Health Assess EXAM 1

CDC 5 Determinants of Health

1. Genetics/biology (age & sex)

2. Individual behavior (alcohol use, unprotected sex, smoking)

3. Social environment (income and lifestyle)

4. Physical environment (where individual lives)

5. Health services (insurance and access to health care)

Healthy People 2030

• Identifies health risk factors for disease, updated every 10 years

US Preventive Services Task Force (USPSTF): Screening Grades A-D + I

• Creates evidence-based recs for preventative care such as screen tests, counseling, medications

• Ex: Colon cancer screening for all individuals 45+ --> USPTF Grade A Definition

• Nurses should be aware of these recommendations for at risk: populations, genders, age groups

3 Levels of Health Prevention

1. Primary Prevention: improving overall health to prevent disease

2. Secondary Prevention: Early screening to detect disease

1. Tertiary Prevention:Restoring health after illness to prevent death

Nursing Process (ADPIE)

1. Assessment: priority nursing role

2. Diagnosis

3. Planning/Outcomes

4. Implementation

5. Evaluations

Assessment Techniques (IPPA)

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

1. Inspection

requires use of hearing, seeing, smelling, but NO feeling yet

• Indirect Inspection: using specific equipment to improve visualization of an area such as an ophthalmoscope to look at the internal structure of the eye

• Direct Inspection: carefully visualizing and inspecting a specific area

2. Palpation

use back of hand for temp, finger pads for sensation on surface area, ball of hand for vibrations

3. Percussion

• Tympany = loud, high pitch: air in gastric or pneumo

• Dullness/thudlike = medium pitch: fluid in lungs, full bladder, solid organs/mass, liver

• Resonance = mod-loud, low pitch, hollow sound: normal lung

• Hyperresonance = very loud, low pitch, booming: hyperinflated lung

• Flatness = soft, high pitch: muscle, bone, joints, solid mass

4. Auscultation

• Bell of stethoscope for low pitch sounds (heart murmurs) and pediatrics

• Diaphragm of stethoscope for high pitch sounds (resp or bowel)

Vital signs

• Sequence: general survey → temp (36-37.5 C, 97.5-99.5 F) → pulse for HR (60-100bpm) → respiratory rate (12-20bpm)→ BP (120/80) → Pulse O2 (96%+) → pain

Types of Pains

• Colicky Pain: fluctuates in intensity and occurs in waves

• Chronic pain

• Acute pain

• Nociceptive pain: damage to sensory nerves

• Neuropathic: PNS or CNS nerves damages *pins & needles, tingling)

• Radiating Pain: pain travels to diff areas

  • O (onset) P (provocation/cause and palliates/remedy) Q (quality) R (radiation and region) S (severity) T (timing or temporal) (PQRST)

Pain Assessment (OLDCARTS)

OLDCARTS:

O (onset)
L (location/radiation)
D (duration)
C (character of pain)
A (aggravating or alleviating factors)
R (related symptoms)
T (treatments)
S (severity)

Interview vs. Conversation

• Interview: Structured, formal, goal-oriented, directed, professional, questioning, purposeful, evaluative

• Conversation: Spontaneous, casual, informal, relaxed, balanced, interactive, open-ended, socializing

Establishing Trust (AIDET)

A	Acknowledge: the patient and greet when entering room
I	Introduce: yourself by name and answer any questions about cleanliness of room
D	Duration: give the patient and others an estimate of how long it'll take to clean room
E	Explain: what you're doing as you clean diff areas in the room, emphasizing disinfection
T	Thank: the patient after cleaning procedures are done, anything else to assist with

Phases of Health History

Phase 1: History

Phase 2: Psychosocial Assessment

Phase 3: Specialty Assessment

Phase 4: Review of Symptoms

Phase 1: Health History

Chief complaint, history of present illnesses

1. Biographical Data: Name, address, DOB/age, gender, race, religion, primary/secondary language, marital status, occupation, health insurance, allergies, emergency contact

2. Medication Reconciliation: identify all medications & comparing it to physician’s orders

3. Vaccinations

4. Past Medical History: childhood illness, accidents, surgeries

5. Family History: 1st degree relatives

Phase 2: Psychosocial Assessment (BATHE)

Ask about education, occupation, housing, environment, self-care

1. Substances: drugs can have interactions with prescription meds

2. Domestic Violence

Sexual Health

B	Background: What is going on in your life?
A	Affect: How do you feel about that?
T	Trouble: What troubles you the most?
H	Handling: How are you handling that?
E	Empathy: That must be very difficult.

