EXAM 1 health assessment vocab

health prevention

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