Health Assessment Exam 1

weight loss planned

intentional weight loss

weight loss unplanned

involuntary weight loss of greater than 5% of body weight in 1 month or involuntary weight loss of greater than 10% in 6 months; weight loss of more than 20% indicates severe protein-calorie malnutrition

overnutrition

Too much food energy or excess nutrients to the degree of causing disease or increasing risk of disease; a form of malnutrition

malnutrition

deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients

At risk for undernutrition

alcoholics, behavioral/mental health issues, children, chronic/acutely ill, decreased cognitive function, elderly, illiterate, disabled, low income, traumatic brain injured, substance abusers

nutritional health history

focuses on the clinical, physical and psychosocial factors that may affect a patient's nutritional intake; includes

food preparation, weight, dietary preferences, dietary supplements/vitamins, appetite, food intolerances/allergies, water intake

24 hour diet recall

All foods, beverages and accurate amounts (as possible) consumed within the last 24 hours

Body Mass Index (BMI)

a screening tool that identifies the amount of body fat based on height and weight; first tool to indicate nutritional status

inspection

visual examination of the external surface of the body

inspection, palpation, percussion, auscultation

Order of assessment EXCEPT for the abdomen:

Palpation

an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts

percussion

tapping on a surface to determine the difference in the density of the underlying structure

Auscultation

listening to sounds within the body (usually with a stethoscope)

light palpation

detects surface characteristics and accustoms the person to being touched; finger pads 1 cm

deep palpation

assesses an organ or mass deeper in a body cavity; using finger pads of dominant hand gently press down 5 cm

tympany

The percussion note one should hear over the abdomen

Dullness on percussion

sign of fluid or solid mass under area being percussed

Resonance (percussion sound)

a low-pitched, hollow sound, usually heard over normal lung tissue

Hyperresonance Percussion Sound

lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax

flatness

extremely dull sound produced by very dense tissue such as muscle or bone

bell of stethoscope

cup-shaped endpiece used for soft, low-pitched heart sounds; bruits, murmurs

Diaphragm of stethoscope

flat endpiece of the stethoscope used for hearing relatively high-pitched sounds

General Survey

study of the whole person, covering the general health state and any obvious physical characteristics such as posture dress, behavior, level of consciousness, mobility, distress

Temperature normal range

97.5-99.5 F or 36-37 C

hypothermia

body temperature below 95 F 35 C

fever, pyrexia, hyperthermia

temperature greater than 100 F 37.8 C

oral temperature

should not be used on a patient who cannot follow directions, has decreased mentation, is unable to keep mouth closed or breathes through mouth; standard for adult measurement of temperature

tympanic temperature

taken in the ear; should not be used on patient who is experiencing ear pain, ear drainage or has a large amount of wax

temporal temperature

Measurement of body temperature at the temporal artery on the forehead; usually 0.5 F (0.3 C) lower than oral temp

rectal temperature

temperature taken in the rectum; can stimulate the vagus nerve; contraindicated in rectal surgery, rectal disease, low WBC, blood clotting disorder, neurologic disorders, cardiac disease, diarrhea and hemorrhoids; 0.5 F (0.3 C) higher than oral temp

radial pulse

the pulse felt at the wrist; 60-100bpm expected

apical pulse

pulse taken with a stethoscope and near the apex of the heart

pulse deficit

the apical and the radial pulse rates.

bradycardia

slow heart rate (less than 60 bpm)

Tachycardia

rapid heart rate greater than 100 bpm

pulse volume scale

0 Absent pulse

1+ Weak and thready pulse, difficult to palpate

2+ Normal pulse, able to palpate with normal pressure

3+ Bounding pulse, may be able to see pulsation

Respiratory Rate (RR)

Number of breaths per minute; Adults = 12-20

Tachypnea

Increased breathing rate above 20 bpm

bradypnea

abnormally slow breathing (less than 12 breaths per minute)

depth of respiratory rate

shallow vs deep

rhythm of respiratory rate

regularly spaced or irregularly spaced

respiratory effort

Work of breathing-relaxed easy breaths expected

Dyspnea: labored breathing

Orthopnea: inability to breathe when horizontal

Systolic Blood Pressure (SBP)

The pressure in arteries and other blood vessels when the heart is contracting; the first (top) number recorded.

Diastolic Blood Pressure (DBP)

The pressure in arteries and other blood vessels when heart is at rest or between beats; the second (bottom) number recorded.

blood pressure levels in adults

normal: systolic <120, diastolic <80

elevated: systolic 120-129, diastolic <80

hypertension stage 1: systolic 130-139, diastolic 80-89

hypertension stage 2: systolic >140, diastolic >90

hypertensive crisis: systolic >180, diastolic >120

orthostatic vital signs

blood pressure & pulse taken lying, sitting, & standing and documented indicating the corresponding position

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

objective data

information that is seen, heard, felt, or smelled by an observer; signs

Four key principles to inclusive assessment

1. treat every health assessment as an act of humanity

2. health assessments are not about "sameness"

3. examine your own personal biases

4. cultivate a safe environment of care

Cultural Sensitivity

recognizing and respecting the differences between cultures

cultural competency

the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients

cultural humility

process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners

Cultural safety

Culturally appropriate health services to disadvantaged groups while stressing dignity and avoiding institutional racism, assimilation (forcing people to adopt a dominant culture), and repressive practices.

