Health Assesment: exam 1

Evidence-Based Practice (EBP)

considered the 'gold standard' a process used to review, analyze, and translate the latest scientific evidence - research studies, guidelines etc.

EBP decision making

- evidence-based research and theories
- patient values & preferences
- clinical skills/ expertise
- physical exam and assess patient

- patient values & preferences

- clinical skills/ expertise

5 steps of EBP

1) ask a clinical question
2) collect the most relevant and best evidence
3) critically appraise the evidence
4) apply relevant evidence in practice
5) assess outcomes

the nursing process

(ADPIE)

Assessment
Diagnosis
Planning
Implementation
Evaluation

Diagnosis

Planning

Implementation

Evaluation

subjective data

what the person or subject says about themselves during the assessment

objective data

what we as health care professionals observe by physical exam through inspecting, percussing, palpating, auscultating

cue

is a piece of information, sign

or a symptom or a piece of lab or

imaging data helps draw conclusions about patients

is a piece of info, sign or symptom, or a piece of lab/imaging data

Assessment (nursing process)

- review of clinical record

- interview
- health history
- physical exam
- functional assessment
- cultural and spiritual assessment
- consultation
- review of literature

cluster data

information to support evidence as well as rule out inconsistent clinical findings in terms of differential diagnosis

*distinguishes relevant signs and symptoms

1st-level priority

Emergent, life threatening, and immediate

2nd-level priority

Next in urgency, requiring attention so as to avoid further deterioration

3rd-level priority

Important to patient's health but can be addressed after more urgent problems are addressed

collaborative problems

approach to treatment involves multiple disciplines

the interview

- 1st step in the therapeutic relationship
- contract between provider and patient
- identifies health strengths and problems as a bridge to physical exam

successful interview components

- gather complete and accurate data
- establish rapport and trust
- teach person ab holistic health
- begin teaching for health promotion and disease prevention

process of communication

- behavior, conscious and unconscious; verbal and nonverbal
- all behavior has meaning
- body language

communication: internal factors

specific to professional
LEAS
- Liking others
- Empathy
- Ability to listen
- Self-awareness

communication: external factors

environment
ERPDN
- Ensure privacy
- Refuse interruptions
- Physical environment
- Dress
- Note-taking

Electronic Health Record (EHR)

- can interfer with provider-patient relationships
- don't allow it to become a barrier
- make sure to also capture: biomedical, psychological, and emotional info

best way to refer to an adult patient when initiating interview

Hello Mr. Jones, what brought you to the emergency department today?

1st 5 verbal responses

reactions to answers provided to you
- Facilitation
- Silence
- Reflection
- Empathy
- Clarification

last 4 verbal responses

expressing thoughts
- Confrontation
- Interpretation
- Explanation
- Summary

traps of interviewing

- Providing False Reassurance
- Giving Unwanted Advice
- Using Authority
- Using Avoidance Language
- Engaging in Distancing
- Using Profession Jargon
- Using Leading or Biased Questions
- Talking too much
- Interrupting
- Using "why" Questions

congruency effect

reinforces verbal message

incongruency

nonverbal message is viewed as the truer one bc it is under unconscious control

nonverbal modes of communication

physical appearance, posture, gestures, facial expression, eye contact, voice, touch

interpreter gender

preference is same gender

nursing techniques to improve literacy

oral teaching, written materials, teach back

standardized communication (SBAR)

Situation, Background, Assessment, Recommendation/Request

S (SBAR)

situation

B (SBAR)

background

A (SBAR)

assessment

R (SBAR)

recommendation/request

mental status

a person’s emotional and cognitive functioning

organic disorders

Caused by brain disease of known specific organic
cause (delerium, alcohol intoxication, dementia, substance withdrawal)

psychiatric disorder

When an organic etiology has not yet been established (anxiety and schizophrenia)

ABCT

mental status examination

A (ABCT)

appearance

B (ABCT)

behavior

C (ABCT)

cognitive functions

T (ABCT)

thought processes and perceptions

when is a full mental status examination necessary

intial screening, behavioral changes, brain lesions, aphasia, symptoms of mental illness

what can affect mental exam findings

• illnesses/health problems

• medications

• educational/behavioral level

• stress responses

Appearance (ABCT)

• posture

• body movements

• dress

• grooming and hygiene

• pupils

behavior (ABCT)

• level of consciousness

• facial expression

• speech

• mood and affect

cognitive functions (ABCT)

• orientation: time, place, person

• attention span

• recent and remote memory

4 unrelated words test

memory test when patient is asked to recall 4 words that you gave at 5, 10 an 30 minutes

• Normal response for persons younger than 60 is an accurate 3 or 4-word recall after 5, 10, and 30 minutes.

testing for aphasia

• word comprehension

• reading

• writing

thought processes and perceptions (ABCT)

• thought processes and content

• perceptions

Generalized anxiety disorder scale
(GAD-7)

● Consists of 7 itemized scale
● Higher the score, greater the
likelihood.
● First 2 questions relate to core
anxiety.
● Greater or equal than 3 indicates
diagnosis.

