Health Assessment Exam 1 UCA

subjective data

what the person says about themselves based on how they are feeling

objective data

information that is seen, heard, felt, or smelled by an observer; signs

internal factors of an interview

liking others, empathy, ability to listen, self-awareness

external factors of an interview

ensure privacy, refuse interruptions, physical environment, dress, note-taking, computer charting

stages of an interview

introduction, working phase (asking open ended questions/closed questions & gathering data), and closing

Facilitation

encouraging client to say more

ex: "mmhmm go on"

silence

wait for a response

ex: waiting for response without interrupting

reflection

echo the client's words

ex: repeat part of what the client had said to you

empathy

support patient, allow to feel with the patient

ex: "That must be hard for you.."

clarification

clarify if the patient's words are confusing

ex: "The heaviness in your chest occurs with walking up the stairs or more than 1 block, but stops when you rest. Is that correct?"

confrontation

Clarifying inconsistent information

Focusing client's attention on an observed behavior, action, or feeling

ex: "you look sad or you look angry"

interpretation

make associations

ex: "It seems that every time you feel the stomach pain, you have some type of stress in your life...could it be that you're afraid?"

explanation

sharing information

ex: "You may not eat or drink for 12 hours before your blood test because the food could alter the test results."

summary

condenses facts and validates what was discussed during the interview

ten traps of interviewing

1. Providing false assurance or reassurance

2. Giving unwanted advice

3. Using authority

4. Using avoidance language

5. Engaging in distancing

6. Using professional jargon

7. Using leading or biased questions

8. Talking too much

9. Interrupting

10. Using "why" questions

nonverbal behaviors

- Nonverbal behaviors can tell a story; observe your patient and also be aware of what your nonverbal behaviors are "saying"

-What are some of these behaviors?

Posture, facial expressions, eye contact, tone of voice, rate of speech, pauses while speaking

oral temperature

most convenient/accurate (good blood supply from the carotid artery & quickly respond to changes to the inner core temperature)

rectal temperature

closest to the inner core temperature (patient on left side, lube it, insert 1 inch into the rectum, & leave until it beeps or until 2 minutes) & subtract a degree due to it being closest to our core temperature & we would put an R next to the temperature we documented) ex: 101.9 R

tympanic temperature

infrared emission, noninvasive, nontraumatic, minimal chance of cross contamination (gently place covered probe in ear canal; used more in clinics)

temporal temperature

infrared emission from temporal artery (slide across forehead; behind the ear) not very accurate; more of an average

things that can influence temperature

- Diurnal cycle: any pattern that occurs every 24 hours as a result of planet earth around its axis

- Menstruation cycle

- Exercise

- Age

normal ranges of temperature

Oral: 96.4 F- 99.1 F

Rectal: on average 1 F higher than oral

normal pulse

60-100 bpm

Force: describe 0, 1+, 2+, 3+

0 = absent

1+ = weak, strainy

2+ = good

3+ = over powering, more than usual

tachycardia

Greater than 100 bpm

Caused by: exercise, fever/infection, anxiety

bradycardia

Less than 60 bpm

Caused by: medications, heart problems, common in athletes

tachypnea

RR greater than 20

Caused by: anxiety, fear, exercise, fever, pain

bradypnea

RR less than 10

Caused by: drug overdose, increased intracranial pressure, diabetic coma

normal respirations

Normal: relaxed, unlabored, regular, silent

Regular: count for 30 seconds x2

irregular : count for 1 full minute

blood pressure

force of blood pushing against the vessel wall

systolic pressure

maximum pressure, felt during left ventricular contraction

diastolic pressure

resting, constant pressure exerted between contractions

pulse pressure

difference between systolic and diastolic

5 factors that determine blood pressure

- Cardiac Output: more blood pumped; increased BP

- Peripheral Vascular Resistance: constricted/narrow vessels; increase BP

larger/dilated vessels; decrease BP

- Blood Volume: higher volume = increase BP; lower volume = decrease in BP

- Viscosity: thicker blood increases BP

- Elasticity of Vessels: stiff, rigid vessels increase BP

hypertension

Abnormally high BP

Essential/primary HTN: no known cause; 95% of cases

Often is undiagnosed: "the silent killer"