Phase 3: Specialty Assessments

Functional Assessment (Performance Status): ability to care for oneself and complete the essential activities of daily living (walking, bathing, eating)

1. Barthel Index of ADLs

2. Performance Status Assessment Tools

3. Cultural Identity

   1. FICA Spirituality Assessment Tools

4. Mental Health/Wellness

Cultural Identity (FICA)

F	Faith & Belief: Do you have spiritual beliefs that help you cope with stress?
I	Importance: Have your beliefs influenced how you take care of yourself in this illness?
C	Community: Are you part of a spiritual or religious community?
A	Address in Care: How would you like me to address these issues in your health care?

Religion vs. Spirituality

Religion: A structured system of beliefs, practices, behaviors, rituals, and worship shared by a group of people

Spirituality: A variety of practices exploring the purpose, meaning, and overall direction of life

Situational Awareness

An individual or group’s comprehension and perception of current events

3 Components of Situational Awareness

1. Perception: ability to observe and gather info from environment using the senses

2. Comprehension: understanding and interpretation of perceived info

3. Projection: ability to predict future developments or outcomes based on comprehended info, allowing for decision-making

Nursing Situational Awareness

1. ABC (Airway, Breathing, Circulation)

2. LOC (Level of Consciousness) → AO x 4: time, person, place, situation

3. Oxygen

4. Other body systems assessment based on individual patient issues

5. Safe patient environment → bed position and call bell

6. Clutter & Hazards

7. Emergency equipment working '

8. Assistive devices → glasses, hearing aids, mobility assistance

9. IV access area assessment

10. Medical devices → tubes, drains, catheters

11. Bedside commode, urinal, bedpan for urine elimination

12. Patients have their stuff within reach

Communication

process in which communicators generate social realities within social, relational, and cultural contexts

• (Transactional Model: communication is irreversible)

Barriers to Therapeutic Communication

failure to listen, hearing impaired, language barrier, aphasia

1. Broca’s Aphasia: difficulty EXPRESSING words

2. Wernicke’s Aphasia: difficulty RECEIVING words

Methods of Documentation

Electronic health records (EHRs), source-oriented records, progress notes, problem-oriented medical records, progress notes (SOAP), PIE charting: Problem, Intervention, Evaluation, Focus Charting, charting by exception, SBAR

SOAP + PIE Charting

S	Subjective: "I'm in the worst pain!"
O	Objective: "Patient is A & O x 4, vital signs"
A	Assessment: "Acute pain related to midline surgical incision of the abdomen as evidenced by diaphoresis, HTN, tachycardia"
P	Plan: "Administer ordered pain medications
I	Intervention: Morphine 3 mg IV prn every 6 hours (last dose: ___ @ ___) -- Joy Park RN
E	Evaluation: patient reports pain has decreased

PIE Note:

P	Problem: identified by # and addressed in the documentations used flow sheets
I	Interventions
E	Evaluations

Focus Patient Care Note (Progress Note) (DAR)

D	Data
A	Action
R	Response

Communication Tool between Nurse & Patient (SBAR)

S	Situation: identify self, site, symptom, onset, severity
B	Background: date and time of admission, admitting diagnosis, lab results
A	Assessment: suspected underlying cause or concerns
R	Recommendation: expectation/recommendations

Abdomen: 2 Types of Peritoneum Lining

1. parietal

2. visceral peritoneum

Abdomen: 4 Pairs of Abdominal muscles

1. rectus abdominis

2. transverse abdominis

3. internal abdominal oblique

4. external abdominal oblique

Abdomen: 2 Types of Viscera

1. solid viscera: adrenal glands, kidneys, liver, pancreas, spleen, ovaries, uterus) (when percussed, should be DULL sound)

