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health prevention
keeps people from getting sick, identifying sickness early, treating sickness as needed
primary prevention
health promotion, advisory and consoling services and educational programmes to drive lifestyle changes for the prevention of chronic diseases
ex. health education, immunizations
secondary prevention
health assessment and screening to facilitate early identification of chronic diseases
ex. mammogram, blood work, colonoscopy
tertiary prevention
management of chronic diseases and rehabilitation support services to slow down the progression of diseases
ex. immunotherapy, chemotherapy, radiation therapy
why does the nurse assess health?
to set a baseline for the patient so we can identify changes , to identify what type of care our patients need , to gather info
what skills does a nurse use to access health?
communication (most important)
cognitive
critical thinking
critical reasoning (application of clinical thinking)
intuition
psychomotor (inspection, percussion, palpation, auscultation)
therapeutic communication
introduce self
eye contact
be aware of non-verbal
use active listening
allow client time to answer questions
demonstrate: concern, empathy, compassion, unconditional regard, genuineness, respect, caring
phases of an interview
introductory phase
working phase
summarization phase
closed questions
can be answered with a yes or no
open-ended questions
require clients to describe in more detail what is going on ; tend to yield more accurate, client-specific information
avoid non therapeutic responses such as:
false reassurance
unwanted advice
technical language
changing the subject
biased questions
distractions (non-purposeful)
interrupting
disapproval
being defensive
using authority
poor use of non-verbal communication
health history types
comprehensive
focused or problem-based
follow-up
sources of info
primary and secondary
primary info
from patient
secondary info
children, species
comprehensive health history
most critical first step in determining a client’s problems and needs
contents depend on context (ex. hospital admission, ER visit, primary care visit)
requires excellent communication/interviewing skills
requires excellent critical thinking skills/common sense
key elements of a comprehensive health history
demographic info (name+ DOB)
chief complaint (CC): “what brought you here? " (this will be quotes in pt’s words)
history or present illness (HPI)
medications
allergies
immunizations
Past medical history (PMH)- childhood illness, adult illnesses, accidents/injuries, chronic illnesses, hospitalizations/surgeries, mental/emotional conditions and family history
history of present illness (HPI)
gives a complete description of presenting concern: duration, severity (intensity), character (quality, location, radiation, aggravating factors, alleviating factors) and associated symptoms
OLDCARTS (onset, location, duration, character, aggravating/relieving factors, timing, severity)
OLDCARTS
Onset
Location
Duration
Character
Aggravating Factors
Relieving Factors
Timing
Severity
Onset
when did you first notice it?
how long did it last?
have you had the pain since that time?
then what happened?
have you noticed the pain is worse during your menstrual period?
Location
can you tell me where you feel it?
has this changed over time?
does it radiate (move) to a specific area of the body?
using your finger point to where it hurts.
do you feel it anywhere else?
has the pain moved since it started?
Duration
when did the pain begin?
what were you doing when the pain started?
how long has this condition lasted?
does it come and go?
how often do you have the pain?
is it similar to a past problem? if so, what was done at that time?
is the problem getting better, worse, or staying the same?
if it is changing, what has been the rate of change?
how many times did you vomit?
Character
what does ti feel like?
can you describe the pain? (crushing, stabbing, indigestion like, dull, ache for example)
what do you mean by “sticking pain"?
did you have other symptoms with the pain such as nausea and vomiting, weakness, fatigue, breathlessness, syncope (passing out), cold and clamminess
when you get the pain, is it steady, or does it change?
does the pain radiate such as down the arm, up into the neck for example?
Associated or Aggravating factors
what makes it worse?
what seems to bring it on?
Relieving factors
what have you done that made the pain stop?
what do you do to get more comfortable?
does lying quietly in bed help?
does eating make it better?
do you take anything for the pain and does it help?
Timing
have you noticed it occurring at a certain time of day?
does it occur with exercise?
does it occur at rest?
does it awake you from your sleep?
does it happen after you eat?
