Health assessment information (database)
•History (Subjective Data-70%) • Physical Examination (Objective Data-20%) • Laboratory/Imaging Studies (Objective data-10%)
subjective
symptom: what the patient feels/ communicates
objective
Sign: clinical findings collected during physical examination
Clinical manifestations
signs/ symptoms collected
Three levels of health promotion
Primary= promotion of healthy lifestyle
Secondary= screening efforts to detect disease
Tertiary= minimizing disability from illness/ injury to allow for most productive life within limitations
Purpose of health history
subjective: picture into past and present
comprehensive
problem based
follow- up
screening
Therapeutic communication
most important skill: is communication. -active listening -clarifying
reflecting
open-ended questions
Non-therapeutic communication
using medical terminology w no explanation
interrupting
disagreeing
Health illiteracy
patient does not understand, so help them understand with handouts, video, etc. Help patient understand
Professional nursing behavior
calm, organized, competent, professional
Health history: biographic information
name, age, gender, occupation
CC (Chief Complaint)
presenting problem; why seeking care
HPI (History of Present Illness)
History of present illness - brief history of as to what is wrong with the patient at the present time. chronological record onset- current
HPI: presenting symptoms
-Start with "presenting" symptoms
Description of symptoms in patient's own words ->last time felt well, overall health before, previous episodes of similarity
LOCSTAAM
Location, Onset, Character, Severity, Timing, Associated factors, Aggravating/Alleviating factors, Meaning to the patient
OLDCARTS
Onset, Location, Duration, Character, Aggravating/ relieving factors, Related symptoms, Treatment, Severity
Location
-Point to spot where it hurts or describe
Is it localized or generalized?
Does it radiate (or move toward or away from)?
Ex. stomachache: patient c/o pain in the RUQ that radiates towards the umbilicus
Onset
-When did symptoms first start? -Precipiatating factors? -Setting in which symptom occured? -What were you doing at the onset of symptoms? -Where were you during the onset of symptoms? -Patient c/o pain in the RUQ that radiates toward the umbilicus x 2 weeks. Pain occurs after eating fatty foods
Character
-What the patient feels or symptoms look like -Describe sensation or appearance to the best of the patients ability -Patient c/o stabbing pain in the RUQ thay radiates toward the umbilicus x 2 weeks. Pain occurs after eating fatty food Specific descriptive terms such as... burning, sharp/dull, aching, gnawing, throbbing, shooting, stabbing, crushing, cramping
Severity
-Size, extent, number amount -Measure if possible -Grade on scale 1-10 (for A&O pts) -Better, worse, same? -How limiting are symptoms? -Patient c/o stabbing pain in the RUQ that radiates toward the umbilicus x 2 weeks. Pain= 5/10, occurs after eating fatty foods. No changes in level of pain since onset. For PEDS use: FACES
Timing
Chronological (when started?)
Duration (how long have you had them & how long do they last?)
Frequency (constant, intermittent?)
Pattern (# times per day, week, month, after meals, at bedtime, etc)
Patient c/o stabbing pain in the RUQ that radiates toward the umbilicus x 2 weeks. Pain= 5/10, occurs 1-2 times per day after eating fatty foods and lasts 1 hour. No changes in level of pain since onset.
Aggravating and Alleviating symptoms
-What makes the symptoms worse or better? -What aggravates them- weather, activity, food, medication, standing, bending over, fatigue, time of day, season, etc -What relieves symptoms? (rest, medication, ice, etc) What have you tried to do or take to relieve symptoms
Meaning of symptoms to patient
What are you most worries about Did the pain wake you up from sleep How does it affect daily activities How they have been coping
past medical history
Childhood Illnesses, adult illnesses, Accidents or Injuries, hospitalization, immunization, health examination, screening tests
Family history
genogram, age currently, each persons state of health
Screening tools
substance abuse screening (CAGE, TACE, CRAFFT)
domestic violence screening
eating disorder screening
adolescent screening for general issues HEADSS
CAGE
cut down, annoyed, guilty, eye opener
TACE
Take you to get high (how many drinks), Annoyance (who criticizes your drinking), Cut down on your drinking (should you cut down on your drinking?), Eye-opener (have you ever had an eye-opener drink to wake you up in the AM)
CRAFFT
screening tool for substance abuse in adolescents Car, Relax, Alone, Forget, Friends, Trouble
HITS (DV)
Hurt you physically, Insult or talk down to you, Threaten you with physical harm, Scream or curse at you
HEADSS
Adolescent screening for general issues HEADSS(home life, education, substance use, emotional, sexuality)
Present health status
current health condition, current medication, allergies
General survey
1 step of assessment
observation/ inspection
baseline of info
every day use
SENSES to observe
only senses: visual- see/ look auditory- hear/ listen olfactory- smell tactile- tocuh/ feel
Assessment done head to toe? Why do we do this?
