HA lecture prelims

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Types of Comprehensive Data

Subjective and Objective Data

• Data where the patient describes their pain

• Health history

• Biographical Data

Subjective data

• Data observed by the medical professional

• Physical Characteristics

• Behavior, measurements appearance

Objective data

What are the 3 Basic Knowledge?

1. Types of and Operation of Equipment

2. Preparation of the setting, oneself, and the client for PA.

3. Performance of the 4 Assessment Techniques IPPA.

EQUIPMENTS

• Collect all necessary equipment.

• Promotes organization and prevents hassle

SETTING

• Hospital

• Outpatient Clinic

• Physical’s Office

• School Health office

• etc.

CONDITIONS:

1. Comfortable

• warm room temperature warm blanket.

2. Private area free of interruptions

• close door, pull curtains

3. Quiet area free of distractions

• turn of radio, etc.

4. Adequate Lighting

• sunlight or lamp

5. Firm examination table/bed at a height that prevents stooping. Roll-up stool prn.

6. A bedside table/tray to hold the equipment needed

PREPARING ONESELF

• Assess your own feeling

• Self - confidence in performing PA

GENERAL PRINCIPLES

• Wash hands before and after procedure

• Wear gloves if necessary. 1 glove and 1 PA

• Wear mask / protective eye

Trash bins:

Yellow for _____ objects

Red for _____ objects

• Contaminated

• Sharp

Standard Precautions

Protection for both the client and medical professional. Assuming that every patient has infections.

• Hand Hygiene

• Gloves

• Eye protection

• masks

• etc.

Approaching and Preparing Client:

N-Client relationship (to reduce anxiety)

• Explain the examination to the and its importance.

• Change into gown (remove underwear)

• Respect the client’s desires and request related to PA

• Begin with less intrusive procedures like v/s, ht, wt (reduces anxiety)

• Approach from the right side (most start at right)

4 Techniques of Physical Examination

Inspection — Palpate — Percuss — Auscultate

Physical examination for the ABDOMEN

Inspection — Auscultate — Percuss — Palpate

palpation is done last to prevent aggravation of the bowel sounds.

What do you call bowel sounds?

Borborygmi (10-15 clicks/min)

Close observation of the details of patient’s appearance, behavior, and movement. Using all senses except taste.

Inspection

Tactile pressure from the palmar finger or finger pads to assess areas of skin elevation, depression, temperature, and tenderness. Assess lymph nodes, pulses, contours, size of organs and masses, and joints

PALPATION

Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter of the third finger of the left hand.

PERCUSSION

Use of the diaphragm or bell of the stethoscope to detect characteristics of heart, lung, and bowel sounds

AUSCULTATION

avoid abdominal palpation in patients with _____ and _____

liver tumor and kidney tumors

Palpation: 3 Parts of HANDS

• Fine discriminations

• pulses

• size, shape

• strength

• mobility

• texture

• consistency

Finger Pads

Palpation: 3 Parts of HANDS

• Vibration

• Thrill

Ulnar/ Palmar Surface

Palpation: 3 Parts of HANDS

• Temperature

• Moisture

Dorsal (Back) Surface

_____ is the grating, cracking popping sound and sensation under skin

Crepitus

______ is the palpable vibration nails should be short and hands comfortable (Standard Precaution if applicable)

Fremitus

4 Type of Palpation

• Use dominant and place on top of patient with no depression

• less than 1 cm

• circular motion

Light

This palpation is for pulses, tenderness, surface, skin, texture, temperature, and moisture.

Light

4 Type of Palpation

• use dominant on top and depress

• 1 - 2 cm

• circular motion

Moderate

This palpation is for body organ and their masses (sizes, consistency, and mobility)

Moderate

4 Type of Palpation

• Use the non-dominant hand on top of the dominant hand

• 2.5 - 5 cm

• circular motion

Deep Palpation

4 Type of Palpation

• place the non-dominant hand to press and dominant will feel structure.

Bimanual

3 Types of Percussion

Use 1 or 2 finger(s) (middle/index)

Direct

3 Types of Percussion

One flat hand and other dominant fist to strike

Blunt

3 Types of Percussion

Produces sound vibration solid tissue, soft tone, fluid, air, louder tone, even louder

Indirect

Sounds Produced

Bones

Flatness

Sounds Produced

Liver, spleen, heart

Dullness

Sounds Produced

Stomach, intestine, or nothing inside

Tympany (Hollow)

Sounds Produced

Adult lung

Resonance

Sounds Produced

Child Lung

Hyperresonance

Part of the stethoscope:

• Concave

• Low pitched

• Distal to heart

Bell

Part of the stethoscope:

• flat

• high pitch

• heart, breath, bowel

Diaphragm

What are bruits?

abnormal

• The first and most critical step; the subjective and objective data gathered during the initial health history and physical exam.

• It serves as baseline data and is done repeatedly during every patient encounter.

Assessment

• Has a nursing focus and is based on real or potential health problems or human responses to health problems.

• Use clinical reasoning to formulate diagnoses based on data gathered and the patient’s problem list.

