that is resulting in more pain after it wears off

Sources of pain

Visceral: Larger internal organs

Somatic: Muscles, blood vessels

Deep somatic: Joints, tendons, bones

Cutaneous: Skin

Referred: Pain that shows up on one side of the body but the actual organ causing it is on the opposite side

Pain assessment tools

Wong-Baker FACES scale

Verbal description scale

Visual analogue scale

Nociceptive pain

Pain that occurs from trauma or something causing the onset of pain (triggered by an outside event)

Transduction of pain

Occurs when the incident or trauma occurs, injured tissue sends chemicals that initiates the pain process in our brain

Transmission of pain

Pain impulse moves from the spinal cord to the brain

Perception of pain

You're aware, and you're starting to feel the pain

Neuropathic pain

Pain that does not adhere to your predictable pain diseases, such as diabetes, for example, causing neuropathy pain (pain from an amputation is another example)

- Most difficult type of pain to treat/manage bc it is secondary pain

Modulation of pain

Body starts participating in the pain (releasing neurotransmitters to block some of the pain)