hypotension

abnormally low BP

Caused by: acute MI, shock, hemorrhage, vasodilation

risk factors for hypertension

Smoking

Dyslipidemia

Diabetes mellitus

Age greater than 60

Gender

Family history

lifestyle modifications if you have HTN

Lose weight

Limit alcohol

Increase activity

Reduce sodium intake

Stop smoking

Reduce fat and cholesterol

orthostatic hypotension

Drop in systolic pressure of >20 mmHg or increase in pulse of >20 bpm

What causes this?

Procedure: take BP and pulse

Lying, Sitting, Standing

noiceptive pain

Nociceptive: pain develops when functioning and intact nerves are stimulated

Occurs in phases

Transduction, transmission, perception, and modulation

neuropathic pain

pain from damage to neurons of either the peripheral or central nervous system

Sources of Pain

Visceral

Somatic

Deep Somatic

Cutaneous

Referred

pain assessment tools

Initial pain assessment

Brief pain inventory

Numeric scale

Faces pain scale

PQRSTU method

- Provocation: What aggravates it?

- Quality: description of pain: dull, throbbing, sharp, shooting, etc.

- Region of pain/radiation: what is the location of pain?

- Severity: Rate the pain from 0-10

- Timing: when did the pain start, when does it occur, is it constant or intermittent, how long does the pain last?

- U (how pain affects you): how does the pain affect activities of daily living?

normal BP reading

less than 120/80

the aging adult: temp

more likely to have hypothermia not a fever

the aging adult: heart rate

50-95 bpm, but rhythm is usually slightly irregular

the aging adult: respiratory rate

shallower inspiratory phase, increased response rate

the aging adult: blood pressure

have an increase in both systolic and diastolic pressure

pulse oximeter

a noninvasive method to assess arterial oxygen saturation (SpO2)

normal SpO2

97-99 or greater than 95

visceral pain

originates from the larger internal organs

often described as dull, deep, squeezing, or cramping

somatic pain

originates from musculoskeletal tissues or the body surface

deep somatic pain

comes from sources such as blood vessels, joints, tendons, muscles, and bone

cutaneous pain

superficial pain usually involving the skin or subcutaneous tissue

referred pain

pain that is felt in a location other than where the pain originates

the aging adult: Pain

use the PAINAD scale:

- breathing, vocalization, facial expression, body language, and consolability

- a score of 4 or more requires a need for pain management

physical exam steps

Inspection

Palpation

Percussion

Auscultation

inspection

begins when you first see the client

"concentrated watching"

palpation

- Touch to access:

Texture

Temperature

Moisture

Organ location and size

Swelling

Vibration/Pulsation

Rigidity or spasticity

Creciptation

Lumps or Masses

Tenderness or Pain

how to perform palpation

Calm and gentle

Warm your hands

Start with light palpation to detect surface characteristics

Then perform deep palpation

With deep palpation (as for abdominal contents), intermittent pressure is better than one long, continuous palpation. Avoid any situation in which deep palpation could cause internal injury or pain.

percussion

Tapping the patient's skin with short, sharp strokes to assess underlying structures.

The strokes yield an audible vibration and a characteristic sound that depicts the location, size, and density (air, fluid, or solid) of the underlying organ.

You need a stronger percussion stroke for persons with obese or very muscular body walls.

3 steps to percussion

1.Press the middle fingertip (nondominant hand) firmly against the patient's skin. Avoid bones.

2.Use the middle finger of the dominant hand to strike just below the nail.

3.Percuss 2 times in each location, lifting the striking finger off quickly.

