NURS 3108 - Exam #1

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

1. Primary= promotion of healthy lifestyle
2. Secondary= screening efforts to detect disease
3. Tertiary= minimizing disability from illness/ injury to allow for most productive life within limitations

Purpose of health history

subjective: picture into past and present
1. comprehensive
2. problem based
3. follow- up
4. 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

1. Inspection
2. Palpation
3. Percussion
4. 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

3. 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
1. roles in family
2. special dietary practices
3. note patients surroundings

1. who makes decisions in your family
2. are there any foods forbidden by your culture
3. 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

1. Time
2. Place
3. Situation
4. 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

1. judgement
2. abstract thinking and reasoning
3. memory
4. communication skills
5. calculation
6. Vs
7. 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)