2. hollow viscera: gallbladder, SI, stomach, colon, bladder (when percussed, should be TYMPANIC)

Abdominal Assessment Order

1. inspection

2. auscultation

3. percussion

4. palpation
   (different than normal IPPA)
   (START ON RLQ and go clockwise)

Right Lower Quadrant Organs

• cecum, appendix, part of ascending colon, (right ovary/right spermatic cord, right ureter)

• hollow sound

Right Upper Quadrant Organs

• liver, gallbladder, duodenum (SI), head of pancreas, part of transverse & ascending colon (right adrenal gland)

• solid sound

Left Upper Quadrant Organs

• stomach, spleen (solid), body & tail of pancreas, part of transverse colon & descending colon, (left kidney, left adrenal gland)

• hollow sound

Left Lower Quadrant Organs

• sigmoid colon, part of descending colon (left ureter, left ovary/left spermatic cord)

• hollow sound

Liver

• heaviest & largest excretory organ; filter toxins/nutrients

• produces bile for metabolism

• Diagnostic tests: AST, ALT, ammonia/bilirubin levels, liver biopsy

Gallbaldder

• store, concentrate, and transport bile to the intestines to aid in digestion (to digest fats)

• diagnostic tests: ultrasound, hepatobiliary iminodiacetic acid scan for cholecystitis inflammation

Pancreas

• secretes insulin & releases pancreatic juices

• diagnostic tests: amylase & lipase, glucose

Stomach

• temporary reservoir that stores food and breaks it down

• 3 parts: upper fundus, body, and lower pylorus

• diagnostic tests: esophagogastroduodenoscopy, capsule endoscopy

Spleen

• largest lymph organ (immune system)

• diagnostic tests: complete blood count (CBC)

Small Intestine

• digestion (& absorption of nutrients)

• 3 parts: duodenum, jejunum, ileum (more solid b/c absorbed further down GI)

Large Intestine

• absorption of water and electrolytes

• 4 segments: ascending, transverse, descending, sigmoid colon

Anus & Rectum

• rectum: store processed fecal material

• anus: endpoint of GI tract, internal & external sphincter

Kidneys

• remove waste/drugs, balance body fluids, release hormones

• lie in back part of upper abdomen

Bladder & Ureters

• bladder: reservoir for urine

• ureters: transport urine

Health History GI (OLDCARTS Questions)

weight, appetite, dysphagia, N/V, indigestion/heartburn, constipation/diarrhea, flatulence (gas)

• Onset

• Location

• Duration

• Characteristics

• Aggravating/Alleviating Factors

• Relieving Factors

• Treatment

• Severity

Health History Anus/Rectum

• change in size and diameter of stools

• Hematochezia: color of blood in stool gives you clues to where bleeding is occurring

  • Bright Red Blood: Often from the lower colon, rectum, or anus (e.g., hemorrhoids, anal fissures, colon polyps).

  • Dark Red/Maroon Blood: Can come from higher up in the colon or small intestine.

  • Black, Tarry Stools (Melena): Indicates bleeding from the stomach or upper small intestine

Health History GU

• urination (frequency, incontinence, back pain, dysuria, hematuria)

• if skin is jaundiced, indicates liver issue

• out of country travel

Steps for GI/GU Assessment Exam

1. Instruct patient to empty the bladder. (b/c they can pee themselves)

2. Position patient in the supine position, with head on a pillow and arms by their side. If the patient is unable to flex knees, place a pillow under the knees.

3. Expose the abdomen, place a drape over the patient’s symphysis pubis and chest area for women. (only expose what we need to see to gain trust)

4. If the patient states that he or she has abdominal pain, say that you will assess the painful abdominal area last.

1. Inspecting the Abdomen

• at patient’s side & standing at patient’s feet

  • contour, size, symmetry, hair distribution → flat or round, symmetrical

• skin: color, lesions, veins, hernias → smooth

• movements, pulsations, peristalsis

ABNORMAL:

• sunken/scaphoid, protuberant/distended stomach

2. Auscultating Bowel Sounds of Abdomen

• starting in the RLQ then moving clockwise (RLQ→RUQ→LUQ→LLQ)

• hearing for peristalsis (movement):

  • normal: 5-34 clicks or gurgles/min (borborygmus sound)

  • hypoactive: <5 clicks/min (slow, dec. sounds)

  • hyperactive >34 clicks/min (loud, high-pitched sounds)

• if NO sounds for 3-5 min, then bowel obstruction/ileus (stoppage of peristalsis) = no BLOOD FLOW!!