Pain

is whatever the experiencing person says it is, existing whenever he/she says it does; should be accepted as such and respected

acute pain

short-term, self-limiting, often predictable trajectory; stops after injury heals

chronic pain

Enduring pain that does not decrease over time; may occur in muscles, joints, and the lower back, and may be caused by enlarged blood vessels or degenerating or cancerous tissue. Other significant factors are social and psychological.

intractable pain

severe pain that is extremely resistant to relief measures

intermittent pain

Pain that comes and goes at intervals

phantom limb pain

pain in a limb (or extremity) that has been amputated

radiating pain

starts at the origin but extends to other locations

referred pain

pain that is felt in a location other than where the pain originates

Quality of Pain Descriptors

stabbing, burning, itching, tingling, cramping, aching, dull, tender, shooting, sharp, pressure, crushing, throbbing, etc.

numeric rating scale

patient chooses level of pain for each site 0-10; most adults, but not old

Wong-Baker FACES scale

a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain

PAINAD scale

assessment tool for pain used with dementia patients; assesses 5 common behaviors: breathing, vocalization, facial expression, body language, and consolability. A score of 4 or above indicates a need for pain management.

documentation of pain

Level of pain, description of pain, action taken, response to interventions

OPQRST (pain assessment)

Onset, Provocation, Quality, Region/Radiation, Severity, Timing.

OLDCARTS (pain)

Onset

Location

Duration

Character

Aggravating factors

Relieving factors

Timing

Severity

active listening

Pay close attention to the patient's report and non-verbal cues; maintain good eye contact and express a willingness to listen.

active observing

Concentrate on what you hear and see during the interview.

broad opening questions

Will allow the patient to report more spontaneous information and tell you their story. An example is, "What can I do for you today?"

clarification

Obtain clarification if the patient does not clearly express the problem or issue and you are confused about what the patient is saying to you

confrontation

Give the patient honest and respectful feedback about what you see or hear that is inconsistent with what the patient is telling you.

empathy

Identify, understand, share and accept the patient's feelings.

respect

Be respectful of what the patient is saying and feeling.

exploring

Encourage the patient to give you more details. An example is, "Tell me more about the pain in your back."

facilitation

Use simple verbal statements or words to encourage the patient to continue to tell the story. Statements like "uh huh", "And then?"

focusing

Ask specific questions to collect and clarify data that he patient may not be stating during the interview.

Reflecting/Stating the observed

Repeat the patient's words specifically to encourage elaboration of the patient's self-report; this encourages more discussion. An example of reflection is Patient: "I cannot believe that I did not go for my mammogram and now I may have breast cancer." Nurse: "You sound upset. Are you angry that you did not go for your mammogram?"

transitional statements

Use transitional statements to help redirect the interview to another significant area. An example of a transitional statement is, "Now, I would like to discuss your family history."

Silence

Planned absence of verbal remarks allows the patient and the nurse to think over or feel what is being discussed.

Summarizing

State a brief summary at the end of the interview; this allows for clarification and accurate data of the patient's history or problem.

Leading the patient

Do not lead the patient; patients tell you what they want you to hear and may not always be truthful in their self-report.

Asking too many questions

only ask one question at a time for clarity and to disallow misunderstanding

not allowing enough response time

give the patient enough time to think through the answer

using medical jargon

use simple terms so the patient can understand you

assuming what the patient is saying

Never assume what the patient is saying; this leads to misinterpretations

using cliches

Cliches (e.g. "you will feel better in the morning") show disregard for the patient's feelings. This is giving false reassurance.

Offering false reassurance

Never tell the patient that everything will be fine when it may not be.

Specifically asking "why" questions

A patient may feel offended and feel like you are criticizing; a subtle approach is usually more comfortable

changing the subject inappropriately

Sometimes nurses change the subject abruptly when the interview is uncomfortable; this is not helpful for the patient.

Giving opinions

Do not give your own opinions. If the patient asks, "What should I do?" help clarify the options, and provide information about the choices the patient has and refer the patient to talk with his or her healthcare provider.

Stereotyping

be objective during the assessment; every patient is unique and should be respected regardless of race, religion, gender, sexual preference or age.

using patronizing language

Patronizing language communicates superiority or disapproval. Statements such as, "You know better than that," are patronizing and offensive to the client. Condescending approaches, such as, "You should have used the call button before you got up. You're lucky you didn't hurt yourself," do not communicate respect for the client.

Language interpretation

Explain the right to have a language interpreter. Speak directly to the patient and not at the interpreter. Ask simple and clear questions; provide time for the patient to ask questions. Avoid using family members for interpretation.

open-ended questions

allows the patient to express thoughts and encourage verbalization; this type of question allows the nurse to explore the focused topic more broadly. Start with open-ended questions and then use closed questions.

close-ended questions

used to clarify and focus on specific problems; can usually be answered with one word or "Yes" "No"

Three phases of the interview

1. Introduction

2. Working phase - gather data w/ open-ended questions, then closed questions

3. Closing - gives the patient one last chance to share concerns or express himself or herself

Also briefly summarize what you learned during the interview

comprehensive health history

looks at the whole patient and reviews all body systems; this health history takes time

focused or problem-based history

focuses specifically on an acute problem or symptom that the patient is experiencing