Severity
on a scale of 1 to 10, 10 being the worst pain you can imagine, how would you rate this pain?
how bothersome is this problem?
does it interfere with your daily activities?
does it keep you up at night?
Past Medical History
medical problems (acute, chronic, resolved)
childhood illnesses (with dates)
serious accidents and injuries
hospitalizations (with dates)
surgeries (may be separate)
immunizations
screening tests (mammogram, colonoscopy, Pap smear, lipid levels)
obstetric history (gravida-# of pregnancies , para- # of live births)
Current Medications
prescription
over-the-counter
other supplements (vitamins, herbal products, homeopathy etc.)
“do you take your medications regularly?”
Allergies
medication
food
contact
“what is the nature of the reaction?” (airway/anaphalytic vs integument/rash, GI symptoms, etc.)
Family History
focus on inheritable conditions of the 1st degree (biologic parent, sibling, child) and 2nd degree (aunt, uncle, grandparents, nieces, nephews, half-siblings_ relatives
note age of onset
“what major conditions have inherited predispositions?”
Cardiovascular Disease
premature CHD or sudden death in 1st degree female relative less than age 65 years or 1st degree male relative less than age 55 years
familial hyperlipidemia
Colorectal Cancer
multiple relatives affected OR one or more affected less than age 60 years
FAP- familial adenomatous polyposis
HNPCC- hereditary Nonpolyposis Colon Cancer (more common), poses an increased risk for endometrial cancer in women
Psychosocial History
education
occupation/hobbies
housing
finances (can you financially support yourself?)
exercise
sleep
safety
tobacco use (pack years= packs per day X number of years)
alcohol use
other elicit substances
support systems
stress/coping
sexuality
Functional Assessment
“where was the patient before they got sick?”
ADL’s (washing, toileting, dressing, feeding, mobility, transferring)
Cultural Considerations
communication is culturally influenced
non-verbal differences in eye contact, touching, facial expressions, space, gestures
federal law mandates provision of an interpreter as needed
we cannot assume we know a client’s cultural, religious, and spiritual preferences by what we are taught in the books (must ask0
Review of Systems (ROS)
may reveal things missed in PMH or reveal occult disease
Comprehensive vs. focused
includes: general health, nutrition, skin, hair, nails, head, neck, eyes, ears, nose, mouth, throat, lungs, heart, neck vessels, peripheral vascular, breasts, abdomen, urinary, musculoskeletal
may be done by checklist and reviewed with the client
why do nurses perform physical assessments?
helps with prioritization
identify declining client status
anticipate client needs
improve client outcomes
prioritize care
be a client advocate
emergency assessment
unstable client, immediate concerns
ABC
focused assessment
problem, situation-focused, report-focused, history-focused
also called "episodic assessment”
Inspection
start with a general survey using sight, hearing, and smell
appearance (frail, posture, stature, weight, gait, facial expression)
affect, mood
behavior
signs of illness
odors (alcohol, acidosis, poor hygiene)
speech (fast, slow, hoarse)
signs of distress (pain, breathing, limping)
be aware of symmetry vs. asymmetry
need adequate lighting
Palpation
palpate for temp., moisture, tenderness, pain, lumps, masses, rigidity, crepitation
the palm is most sensitive to vibrations
then ulnar and dorsal surface of the hand is most sensitive to temperature
always start with light palpation, deep palpation follows (abdominal exam)
