HA Exam 1

Purpose of Health Assessment

Systematic method of collecting and analyzing data and informs a pt-centered plan of care

Nursing Process

ADPIE

What does ADPIE stand for?

Assessment

Diagnosis

Planning

Intervention

Evaluation

Subjective data

reported by the pt based on feelings, perceptions, experiences and can’t be measured directly

Objective data

Observed, measured, and verified

• Collected using the senses or instruments

• Observable and quantifiable

Data Collection

During Assessment

1. Nursing history, medical history

2. Professional observations

3. Physical examination

4. Diagnostic test results

Data clustering

process of organizing related pt assessment findings, signs, and symptoms into meaningful groups to identify patterns

Urgent vs nonurgent findings

determines in what order you will see pts

First level priority

Emergent, life-threatening, and immediate

• chest pain

• stroke

• active bleeding

• trauma

Second level priority

Next in urgency after level 1, requiring attention to avoid further deterioration

• post fall

• infections

Third level priority

Important to pt’s health but can be addressed after more urgent problems are addressed

What can lead to mistakenly high BP measurements?

• After physiologically active

• narrow cuff size and/or applied too loosely

• Reinflating during the procedure

What can lead to mistakenly low BP readings?

• Decreased inflation size

• Too large cuff size

Therapeutic Communication Techniques

• Active Listening

• Open-Ended Questions

• Using Silence

• Restating and Paraphrasing

• Reflecting

• Clarification

Open-ended vs closed-ended questions

Open-ended questions allow the pt to explain more, while closed-ended questions are a yes or no answer

10 Traps of Interviewing

1. Providing false assurance or reassurance

2. giving unwanted advice

3. using authority

4. using avoidance language

5. distancing

6. using professional jargon

7. using leading or biased questions

8. talking too much

9. interrupting

10. using “why” questions

ADLs

Activities of Daily Living

• Bathing, toileting, eating, ambulating

iADLs

Needed to live independently

• Housekeeping, shopping, laundry, finances, social interactions

CAGE screening

Alcohol screening: amount, frequency, last drink

Questions asked during CAGE screening

• Have you (or anyone else) ever thought you should cut down on your drinking?

• Have you ever been annoyed by someone coitizing your drinking?

• Have you ever felt guilty about your drinking?

• Do you ever drink in the morning (eye opener)?

FICA screening

Spiritual Assessment Tool

• Faith

• Influence

• Community

• Address

Normal Temperature range

98.6 F or 37 C

What temperature is Hyperthermia (Fever)?

100.4 F or 37.8 C

What temperature is Hypothermia?

<36 C or 96.8 F

What is normal temp influenced by?

Diurnal cycle, Menstruation cycle in women, exercise, age

Different temperature routes

1. Sublingual

2. Tympanic

3. Temporal

4. Rectal

Normal pulse rate and grading scale

Normal pulse is 60-100 BPM and 2+

Grading scale: regular or irregular rhythm and 0,1+,2+,3+,4+

Where is the Apical pulse

5th intercostal space and left midclavicular line

Bradycardia and Tachycardia

Bradycardia = less than 60 BPM and Tachycardia = more than 200 BPM

Normal Respiratory Rate Range

10-20 breaths per minute and a regular rhythm

Tachypnea and Bradypnea

Tachypnea = more than 25 breaths per minute

Bradypnea = less than 10 breaths per minute

What signals increased WOB

• Use of intercostal muscles

• Retractions: sinking in of the skin around the chest and neck

• Use of accessory muscles

• Nasal flaring

• Grunting

• Thoraco-abdominal paradox

• Posture

Elevated BP

120-129 systolic / <80 diastolic

Stage 1 Hypertension (HTN)

130-139 systolic / 80-89 diastolic

Stage 2 Hypertension (HTN)

greater than or equal to 140 / greater than or equal to 90 diastolic

Hypotension

<90/60

What is systolic BP?

Max pressure during LV contraction

What is diastolic BP?

during resting/filling

What is the pulse pressure?

