health assessment exam 1

health

state of complete physical, mental, social well being, not just not having disease

8 dimensions?

physical, emotional, social, spiritual, environmental, intellectual, financial, occupational

spiritual?

values and beliefs of pt

intellectual

ability to learn, health and literacy in general

occupational

does work stress you out physically/mentally?

types of health assessment

comprehensive - overall, physical, new pt

problem focused - focus on a problem, ex. headache

emergency - ex. moorcycle accident

episodic - chronic disease, come back and visit every 4 months

screening - general forms for general population

levels of health

primary - prevent occurance of disease

secondary - find out disease early on and managing it

tertiary - minimize severity of chronic disease ex. HTX pt develops kidney disease = dialysis for kidney n

nursing process

assessment

diagnosis

plan

intervention

evaluations

signs

objective, what you can measure (weight/temp)

symptoms

subjective, what pt feels (naseua or pain)

interviewing phases

preinterview - prepare and look at charts/ lookup disease

introduction - why r u here, who r u

working - asking q from broad to narrow

termination - summarize so both understand what plan is

open ended questions

how are you today

what brings you here today

what problems have you been having

oldcarts

onset

location

duration

characteristics

alleviating or aggravating factors

radiating or relieving factors

timing

severity

what is confrontation in an interview?

asking pt something you see, “you sound angry”, “youre rubbing ur belly”

direct questioning

occurs after person shared story, dont use bias (be gentle)

patient history

identify problems

establish reliability - is pt a reliable storyteller?

consider - supression or underreporting of info

remain subjective to info pt gives (think abt it in their shoes)

adapt to modifications (age, physical, emotional)

patient hx order

identifiers - name, date, time, gender, race, marriage status, religion, occupation

chief complaint - significant or most serious symptom/sign that brings them in

HPI - explore - stability, first symptoms, typical attack, impacts

PMH - adult medical illness, surgery/procedures, childhood illness, trauma, meds, allergies, transfusions, emotional status

FH - illness similar to patient, history of disease, cultural background, depression, htx, cancer

SH - personal status, occupation, habits, home life, military, religious, access to care, ADL, sleep patterns, relaxation

ROS - look at all systems

nutritional health history

HPI/RS< PMH, MEDS, FH, PSH, dietary intake, exercise

nutritional deficiencies results

skin 0 dry skin, turgor, edema (low protein lvl, fluid in bwtn skin), ecchymosis (bruise)

hair - dull, alopecia

nails - clubbing, white spots, white streaks

cardio - arrhythmia, heart block, edema, bp

GI - distended abdomen

musculoskeletal - muscle weakness, malformation, peripheral neuropathy (damage to nerves outside brain)

neurologic - altered mental status

anthropometric measurement (bone, muscle, adipose)

quantitative measurement

heigh, weight, BMI, circumference, skin fold thickness,nutritional status

BMI

look at frame of body

weight/height

underweight - <18.5

normal - 18.5.24.9

overweight - 25-29.9

obese - >30

wasit circumference

above hip after exhale

large circumference = cardiovascular disease risk up

females - <35

males <40

dietary intake

24 hour recall - what have you eaten in order

food diary - take notes

food frequency

my plate and healthy eating plate

suggestions of portion sizes of fruits, grains, veggies, proteins, and dairy/water

fruits

- apples, bananas, organes, strawberries, grapes, mangoes

grains

brown rice, oatmeal, break, pasta, barley, cereal

refined grains - white rice, white break, crackers

veggies

broccoli, spinach, lettuce, tomatoes, bell peppers, cucumbers, potatoes

protein

meats, tofu, fish, eggs, peanut butter

vital signs and ranges

heart rate - 60-100bpm

blood pressure - under 120/80 mmhg

respiratory rate - 12-20 breaths/min

temp - 37 or 98.6f

pain - scale

pulse ox - indirect reading of oxygen usage

heart rate

contraction of myocardium

RRR regular rate and rhythm

radial

apical (5th rib)

check equality too

cardiac output

HR x stroke volume (amount pumped out per beat) = CO

vol pumped out by heart per min

blood pressure

CO x systemic vascular resistance

systolic - myocardium contracting

diastolic - myocardium relaxing

pulse pressure - systolic - diastolic (normal 30-40)

BP cuff problems?

too small = high BP

too big = high on large arm, low on small arm

arm above heart = high bp

arm below heart = low bp

has to be 40 percent of upper arm and 80 percent wrapped around (the puffy part)

orthostatic hypotension

drop in SBP >20mmhg or DBP 10mmhg within 3 mins standing

fall risk

causes: meds, long bedrest, hypovolemia (low circulation)

BP GUIDELINES

normal <=120, <=80

elevated 120-129, <80

stage 1 HTN 130-139, 80-89

stage 2 HTN <=140, >=90

HTN crisis >180, >120

things so BP reading is proper

sit, legs uncrossed, arm level at heart, no caffine, cuff size, deflate right

trend with BP

older = systolic increases

temp measurements

core

infared

temportal - forehead scan

tympanic - ear, reliable

oral

axillary

rectal - young kids

98.6 normal

dinural fluctuations 1-1.5f, during sleep temp goes down

menstrual fluctuations .5-1f

hypothermia

under 35c 95f

pyrexia/fever

over 101

hyperthermia

over 104

average temp

96.8 -100.4, normal is 98.6

ranges in peds (with age)

HR - goes down

RR - goes down

BP - goes up

temp - same

pain?

subjective

uncomfortable and emotional experience associated with actual or potential tissue damage

what plays a role in pain

previous experiences, culture and beliefs, attitudes toward using meds, illict drug history, fear of addiction

how to assess pain?

self reporting, observation, OLDCARTS, number pain scale, visual (point on graph where your pain falls), descriptive words, painometers

assess pain in peds?

wong/baker face rating scale or the oucher

assess pain in nonverbal kids?

FLACC: face legs activity cry counsolability

each is 0-2 score and adds to 10

OR

nonvocal complaints (groans), grimace face, bracing (clutching), restlessness, rubbing

acute pain?

short, begins suddenly, signs of problem, can be mild and last minutes or severe and for weeks

chronic pain

3-6 months, comes in intervals

can stem from trauma that even healed hurts

no obvious sign can be possible

change in mood, appetite

pain types

somatic/nociceptive - localized, can point to it, tissue damage

visceral - deeper in body, cant point to it

idiopathic - so stupid bc dont know where it comes from (headaches, ibs, anxiety)

neuropathic - ex. foot alsleep, injury to CNS/PNS

when perscribing pain meds what do you have to factor?

not biased

educate patient

look at the efficacy of med and pain management - if they solve it will the ADL go up? are there adverse effects to med that can cause other problems?