wear gloves when touching mucous membranes (or any area where there may be body fluids)
Percussion
percussion tones are used to assess location, shape, size, and density of tissue
uses the fingers to create vibrations on the body surface
blunt percussion can produce pain when an underlying structure is inflamed (as in a kidney infection)
Auscultation
stethoscope
clean between clients
ear pieces point towards your nose
diaphragm: high pitched sounds (heart, lungs, abdomen)
bell: low pitched sounds (blood vessels)
Important health assessment red flags
fever
respiratory: abnormal respiratory rate (either too high to too low), decreased O2 sat with increasing oxygen needs, shortness of breath
cardiac: reduced systolic blood pressure, abnormal pulse, client report of chest pain
neurologic change: altered mental status, change in LOC
change in pain status
active bleeding
vomiting
sensory motor deficit
pallor, pulseless, paresthesia (pins and needles), pain, coolness or extremities
dizziness (fall risk)
poor urine output (less than 30mL per hour0
upper respiratory tract
nose and oropharynx
lower respiratory tract
trachea
bronchi
anterior thorax
posterior thorax
lobes of the lungs (RML only anteriorly)
pulse oximeter
measures oxygen saturation (spO2); % hemoglobin saturated with oxygen
arterial blood gases (ABGs)
measurements of oxygen and carbon dioxide in the arterial blood (radial, femoral, brachial artery sites)
normal:
pH (7.35-7.45)
PaO2 (75-100 mmHg)
PaCO2 (35-45 mmHg)
HCO3 (22-26 meq/L)
SaO2 (95-100%)
thoracentesis
insertion of a needle into thoracic cavity to analyze and, or remove fluid from the pleural space (fluid means that lungs cannot inhale all the way)
bronchoscopy
scope procedure to provide a direct visualization of larynx, trachea, and bronchial tree
chest x-ray
projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures
lung biopsy
removal of a small piece of lung tissue for analysis
Mantoux test
intradermal insertion of tuberculin purified protein derivative to assess for tuberculosis exposure
reassess in 48-72 hours for induration
PMH for a respiratory assessment
asthma
pneumonia
emphysema
frequent upper respiratory infections (URIs)
allergies
TB
last TB lest
flu vacine, pneumococcal vaccine (>65 yrs or immunocompromised), covid vaccine
meds (OTC, inhalers, steroids, ACE inhibitors (cough)
FH: lung cancer, COPD, cystic fibrosis
SH: smoking (2nd hand smoke), occupation (exposure to chemicals, asbestos), hobbies, exposure to radon, travel
ROS: persistent cough, dyspnea (exertion vs. rest), wheezing, sputum, fevers, night sweats,\
possible causes of a dry, hacking cough
viral infections
interstitial lung disease
tumor
allergies
anxiety
possible causes of a chronic, productive cough
bronchiectasis
chronic bronchitis
abscess
bacterial pneumonia
tuberculosis
possible causes of a wheezing cough
bronchospasm
asthma
allergies
congestive heart failure
possible causes of a barking cough
epiglottal disease (croup)
possible causes of a stridor cough
tracheal obstruction
possible causes of a morning cough
smoking
possible causes of a nocturnal cough
postnasal drip
congestive heart failure
coughing associated with eating and drinking
neuromuscular disease of the upper esophagus
what will a nurse see on assessment if client is in acute respiratory distress?
confusion, combativeness (a sign of decreasing in oxygenation)
pausing for breath
dyspnea at rest
use of accessory muscles
hypotension, cyanosis
RR >30 breaths per min
O2 saturation <90%
what will the nurse do if their patient is in acute respiratory distress?