- Based on NANDA (North American Nursing Diagnosis Association)

Diagnosis

Devising the best course of action to address the diagnoses. Nurse and patient select goals for each problem in order to alleviate, decrease, or prevent those problems.

Planning

Types of Planning

Ongoing/Partial, Focused/Problem Oriented, and Emergency Assessments

• This consists of the data collection that occurs after the comprehensive database is established.

• Consist of mini overview of the client’s body system and holistic health

• The client is reassessed to determine any changes and detect new problems (using patterns)

• Usually performed when the client had a previous interaction with the nurse whenever and wherever.

• Frequency is determined by acuity

Ongoing or Partial assessment

• It is performed when a comprehensive health assessment exists for a client who comes to the health care agency for a specific concern.

• Does not address other areas not related to the concern.

Focused or Problem Oriented Assessment

• A very rapid assessment performed in life threatening situations

• The only major concern for this is to determine the client’s life-sustaining physical functions.

Emergency Assessment

A comprehensive health assessment consists of both a ______ and ________.

comprehensive health history and complete physical examination

• Focuses on disease, injury, or pathological process (e.g., Diabetes Mellitus, Myocardial Infarction).

• Determine the cause and pathology of the illness to guide curative/restorative medical treatment.

MEDICAL DIAGNOSIS

• Focuses on the patient's actual or potential reaction to health problems or life processes (e.g., risk for falls, anxiety, ineffective coping).

• Develop independent interventions to manage symptoms, promote health, and address holistic patient needs (physical, emotional, social).

NURSING DIAGNOSIS

SCOPE OF HEALTH ASSESSMENT IN NURSING

• Nurse collects comprehensive data pertinent to client’s health/situation

STANDARD 1

SCOPE OF HEALTH ASSESSMENT IN NURSING

Analyzing the data to determine the diagnosis

STANDARD 2

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• The start of patient’s condition

• When did the symptoms start?

O (ONSET)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• Where the sensation or pain is felt

L (LOCATION)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• How the condition has lasted

• How long has the symptom lasted? Is it constant or intermittent?

D (DURATION)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• used with pain concerns to better categorize the pain

• What does the symptom feel like (e.g., sharp, dull, burning)?

C (CHARACTER)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• helpful hints to determine what makes a condition better or worse

• What makes it better or worse?

A (AGGREVATING/ALLEVIATING)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• Helpful in determining if the pain has radiated to the other parts of the body

• Does the symptom spread to other areas?

R (RADIATION)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• time-related element to help determine when a symptom occurs. For example, stomach pain always felt after eating might have a different cause than before or during eating. -

• Is the symptom constant or does it come and go?

T (TIMING)

TAKING OF PATIENT’S HISTORY OF PRESENT ILLNESS

• often graded on a 1-10 scale, but it can also be measured subjectively

• How bad is the symptom, often rated on a 1-10 scale?

S (SEVERITY)

Vital signs include:

Temperature, Pulse rate, Respiratory rate, Blood Pressure, and Oxygen Saturation

• 36.5 - 37.5 degrees C

• _______/fever (too hot) and ________ (too cold)

Temperature

• hyperthermia

• hypothermia

• 60 - 100 bpm

• heart rate is consistently too fast (_______, >100 bpm) or too slow (_______, <60 bpm at rest) or irregular

Pulse Rate

• tachycardia

• bradycardia

• 12 - 20 cpm - Abnormally High Respiratory Rate (________) rapid respiratory rate, typically above 20 breaths per minute in adults.

• Abnormally Low Respiratory Rate (________) abnormally slow respiratory rate, typically fewer than 12 breaths per minute in adults.

• _____: Complete stop in breathing.

Respiratory rate

• Tachypnea

• Bradypnea

• Apnea

• 120/80

• __________: Consistently high readings indicate increased cardiovascular risk.

➢ Elevated: 120-129 systolic AND <80 diastolic.

➢ Stage 1: 130-139 systolic OR 80-89 diastolic.

➢ Stage 2: ≥140 systolic OR ≥90 diastolic.

➢ Hypertensive Crisis: >180 systolic AND/OR >120 diastolic (Medical emergency)

• __________: Can cause dizziness or fainting, often from dehydration, heart issues, or certain medications, and is sometimes diagnosed by a significant drop when standing.

Blood pressure

• High Blood Pressure (Hypertension)

• Low Blood Pressure (Hypotension)

• 95 - 100%

• Low Oxygen Saturation (Hypoxemia)

• ➢ Normal: 95-100% (may be lower for individuals with COPD).

• ➢ Abnormal/Low: Below 95%.

• ➢ Concerning: Below 92%, contact a doctor.

• ➢ Emergency: Below 88-90%, seek immediate care

• High Oxygen Saturation (Rarely an Issue)

• Extremely high readings

Oxygen saturation

• Collection of subjective data as well as objective data on the client’s present history

• Frequency depends on the client's age, risk factor, health status, health promotion practices, and lifestyle.