Difference between systolic and diastolic

Formula for mean arterial pressure (MAP)

MAP=(SBP + 2 x DBP) / 3

How many mmHg are needed to maintain organ perfusion?

greater than or equal to 60mmHg

What is the level of BP determined by? (5)

1. Cardiac output

2. Peripheral vascular resistance

3. Volume of circulating blood

4. Viscosity

5. Elasticity

Which factors could cause a falsely low BP reading?

• Using a cuff that is too large

• Deflating the cuff too quickly

• Positioning the arm above the level of the heart

Which factors could cause a falsely high BP reading?

• Taking BP immediately after exercise

• Re-inflating the cuff during the procedure

• Pt’s legs crossed

• Taking BP after pt just had a cigarette

What finding confirms orthostatic hypotension?

• A systolic BP decrease of 25mmHg after standing

• A diastolic BP decrease of 10mmHg after standing

Average BP varies normally w many factors including…

• Age: gradual rise

• Sex: after puberty females lower BP than males & after menopause higher

• Race

• Social Determinants: can lead to increased risk of HTN

• Diurnal rhythm

• Weight

• Exercise

• Emotions

• Stress

Orthostatic Vital Signs

Used when suspect volume depletion, concerns related to BP meds, dizziness, or syncope

• Primarily used to check for orthostatic hypotension

Positions to take orthostatic BP (3)

1) Take when supine

2) Take when sitting

3) Take when standing

• 3 mins in between each

• check for drops in BP w/in 3 mins of standing

Normal pulse ox

95 or greater on room air

Visceral Pain

Internal organs

• dull, squeezing, cramping

• direct injury to organs

Somatic Pain

Musculoskeletal or body tissue

• Deep somatic: blood vessels, joints, tendons, muscles, bones (aching, throbbing)

• Cutaneous: skin surfaces and subcutaneous tissues (superficial, sharp, burning)

What pain assessment tool is used for kids?

Wong-Baker FACES pain rating scale

Nociceptive Pain

painful sensations transmitted to the CNS

Neuropathic Pain

Pain to lesion or disease in nervous system

Referred pain

pain felt at a diff site than originates

• both sites innervated by same spinal nerve

Inspection assessment of Respiratory

• Level of consciousness

• Facial expression

• Skin color & condition

• Position

Things to note on facial expression during inspection of respiratory

• tense, strained, tired

• pursed-lip breathing

Things to note on skin color & condition during inspection of respiratory

• cyanosis: bluing or graying

• pallor

• Nail beds: color, clubbing, capillary refil

Thoracic cage ratio

Anterior-Posterior (AP: Transverse Ratio 1:2 or 0.7

Barrel chest closer to 1:1

Palpation tests during respiratory assessment

• symmetric expansion (butterfly)

• palpate for lumps, masses, tenderness

• tactile fremitus

What does a decreased tactile fremitus indicate?

Obstruction: pleural effusion, pneumothorax, emphysema

What does an increased tactile fremitus indicate?

consolidation of tissue (pneumonia)

What should be heard when percussing lungs fields?

Resonance

What do hyperresonance and dullness over lung fields indicate?

Hyperresonance: lower-pitched, booming sound = more air

Dull: thud or muffled sound = obstruction

Adventitious (Abnormal) Lung Sounds

1. Crackles

2. Wheezes

3. Rhonchi

4. Stridor

What does crackles indicate in the lungs?

Popping sounds: fluid in the alveoli

• pneumonia

• heart failure

What do wheezes indicate in lung sounds?

High-pitched: Narrowed airways

• asthma

What does rhonchi indicate in lung sounds?

low pitched snoring: secretions in large airways

What does stridor indicate in lung sounds?