elevate the head of the bed (helps to open airway)
call for assist/rapid response team
do immediate assessment
start oxygen and Broncho dilating inhalers
Exam tips for respiratory assessment
optimal exam: client is in sitting position
do not palate, percuss, auscultate though clothing
clean diaphragm of stethoscope with alcohol prior to exam
for auscultation, have client take slow, deep breath though mouth
have client cough to clear secretions as needed
Overall inspection during respiratory assessment
overall appearance
evidence of respiratory issues:
tripod position
flared nostrils
pursed lip breathing
air hunger (work of breathing)
skin color: pallor, cyanosis
weight
clubbing
audible wheezing
Inspection of Thorax
use of accessory muscles
retractions
spine deformity: scoliosis
chest configurations: barrel chest, kyphosis
AP diameter of chest (normally 2:1)
pectus excavatum
sunken or funnel chest
pectus carinatum
pigeon chest
bradypnea
RR les than 12 breaths per min
tachypnea
RR more than 20 breaths per min
Kussmaul’s respirations
abnormally rapid, deep, labored breathing
Biot respirations
irregular breathing of variable depth (often shallow) alternating with shallow breathing apnea
Cheyenne-stokes respirations
gradual increase in depth of respiration, followed by gradual shallow breathing with periods of apnea
Apnea
absence of breathing or abnormal pauses in breathing
Palpation for respiratory assessment
lumps, masses
tenderness
symmetry (1 inch)
equal expansion
crepitus (subcutaneous emphysema)
tactile fremitus
Palpation of tactile fremitus
ask the client to say “ninety-nine” several times in a normal voice
you should feel palpable vibrations transmitted through the tissues (use palmar or ulnar surface of hands)
increased tactile fremitus
suggests consolidation (increased tissue density such as tumor or mass, or infection) of the underlying lung tissues
decreased tactile fremitus
suggests fluid (vibrations obstructed by fluid in the tissues of the lung, decreased air movement (emphysema
Percussion of respiratory assessment
explain procedure to the client
percuss from side to side and top to bottom
omit the areas covered by the scapulae
compare one side to the other looking got asymmetry
note the location and quality of the percussion sounds you hear
dullness of percussion over the lung indicated increased lung tissue density (consolidation)
normal=resonance
normal breath sounds
vesicular
bronchovesicular
bronchial
vesicular
low pitch, soft intensity
heard over peripheral lung fields
inspiration longer and louder than expiration
bronchovesicular
medium pitch , moderate intensity
heard over lower bronchi anteriorly (mid-chest0 and between the scapulae posteriorly
bronchial
high pitch, hollow, tubular, loud intensity
heard over trachea and large bronchi
expiration sounds are louder and last longer than inspiratory sounds an there is a pause between
adventitious breath sounds
crackles (rales)
wheezes
rhonchi
pleural friction rub
stridor
crackles (rales)
sound produced when air passes over retained airway secretions/fluid in alveoli (pulmonary edema, CHF, pneumonia)
wheezes
high-pitches whistling, musical sound when air is forced through a narrow airway (due to foreign body or other obstruction such as asthma)
rhonchi
loud, deep, low-pitched sounds (like snoring) in upper bronchi during exhalation
secretions in large airways (bronchitis)
pleural friction rub
grating, loud, harsh, deep sound causes by inflamed parietal and visceral pleural surfaces rubbing together
heard during inspiration or exhalation
stridor
high pitched crowing on inspiration (upper airway obstruction)
a sign of respiratory distress and is a medical emergency!!
bronchophony
ask the patient to say “ninety-nine”
over normal lung tissue, the words sound muffled
over consolidated areas, the words seem unusually loud
egophony
ask the patient to say “E”
over normal lung tissue, the sound is muffled
over consolidated lung tissues , it will sound like the letter “A”
whispered pectoriloquy
ask the patient to whisper “1..2..3”
over normal lung tissue, the numbers will be almost undistinguishable
over consolidated lung tissue, the numbers will be loud and clear
health promotion for respiratory system
smoking cessation
vaccinate (influenza, covid-19, and pneumococcal vaccines)
prevent infection
exercise
common client reports that may be related to a CV disorder
chest pain
palpitations
syncope
fatigue
dyspnea
weight gain
chest pain associated with MI/ acute coronary syndrome
sudden onset of pain, diffuse, may be described as “crushing”, radiates to left arm or jaw, lasts more than 20 minutes
often associated with anxiety, sweating
nausea, vomiting, dyspnea, palpitations and anxiety
Cardiovascular Nursing Assessment
HPI (OLDCARTS)
PMH
FH
SH
Meds
HPI CV assessment
chest pain (onset, intensity, location, radiation, quality, duration, constant vs paroxysmal, aggravating factors, relieving factors, associated symptoms (fatigue, N+V, exercise intolerance, etc.)
PMH CV assessment
HTN, rheumatoid fever, autoimmune dx, cholesterol levels, diabetes, heat, disease, heart murmur, last ECG