cephalocaudal; clean to dirty
key concept is to assess for:
symmetry
Initial observation
mental status? Where did you find pt? General appearance? Overall development and nutrition Noticeable odor dress/ grooming hygiene appropriate
first impression
speech Facial expressions & affect Behavior Breathing Age Response to questions Tremors/tics Eye contact skin color family posture
assessment techniques
Inspection
Palpation
Percussion
Auscultation
inspection 1
what do you see
palpation 2
hands to detect tenderness/ painful areas
temp
texture
moisture
masses
Light palpation
one hand 1/2 in deep (1 cm) RN's use
deep palpation
two hands 1 1/2 in (4 cm)
organ size
advanced practice
bimanual palpation
two hands to assess the kidneys and uterus
advanced practice
percussion 3
striking, tapping of body to produce sound/ vibration
Palpating technique
-finger pads are most sensitive part of the body
dorsal to assess temp
warm hands, short nails
tell pt
direct percussion
involves striking a finger or hand directly against the patient's body
indirect percussion
tapping a finger on another finger help against chest wall/ abdomen
Auscultation 4
listening with stethoscope-- amplifies sound in body cavities/ blocks room sounds
must have diaphragm and bell
Diaphragm
high-pitched sounds like breath, bowel, and normal heart sounds
hold firmly on skin
Bell
best for low pitched sounds like extra heart sounds, murmurs
lightly against skin
Culturally competent care
delivered when nurses value health or illness through patient's eyes
Diverse cultural example
Native Indians emphasize spirituality
nurse touching someone has spiritual power
honor includes components of appreciation and respect
"Melting pot"
U.S. has many cultures and religions
20% speak other language than english at home
Diversity can create challenges when caring for a patient but
do not force compliance but work with beliefs and value systems
cultural competence
Learning process:
self-awareness
reflective practice
knowledge or core cultural issues
cultural competence
recognizing ones own culture, values, biases, and using patient-centered communication skills
required acceptance
Cultural competence requires healthcare providers to be sensitive towards__________
Patients Heritage, sexual orientation, socioeconomic situation, ethnicity, cultural background
You are not responsible for knowing _a, practices, and values of all groups. You ARE responsible for asking about b
a) health beliefs b) beliefs
Culture
All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview.
Ethnicity
Social group within a cultural and social system that share common cultural and social heritage including: Ex. language, history, religion, symbols, folklore
Race
is genetic in origin and includes physical characteristics Ex. skin color, bone structure, eye color, hair color
religion
An organized system of beliefs, rituals, and practices with individual participants
spirituality
broader concept: Prayer Meditation Listening to music Intentional appreciation of beauty Being present in the world with others
Impact of culture
influences way patients seek medical care and clinicians provide care
1 become culturally competent
respect pt by assessing individuals
beliefs, values, preferences, needs
2 do not stereotype
recognize uniqueness
Develop a Template for Assessment
Direct the assessment of patient's health beliefs and practices that reflect his/her cultural heritage.
Personal and psychosocial open ended questions
allow for the patient to give own response and elaborate
open ended question examples
roles in family
special dietary practices
note patients surroundings
who makes decisions in your family
are there any foods forbidden by your culture
any religious symbols
VS: Temperature
-regulated by hypothalamus body generates heat by shivering and vasoconstriction & cools by vasodilation
vasoconstriction
Reduces blood flow and heat transfer by decreasing the diameter of superficial blood vessels.
vasodilation
increase heat loss through skin; evaporation of perspiration. Widening of blood vessels
pyrexia
fever response
Temperature range
97.2 F- 99.9 F (36.2 C-37.7 C) fever is T>100.4 (38 C) oral, rectal, axillary, tympanic, forehead
VS: Pulse
heart rate. ventricular heart contraction pushes a pressure wave of blood throughout arterial system
Pulse range
60-100 bpm carotid, brachial, radial, femoral, popliteal, dorsalis
VS: Respiratory rate
inspiration: diaphagram moves downward, external intercostal muscles increase expiration: internal intercostal muscles decrease diameter
Respiratory rate range
12-20 breaths/ min
tachypnea
faster than normal respiratory rate
bradypnea
slower than normal respiratory rate
VS: blood pressure
force of the blood against the wall of an artery as the ventricles contract and relax
blood pressure range
120/80 (systolic: 120-139) (diastolic: 60-89)
VS: Pain
common, uncomfortable sensation and emotional experience associated with actual or potential tissue damage
Acute pain
is sudden, of short duration, and usually associated with surgery, injury, or acute illnes
Chronic pain
is persistent, lasting weeks, or months, or longer; usually sustained by a pathophysiologic process
Neuropathic pain
pain is long-term, associated with damage or dysfunction of the CNS or PNS.
Pain in infants/ children
-Increased pulse and respiratory rate -Lower blood pressure than adults -Behavioral cues -Less able to modify pain impulses -Easily distracted but still have pain -Different pain scales
pain in older adults
-No diminished perception of pain -Decreased pain threshold -Pain from chronic conditions
Pain is subjective or objective?
subjective!
Pain scales
OLDCARTS or LOCSTAAM
numeric: 0-10 -descriptive: none-worst -visual: point to an area on scale
children, Under sedation: wong/baker FACES -infants: observe the behavior
To assess pain you inspect:
body movements, facial expressions, vocal, vitals, pupils, attention span, palpate skin
Pain control measures
Distraction, relaxation, ice, heat, massage, transcutaneous electrical nerve stimulation (TENs), acupuncture
Alert and orientated x 4 (A&Ox4)
-most important indication of neurological status -test in order: time, place, situation, and person -pt becoming disorientated will lose in that order
A&O X4 steps
Time
Place
Situation
Person
Glasgow Coma Scale (GCS)
a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints (higher the better -- best 15)
cerebral functioning
judgement
abstract thinking and reasoning
memory
communication skills
calculation
Vs
Eyes
Nutrition: Subjective Assessment
Questions explore dietary intake and perceived nutrition-related problems
Tools for nutrition assessment
•24-hour Dietary Recall •Typical Day •Use of food diary •Food frequency questionnaire •Comprehensive diet history (more often done by nutritionist) •Use of tools: 'My Plate' •Assessment of diet in terms of variety of foods, serving sizes, disease specific, etc.
Nutrition: Physical Assessment (Objective)
•Height & Weight (BMI) •Waist Circumference •General appearance & orientation •Skin (hydration, vitamins) •Hair & nails (protein, iron) •Eyes (vitamin deficiencies [A]) •Oral Cavity (ability to eat, vitamin deficiency [B]) •Extremities (size, shape, movement, strength)