3. Percussing the Abdomen

• use 2 fingers to tap on abdomen and hear sound and assess tenderness or inflammation

• normal sounds:

  • tympany: high-pitched drum-like sound in HOLLOW organs (ex: stomach, intestine, colon)

  • dullness: low sound in SOLID organs (ex: liver, spleen)

ABNORMAL:

• in distention, excessive high-pitched sounds → means trapped gas or fluid (ascites)

• dullness, pain

4. Palpating the Abdomen

• light, then deep palpation to assess tenderness

• nondominant hand over dominant hand, press down 1.2-2 iniches

ABNORMAL:

• Rovsing Syndrome: when palpation on LLQ causes pain in RLQ

• Blumberg Sign (Rebound Tenderness): press slowly on tender area and let go.. if extremely tender = peritoneal inflammation (infection)

Stool Inspection

• volume, color, odor, consistency, shape, constituents

Urine Inspection

• color, odor, turbidity (clear or cloudy), pH, specific gravity, constituents (abnormal: blood, pus, glucose, protein), amount

• urine output: 30 mL/hour

  • if urine output is TOO LITTLE, then blood loss (hypovolemia)

  • if urine output is TOO MUCH, then urinary retention (waste gets absorbed)

Healthy People 2030 for Cancer

• Goal: reduce the # of new cancers, disability, and death

• Colon Cancer Screening: screen for colon cancer depending on family hx, but begins at age 45 for both men and women

Medication Reconciliation

• creating an accurate list of a patient’s current medications and comparing it with physician’s admission, transfer, and discharge orders

Glands Affecting Integumentary System

• sebaceous glands & sweat glands

  • Eccrine: produce sweat

  • Apocrine: produce body odor

• if glands are blocked, swelling can occur

Integumentary System Assessment Factors

• family hx, allergies, skincare, skin color/texture, moles or lesions, rashes, hair, nails

[Assessing Skin]

• inspection: personal hygiene, body odor, skin color (cyanosis: decreased oxygenation, pallor: paleness, jaundice: yellowish tint, erythema, hyper/hypopigmentation)

  • assess the conjuctiva, palm of hand, and mucous membranes for color changes

• palpation (wear gloves): compare for SYMMETRY, turgor (dehydration), temperature (using dorsal surface of hand), moisture

Mole Assessment (ABCDE)

• Asymmetry

• Border

• Color

• Diameter

• Evolving/Elevated

Primary Lesions

reaction to external or internal environment; may be present at birth or develop during lifetime

Secondary Lesions

progressive changes in primary lesions, trauma, or injury to the primary lesion

Macule

• primary lesion

• <1 cm, flat, round

• ex: freckle

Patch

• primary lesion

• >1 cm, flat, irregular

Papule

• primary lesion

• <1 cm, solid, elevated, rough, red

• ex: keratosis, warts

Plaque

• primary lesion

• grouping of thickened papules

• ex: Psoriasis

Vesicle

• primary lesion

• <1cm, raised, round, fluid-filled

• ex: herpes zoster

Nodule

• primary lesion

• >1.5 cm, solid/firm, elevated, palpable

• ex: vascular nodule

Pustule

• primary lesion

• a raised vesicle filled with PUS

• ex: acne

Bulla

• primary lesion

• >1cm, elevated, circumscribed, fluid-filled

• ex: blister

Wheal

• primary lesion

• raised swelling, red bumps, welts, itchy skin

• ex: hives

Scale

• secondary lesion

• build up of dead skin cells, flaky

• ex: eczema

Crust

• secondary lesion

• dried blood, serum, pus, normal healing

Excoriation

• secondary lesion

• hollow crusted area, exposed dermis

• ex: incontinence

Erosion

• secondary lesion

• a depression area, moist, shiny, superficial epidermis loss

• ex: candidiasis

Ulcer

• secondary lesion

• concave, variable in size, exudate

• ex: pressure ulcer

Fissure

• secondary lesion

• linear crack or break in skin

• ex: cheilitis

Scar

• secondary lesion

• discolored fibrous tissue over healed surgical scar/wound

Keloid

• secondary lesion

• excessive collagen production beyond wound or incision

Distribution of Lesions

• diffuse/generalized (over entire body, hives)

