Lec 2: Collecting data

when does the general survey begin

first moment of encounter with patient and continues throughout the health history

what 5 factors affect BP

1. cardiac output

2. peripheral vascular resistance

3. circulating blood volume

4. viscosity

5. elasticity of the vessel walls

general survey

first component of the assessment

• helps form a holistic/global impression of the person

• notes physical appearance, body structure, mobility, behavior

what do we look for with behavior

• LOC: are they alert

• facial expression: drooping of face

• speech: quiet/forced, right words, slurred, language

what do we look for with physical appearance

• overall appearance

• breathing

• hygiene and dress

• skin color/lesions

• body structure/development

what do we look for with mobility

• posture

• range of motion (ROM)

• gait

• position of comfort

Level Of Consciousness (LOC)

person, place, time = orientated x3

• do they know who they are, where they are, what time it is

what levels of consciousness indicate something is wrong

• confusion

• agitation

• restlessness

• drowsiness

• lethargy (slow response, tired)

• obtunded (dull or reduced LOC)

• stupor

• coma

what are the steps for assessment for LOC

• spontaneous: enter room, observe

• usual voice: state patients name, ask them to open their eyes

• loud voice (both ears): repeat what you said in usual voice

• tactile: touch patients arm/shoulder

• pressure: put pressure on patients nail bed, do no harm, observe for eye opening

• pain: trapezius pinch, do no harm, observe for movement

what are the Anthropometric measurements

• height

• weight

• BMI calculation

since BMI is not the most accurate measurement tool, what would we do instead

look at waist

• higher waist circumference=higher risk

what are Anthropometric measurements used for?

• identifies risk factors

• calculate dosages

what is the purpose of vital signs

reflect health status, cardiopulmonary function, and overall body function

• need to assess patient medications first

• take temp, necessary (36-37 etc)

• frequency

• baseline

what do height/weight tell us, what should we note about them?

• changes?

• medication dosages

• first sign of endocrine disorder (sudden weight gain)

height and weight for Pediatric health assessment signs

• percentile for development tracking

• metabolic disorders, FTT, abuse, infection

• 0-3 years head circumference also important

what do we do for Cardiac/renal/ICU patient assessment

daily weight

what do we take note of with nutrition and hydration

part of general survey

• weight loss/gain

• appetite (question based, not general survey)

• intake: changes, swallowing

• dehydration: skin, mucosa, tears (affects BP, electrolytes), no peeing/vomiting

• nausea/vomiting

what affects BP

• cholesterol

• stress

• hydration

• blood volume (pregnancy)

• medications

• sodium levels

• kidney function

RN Objectives/goals for the Health Interview

• continue general survey observations

• establish therapeutic relationship with patient/family

• demonstrate nurses sense of caring for patient

• gain insights about concerns

• identify expectations of health care providers/system

• introduce client to health care facilities

what is the first step to for completing an effective interview

determine what you need to do

• urgent?

• focused? (chief complaint)

• comprehensive? (everything)

accurately document appropriate info

primary data source

the patient

• subjective

secondary data source

• family members

• charts

• this objective data should be used to validate what you already believe is happening

Planning the Health Interview as an RN

• self reflection

• review information

• establish goals for the interview

• professional appearance/behaviour

what are all the steps for the health interview

1. wash hands, don appropriate PPE (gloves for body fluids)

2. greet, introduce self, establish rapport

3. make client comfy (position at eye level, preferred sitting in a chair)

4. ask permission

5. invite clients story using open-ended questions

6. establish agenda collaboratively

7. clarify clients info

8. create shared understanding of the concern

9. summarize/plan next steps

10. end interview

what are the components of the health interview

1. demographic data (confirm identity)

2. reasons for seeking care (10 attributes of sign/symptom)

3. health history, allergies/response

4. current medications/indications

5. family history

6. personal/social history

7. review of systems

8. functional health questions

what should you do when sensitive topics brought up

• be non-judgemental (as if your in court)

• explain why info is needed

• say i ask all my clients this question

• ask near end of health history when client may feel more comfy

Cultural & Environmental Considerations

cultural factors influence beliefs of patients about their health status

• illnesses are more common among groups (ethnics) of patients

• patients envir might include safety in the home, transportation issues, or community involvement

• exposure history

what is a sign

• action or physical manifestation

• objective data

• observable through senses

• collected during physical exam

what is a symptom

• sensation/emotion perceived or experienced

• subjective data

• not observable by others

• collected during interview

what are the 10 attributes of a sign/symptom

• location

• associated signs/symptoms

• timing

• environmental/exposure factors

• relieving factors

• severity/quantity

• nature/quality

• aggravating factors

• patient perspective

• significance to client

timing

• when symptom began

• the duration

• continuous pain or sudden

environmental/exposure factors

anything in patients surroundings at home/work that may be related to symptom

severity/quantity

how bad is the pain/concern

• pain scale

nature/quality

what is the symptom like ex colour, type, sharp/burning pain

patient perspective

thoughts from the patient about what they think is happening

significance to patient

effect on the patients lifestyle

how do i know what to ask

• if patient answers indicating a change/concern, you pivot and use analysis of signs to explore further

• if comfy, you can combine systems

• the history and ROS guides determines your physical exam

• physical exam is used to validate your hypotheses

what is asked during past health history

• medical (asthma, diabetes)

• surgical

• obstetric (pregnancy, period)

• mental health

what is the purpose of collecting family history

identify disorders that patients may be at risk

• provide health education

functional assessment def

ability to perform self care/daily living activities

• ex eating, dressing, grooming

what are indicators of urgent assessment

extreme anxiety, acute distress, pallor, cyanosis, and a change in mental status

• less than 10 breaths/min or greater than 32 breaths/min

• o2 saturation less than 92%

• pulse less than 55 bpm or greater than 120 bpm

• systolic BP less than 100 or greater than 170

• temp less than 35C or greater than 39.5C

what makes up the 6 vital signs

1. temp

2. pulse

3. respirations

4. BP

5. pain

6. functional ability

when do nurses take vital signs

• upon admission to a facility

• before/after surgery

• before, during, and after administration of medications that affect vital signs

• per the institutions policy or doctors orders

• any time patients condition changes

• before/after procedure affecting vital signs