- Lift the rest of the stationary hand up off the person's skin

- The goal is to hit the portion of the finger that is pushing the hardest into the skin surface.

characteristics of percussion

1. Resonant- clear, hollow

- Over normal lung tissue

2. Hyper resonant- booming

- Abnormal in the adult, over lungs with increased amount of air as in emphysema

3. Tympany- musical and drumlike

- Over air-filled viscus (e.g., the stomach, the intestine)

4. Dull- muffled thud

- Relatively dense organ as liver or spleen

5. Flat- dead stop of sound, absolute dullness

- When no air is present, over thigh muscles or bone or over tumor

Auscultation

- Listening to sounds produced by the body.

Heart, blood vessels, lungs, abdomen

Stethoscope

The slope of the earpiece should point forward toward your nose.

Diaphragm- breath, bowel, normal heart sounds (high pitched sounds)

Bell- extra heart sounds, murmurs (low pitched sounds)

Room must be quiet.

Warm your stethoscope.

Clean with alcohol wipe.

Never listen through a gown or clothing.

Safety

- Always start by identifying your patient (2 forms: Name & DOB/wristband)

- Hand Hygiene

- Bed height: You should be able to stand without stooping; when working raise it to your level

- Side Rails: make sure they are up when you leave the patient

- Before you leave a hospitalized patient, lower the bed to reduce the risk of falls; make the person comfortable and safe; return the bedside table, television, or any equipment to the way it was originally; and make sure the call button is available.

- Equipment easily accessible and organized on the bedside table.

- Trash can nearby.

- Wear gloves when the potential exists for contact with any body fluids (e.g., blood, mucous membranes, body fluids, drainage, open skin lesions).

- Wear a gown, mask, and protective eyewear when the potential exists for any blood or body fluid spattering (e.g., suctioning, arterial puncture).

4 times to perform hand hygiene

1. Before and after every patient encounter

2. After contact with blood, body fluids, secretions, and excretions;

3. After contact with any equipment contaminated with body fluids;

4. After removing gloves.

physical appearance: general survey

- Level of consciousness (LOC)—The person is alert and oriented to person, place, time, and situation (A&O x3)

Abnormal: Confused, drowsy, lethargic

- Skin color—Color tone is even, skin is intact with no obvious lesions.

Abnormal: Pallor, cyanosis, jaundice, erythema, lesions

- Overall appearance—No signs of acute distress are present.

Abnormal: Diaphoresis, clutching the chest, shortness of breath, wheezing, facial grimace, holding body part.

body structure: general survey

- Symmetry—Body parts look equal bilaterally and are in relative proportion to each other.

- Posture—Erect

- Position—The person sits comfortably with arms relaxed at sides.

Abnormal: Tripod, fetal position

- Obvious physical deformities: Note These

mobility: general survey

- Gait—Walk is smooth and even.

Abnormal: Shuffling, limping, assistive devices

- Note how patient is walking, if any assistive devices are being used

behavior: general survey

- Mood and affect—Pleasant and cooperative.

Abnormal: Hostile, distrustful, suspicious, crying, depressed, anxious

- Speech—Articulation (the ability to form words) is clear and understandable.

Abnormal: Dysarthria, dysphasia

- Speech pattern—The stream of talking is fluent with an even pace. The person conveys ideas clearly.

- Dress—Clothing is appropriate to the climate.

- Personal hygiene—The person appears clean and groomed appropriately.

Abnormal: Unkempt appearance in an individual who previously had good hygiene may indicate depression, malaise, or illness.

body mass index (BMI)

- Marker of optimal healthy weight for height and an indicator of obesity or malnutrition.

- A healthy BMI is a level of 18.5 or greater to less than 24.9

the aging adult: general survey

- Posture—Kyphosis (humpback appearance)

- Gait—Older adults often use a wider base to compensate for diminished balance, arms may be held out to help balance, and steps may be shorter or uneven. Shuffling is abnormal and usually an indicator of Parkinson's disease.

- Weight: Starts to decrease.

Additional fat is deposited on the abdomen and hips.

Height: Become shorter because of thinning of the vertebral disks, shortening of the individual vertebrae, postural changes of kyphosis, and slight flexion in the knees and hips.