• scattered

• localized (limited discrete area, insect bite)

• regional (head or torso)

• dermatome (connected to spinal nerves)

• extensor surfaces (elbows & kneecaps)

• intertriginous areas (skin folds)

Pattern of Lesions

• round/oval (eczema)

• discrete (lesions are separate, moles)

• grouped/clustered

• confluent (lesions run together, measles)

• linear (contact dermatitis)

• arciform (lesions in arcs, partial rings)

• iris (bull’s eye rash, Lyme’s disease)

• reticular (meshlike rash, cold-induced)

• gyrate (lesions in serpentine configuration)

• annular/circular (ring shape)

• polycyclic (concentric circles, hives)

[Hair & Scalp Assessment]

• hair amount, distribution, cleanliness

• inspect hair color, texture, lesions (palpate the scalp)

ABNORMAL:

• brittle/thin hair, lesions on scalp, tender scalp

• alopecia, tinea capitis

[Nail Assessment]

• inspect color & markings, shape & contour, nail base angle 160 degrees, firmly adhere to the nail bed, nail beds pink

• palpate nailbeds: perform capillary refill rest <2 seconds

ABNORMAL:

• clubbing (usually in smokers → decreased oxygenation, bronchitis)

• beau’s line, onychomycosis, spoon nails

• fungal infection (yellow)

[Wound Assessment]

• location of wound, size, infected?

• open wound (granulation: healthy red, slough: exudate/drainage, eschar: necrotic tissue usually black)

• wound odor

• drainage: (serous: clear and watery, sanguineous: bright/fresh red blood, serosanguineous: light pink blood, purulent: dark yellow to green)

  • amount of drainage: small (<1/3 dressing), moderate (1/3-2/3 dressing, large (2/3 dressing)

• presence of sutures or staples

Wound Healing

1. Primary Healing: immediate closure of wound, usually surgical incision → edges are approximated (brought together) using sutures or staples

2. Secondary Healing: used for large, open wounds that cannot be closed immediately → heals from bottom up and sides in through granulation

3. Tertiary Healing: wound is left open for 3-7 days, granulates outward, then later surgically sutured

Phases of Wound Healing

1. Hemostasis (blood clotting immediately)

2. Inflammation (WBCs)

3. Proliferation (new tissue layer of epithelial cells)

4. Remodeling (new collagen tissue, scar)

Types of Wounds

• Abrasion, abscess (pus), contusion (bruise), crushing, excoriation (too much exfoliation), incision, laceration (jagged tear caused by trauma), penetrating, puncture, tunneling (not healing)

Stages of Pressure Ulcers

1. Stage I: non-blanchable erythema (redness doesn’t go away when pressed); skin is intact

2. Stage II: partial thickness loss involving both epidermis and dermis (blister)

3. Stage III: full thickness loss involving subcutaneous tissue (fat)

4. Stage IV: full thickness loss with muscle or bone showing

5. Unstageable pressure ulcer (necrotic dead, black tissue)

Pressure Ulcer Assessment

• location of ulcer

• length x width x depth (using cotton tip applicator)

• assess for undermining: pocket under edges of wound

• assess for tunneling: a narrow passageway from wound bed into subcutaneous tissue or muscle

• signs of inflammation (red indicates vasculature healing, good!)

• amount and color of exudate (drainage) → don’t want yellow drainage

  • serous, serosanguineous, purulent

  • slough is yellow = sign of necrotic tissue (infected)

  • eschar is black = dehydrated necrotic tissue (must be cut out)

Gallbladder

• stores bile and releases bile