Patient Health Questionnaire-2 (PHQ-2)

● 2 questions about depressed mood
and anhedonia (lack of interest).
● Serves as a screening tool to use
full PHQ-9 tool

PHQ-9

• 9 questions that relate to frequency
  of occurrence of symptoms

• Higher the score, the greater the
  likelihood of functional impairment
  or clinical diagnosis.

Mini-Mental State Exam (MMSE)

● Concentrates only on cognitive
functioning
● Standard set of 11 questions
requires only 5 to 10 minutes to
administer.
○ Useful for both initial and serial
measurement
○ Detect dementia and delirium
and to differentiate these from
psychiatric mental illness.
○ Normal mental status average
27; scores between 24 and 30
indicate no cognitive
impairment

Montreal Cognitive Assessment (MoCA)

● Examines more cognitive domains,
more sensitive to mild cognitive
impairment
● Ten minutes to administer
○ Total score of 30 with a score of
greater to or equal than 26
considered normal

ABCT additional guidelines

used for aging adults:

• behavior (level of consciousness)

• orientation

• cognitive functions (new learning)

what is often misdiagnosed in aging adults

confusion

when to check mental status

after checking sensory status, vision, and
hearing

mini-cog

Reliable and quick instrument to screen for
cognitive impairment in healthy adults
● Consists of three-item recall test and clock-
drawing test
● Tests person’s executive function, including
ability to plan, manage time, and organize
activities, and working memory
● Those with no cognitive impairment or
dementia can recall the three words and draw
a complete, round, closed clock circle with all
face numbers in correct position and
sequence and hour and minute hands indicating time requested

health

the state of
complete physical, mental, and
social well-being, not just the
absence of disease or
infirmity.

holistic wellness

• physical

• intellectual

• emotional

• social

• spiritual

• environmental

general survey

• physical appearance

• body structure

• mobility

• behavior

• measurements

what is a general survey

the study of the whole person

physical appearance (general survey)

• age

• sex

• level of consciousness

• skin color

• facial features

• overall appearance

body structure (general survey)

• stature

• nutrition

• symmetry

• posture

• position

• body, build, contour

mobility (general survey)

• gait

• foot placement

• range of motion

• no involuntary movements

behavior (general survey)

• facial expression

• mood and affect

• speech

• dress

• personal hygiene

measurements (general survey)

• weight

• height

• BMI

• waist circumference

kyphosis

flexion in the back occurring at age 80

nutritional status

the degree of balance between nutrient
intake and nutrient requirements.

adult overweight BMI

25+

adult obesity BMI

30

physiologic changes in aging adults that directly affect nutritional status

poor dentition, decreased visual acuity, decreased saliva production,
slowed gastrointestinal motility, decreased gastrointestinal absorption,
and diminished olfactory and taste sensitivity

parameters of nutrition screening

weight and weight history, conditions associated with increased
nutritional risk, diet information, and routine laboratory data.

comprehenesive nutritional assessment

for those who have been identified as nutritional risk:

• Dietary history and clinical information

• Physical examination for clinical signs and anthropometric measures

• Laboratory tests

marasmus

protein-calorie malnutrition

kwashiorkor

protein malnutrition

Metabolic Syndrome (MetS)

diagnosis:

• glucose level: 100 mg

• triglyceride level: above 150 mg

• hypertension: systolic and diastolic parameters

bariatric surgery

surgery used to manage obesity

2 main pathways of pathological pain

nociceptive and neuropathic

process of nociception

perception, modulation, transmission, transduction

what does neuropathic pain imply

implies abnormal processing of pain message that is difficult to assess and treat

neuropathic conditions that may lead to development

Diabetes mellitus, herpes zoster (shingles), HIV/AIDS,sciatica, trigeminal neuralgia, phantom limb pain, and/orchemotherapy

sources of pain

visceral , somatic, cutaneous and referred

referred pain

pain felt at a particular site but originates from another location

S (PQRST)

Severity (pain scale)

CRIES infants

■ Measures postoperative pain in preterm and term neonates
■ Examines physiologic and behavioral indicators on 3-point scale

A (FLACC)

activity

PAINAD

Pain Assessment in Advanced Dementia
○ Evaluates 5 common behaviors
■ Breathing, vocalization, facial expression, body language, and consolability
■ Quantified behaviors and rated 0, 1, 2
■ Total score metric 0 to 10
■ Score of 4 or more requires treatment.

cellular metabolism

requires a stable core, or 'deep body,' temp of a mean of 37 degrees C or 98.6 degrees F at rest

what is temperature influenced by

Diurnal cycle
menstruation cycle
exercise
age

pulse pressure

difference between systolic and diastolic
Reflects stroke volume

Mean Arterial Pressure (MAP)

pressure forcing blood into tissues,
averaged over cardiac cycle

doppler/sphygmomanometer

measures blood pressure