INITIAL COMPREHENSIVE

PREPARING FOR ASSESSMENT

• Nurse should review client’s ________ (if available)

• Keep an open mind to avoid __________ that may alter ability to collect accurate data

• __________ with client and be prepared for additional data

• ______ and _____ materials that you will need for the assessment

• medical record

• premature judgements

• Validate information

• Obtain and organize

• Basis for selecting interventions, achieving outcomes, and communicating care needs.

• Analyzing assessment data (patient's physical, emotional, social, spiritual state) to find patterns and problems.

DIAGNOSIS

Components (P,E,S)

(Label): The unhealthy state (e.g., Impaired Physical Mobility).

P (PROBLEM)

Components (P,E,S)

(Related to): The cause or contributing factors (e.g., related to pain).

E (ETHIOLOGY)

Components (P,E,S)

(Defining Characteristics): Subjective/objective data (e.g., as evidenced by guarding behavior).

S (SIGNS/SYMPTOMS)

the crucial step where nurses develop a patient-centered strategy, setting priorities, formulating measurable goals/outcomes, and selecting specific interventions to address health needs identified during assessment, creating a collaborative care plan for continuity and effectiveness.

PLANNING (BE SPECIFIC)

Key Components of Planning:

Deciding which problems need immediate attention (e.g., life-threatening issues first) using frameworks like Maslow's Hierarchy

Prioritizing

Key Components of Planning:

Creating patient-centered, realistic, measurable, achievable, relevant, and time-bound (SMART) goals and expected outcomes

Goal Setting

Key Components of Planning:

Choosing specific, safe, and evidence-based nursing actions (e.g., monitoring vitals, patient education, assisting with mobility) to achieve goals.

Selecting Interventions

Key Components of Planning:

Writing the plan into a formal care plan for clear communication and continuity of care.

• Short-term and Long-term Goal that you think you can do to relieve the patient

Documentation

IMPELEMENTATION

Actions a nurse can initiate independently based on clinical judgment, without a doctor's order, to address patient needs and goals.

Independent Nursing Interventions

IMPELEMENTATION

Actions that require a specific order or prescription from a physician or other authorized healthcare provider (like an NP or PA).

Dependent Nursing Interventions

PROCESS OF EVALUATION

• Review Goals: Look at the specific, measurable outcomes established earlier.

• Collect Data: Reassess the patient through physical exams, vital signs, lab results, and patient reports.

• Analyze & Compare: Determine if outcomes are met, partially met, or not met within the timeframe.

• Document & Decide: Record findings and decide whether to: - Continue: the plan (goal met). - Modify: interventions (goal partially met). - Revise: goals or reassess for new problems (goal not met).

Nursing interview has two focuses:

• Establishing rapport and a trusting relationship with the client to elicit an accurate and meaningful information

• Gathering information on the client’s overall information

PHASES OF THE INTERVIEW

• Review the medical record before meeting the client

• May reveal client’s past history and reason for seeking health care

• Need to rely on interviewing skills to elicit valid and reliable data from client

Preintroductory Phase

PHASES OF THE INTERVIEW

• Nurse explains the purpose of interview, discuss the types of questions that will be asked, explains the reason for taking notes, and assure the client that confidential information will remain confidential

• Ensure client’s comfort and privacy - Interview at eye level with client demonstrates respect and places the nurse and client at equal levels

Introductory Phase

PHASES OF THE INTERVIEW

• Listens, observe cues, and uses critical thinking skills to interpret and validate information received from the client - Nurse and client collaborate to identify the client’s problem and goals

Working phase

PHASES OF THE INTERVIEW

• Summarizes information obtained during the working phase and validates problems and goals with client

Summary and Closing Phase

COMMUNICATION DURING THE INTERVIEW

non-verbal and verbal communication

VERBAL COMMUNICATION

To elicit client’s perceptions and feelings - “How, “what”

Open-Ended Question

VERBAL COMMUNICATION

To obtain facts and to focus on specific information

Close-Ended Question

VERBAL COMMUNICATION

List of words to choose from in describing symptoms, conditions or feelings

Laundry List

VERBAL COMMUNICATION

Helps to clarify information that client has stated

Rephrasing

VERBAL COMMUNICATION

Well-placed Phrases

Well-placed Phrases

VERBAL COMMUNICATION

What the client tells you and what you observe

Inferring

VERBAL COMMUNICATION

Provide client with information as questions and concerns arise

Providing Information

________ is original, firsthand information collected directly by the interviewer from the source, such as the patient or study participant, for the specific needs of the assessment or research.

Primary Data

This is the primary and most important source of data in a clinical setting, providing subjective information about their symptoms, perceptions, and experiences.

The Client/Patient

Direct, structured, or semi-structured conversations with the individual to gather specific, real-time information.

Interviews

The healthcare provider's own observations of the patient's condition, behavior, or interactions (e.g., observing hand hygiene practices or physical symptoms).

Direct Observation

Objective data collected through physical assessments, lab tests, vital signs (e.g., blood pressure, weight, temperature), and diagnostic results.

Physical Examinations and Clinical Measurements