Very high pitched: upper airway obstruction

• can be heard w/o a stethoscope

• emergency if heard

Normal respiratory pattern for adult

Rate: 10-20 breaths per minute

Pattern: even, regular

Depth: 500-800mL

Tachypnea

• Rapid, shallow breathing

• >24 breaths per minute

• can be respiratory insufficiency, pneumonia, alkalosis, CNS

Hyperventilation

• Rapid, deep breathing

• Can be extreme exertion, fear, anxiety, CNS

• Blows off CO2 can lead to alkalosis

Bradypnea

too slow

• <10 breaths per min

• can occur w hypoventilation

Hypoventilation

too little air

• shallow or inadequate breathing

• not enough alveolar ventilation

• C02 may increase

Cheyne-Stokes respiratory patterns

Abnormal cycle w waxing and waning respirations w apnea between

• causes: heart failure, meningitis, drug OD, increased ICP

• abnormal in awake adults but may occur during sleep in infants and older adults

Biot Respirations

similar, but irregular

• 3-4 respirations followed by apnea

• Causes: trauma, brain abscess, heat stroke, meningitis, encephalitis

Common respiratory conditions found in inspection

Inspection: AP:T diameter 1:2, relaxed, RR 10-20, regular, no cyanosis or pallor Sp02 >95%

Common respiratory conditions found in palpation

symmetric chest expansion, tactile fremitus present and equal bilaterally, no lumps, masses, or tenderness

Common respiratory conditions found in percussion & auscultation

resonance throughout lung fields and clear lung sounds throughout

What’s happening during Air trapping?

too much air —> Hyperresonance and decreased breath sounds

What’s happening during fluid filled alveoli?

Alveoli or pleura filled w fluid —> dullness and crackles

What’s happening during collapse?

Lung not expanding —> decreased expansion and decreased breath sounds

What’s happening during obstruction?

Narrowed airways —> wheezes and prolonged expiration

What’s happening during perfusion problem?

Blood flow issue —> shortness of breath and clear lungs

Air trapping conditions

Asthma, emphysema, pneumothorax

• increased WOB, tachypnea, SOB, decreased SpO2, prolonged expiration

• decreased tactile fremitus

• hyperresonance

Fluid related lung conditions

Pneumonia, heart failure, pleural effusion, ARDS

• Tachypnea, dyspnea, decreased SpO2

• Chest expansion on the affected side, fremitus may vary

• Dull percussion

• Crackles

MMSE

Mini-Mental State Exam

• 11 questions, takes 5-10 mins

• Focuses on Cognitive function only

• Used to detect dementia or delirium

• Score: 24-30 = Normal

MoCA

• Requires certification to administer

• Takes 10 mins

• Total score of 30

• Above 26 is normal & lower = mild cognitive impairment

GAD-2

Generalized Anxiety Disorder

• Consists of a 7-item scale (think doctor’s office print out)

• Higher score = greater likelihood

• If score >3 = positive

GAD 7

Identifies probably anxiety + severity

PHQ 2

Patient Health Questionnaire

• Asks 2 questions about depressed mood and anhedonia (lack of interest)

• Serves as a screening tool to use full PHQ 9 tool

PHQ 9

Patient Health Questionnaire 9

• Series of 9 questions requiring adding column totals that relate to the frequency of occurrence of symptoms

• Higher the score, the greater the likelihood of functional impairment or clinical diagnosis

PHQ 9 severity

5-9: minimal depressive symptoms

10-14 minor depressive symptoms

15-19 major depression, moderate

> 20 major depression

OLDCARTS

Pain description

Onset

Location

Duration

Characteristics

Aggravating factors

Relieving factors

Treatment

Severity

Fine Crackles

High pitched, short, cracking or popping

• Due to air entering deflated airways and popping them open

• Usually during inspiration

• Collapsed alveoli

Coarse Crackles

Loud, low-pitched, bubbling or gurgling sounds

• pneumonia

• may improve w coughing or suctioning

• due to air moving through secretions or fluid

Pleural Friction Rub

Superficial, coarse, low-pitched, rubbing

• Due to pleural inflammation causing tissue to rub together on inspiration

Wheezes

High-pitched, musical, squeaking

• Louder during expiration

• Narrowed airways

• Ex. Asthma

Rhonchi

Low-pitched wheeze, snoring

• Secretions in large airways (obstruction)

• Heard throughout the cycle

Stridor

High-pitched, inspiratory

• louder in neck than over chest

• upper airway narrowing d/t obstruction

• choking = deadly

• heard w/o a stethoscope

• during inspiration