Health assessment review day1

Chaoter 1,2,3,8 and 14

Assessment

Assessment

Collecting subjective and objective data

Diagnosis

Analyzing subjective and objective data to make and prioritize professional clinical judgments (client concerns, collaborative problems, or referral)

Planning

Generating solutions, developing a plan, and determining which outcomes need to be met first

Implementation

Taking action. Prioritizing and implementing the planned interventions

Evaluation

Assessing whether outcomes have been met and revising the plan if the interventions did not make a difference

Scope and standards of practice

Collect data in a system manner, prioritizes data collection; involves the patient and the family.

Used EBP assessment techniques

Synthesis data and document findings

Derives diagnoses based on assessment date

Purpose of health assessment

Collect subjective and objective data to determine a clients overall level of functiong to make a professional clinical judgment (nursing diagnosis)

Framework for assessment

History of present health concern (chief complaint)

personal health history

Family history

Lifestyle and health practices

Initial comprehensive assessment

Collection of subjective and objective data about the clients perception of health of abll body parts or systems, past med history, family history and health practices

Ongoing or partial assessment

Collecting data after initial comprehensive assessment (E.g reassessment or shift assessment)

Focused/problem-oriented assessment

Assessing a particular client problem

Emergency Assessment

Vary rapid assessment in life threatening situations (E.g ABC’s, chest pain)

Steps of health assessment

Collection of subjective data

collection of objective data

validating assessment data for accuracy

Documenting data

prep for assessment

review client record first (gives info about the client like education level and occupation; background info like do they have chronic disease, ADL difficulty)

Educate yourself. about diagnoses, tests

Avoid premature judgments (chronic disease, alcohol abuse)

Get supplies for assessment

Collecting subjective data

Biographical info (name,DOB, etc)

History of present health concern (feeling, physical symptoms)

Personal health history

Family health history

health and lifestyle practices

Collecting objective data

Physical characteristics

Body functions (vitals)

appearance

behavior

measurements

results of labs/tests

Validation of data

Ensures that assessment process isn’t ended before all relevant data is collected

Steps of Analysis

Identify abnormal data and strengths

Cluster that data

draw inferences and identify problems

propose possible nursing diagnoses

check for defining characteristics

confirm or rule out nursing diagnosis

document conclusion

Factors affecting health assessment

Client’s culture (taboos), family, community (poverty) and spirituality (preferences)

Subjective data

Symptoms, feelings, perception, desires, preferences, ideas, beliefs, values

Personal info obtained in an interview that is elicited and verified by the client.

Provides clues to various problems and risk problems

Interviewing

Needed so that you can obtain a valid nursing health history.

Establish rapport and trusting relationship so that you can get client info

pre-interaction of interview phase

review client data from medical record

beginning of the interview

introduction, privacy ensure, nurse relaxes client

Closing of the interview

Condcuting, summarizing areas of concerns or importance, client asks any questions

introductory phase of interview

pre-intro: review health record, explain purpose of interview, ensure HIPPA (client confidentiality), make sure client is comfortable and has privacy, develop trust and rapport with verbal/nonverbal skills.

try to sit down with patient

Working phase of interview

Get biographical data, hx of present health concern, past health hx and family hx, review of body systems, lifestyle and health practices, listening and observing client, collaborating with client to identify problems and goals

summary/closing phase of interview

Should not end abruptly, summarize info obtained in working phases, validate problems and goals, identifying/discussing possible plans to resolve client problem, ask about client concerns/ further questions.

nonverbal communication

appearance —> should be proffesional (uniform/ID)

Demeanor —> Warm, professional

Facial expressions —> neutral, friendly

silence —> allows client to reflect

Lisening —> active listening

Posture —> same level as client (open posture_

Attitude —> nonjudgmental and accepting

nonverbal communication to avoid

too much/little eye contact

being in personal space(<2-3 ft)/distant

Standing —> makes pT feel inferior

verbal communication

Open-ended questions statements (how?/ What?/ Tell me) —> Use these three first

Close-ended communication (when?/ Did?) —>useful to keep the interview on course and clarify info from open open-ended Q’s

Laundry list —> list of words ( is pain sharp, dull, radiating, etc)

Rephrasing —> Clarifying information client said and allows reflection

Well-placed phrases —> “Yes, go on” Encourages client to continue

Inferring —> may elicit more data and verify existing data. DO NOT LEAD THE CLIENT TO UNTRUE STATEMENTS

Providing information —> Give the client information as questions and concerns arise

verbal communication to avoid

Biased or leading questions, rushing through interview, reading questions, FALSE ASSURANCES, ADVICE, using authority, professinal jargon, talking to much, interrupting, “ WHY QUESTIONS”

Older adult considerations for obtaining data

May be frail or health, assess hearing and if decreased speak slowly and face client, trust is KEY

Cultural considerations

reluctance to share personal info

differences in language/ non verbal

variation in disease/illness

variation in time orientation

family role

Working with interpreter

prepare ahead of time, nurse must be present, be patient with the patient, speak clearly/slowly, pause to allow interpreter to translate, avoid side convos with interpreter, use trained interpreter (no patient family/friends), NO CHILDREN

Anxious clients

work in a simple, organized format

explain your role and purpose

ask simple, concise questions

avoid being anxious

Take your time, DO NOT RUSH

decrease external stimuli (close door, TV, etc)

Angry clients

approach in calm, reassuring, in control manner

let them vent

avoid arguments or touching client

obtain help from other health care professionals

give personal space

depressed client

express interest in client

do not communicate in upbeat, encouragingmanner

manipulative clients

provide structure and set limits, obtain an objective opinion from other colleagues

discussing sensitive issues

be aware of your own opinions

Ask simple question in nonjudgmental way

allow client time to vent

if you are not comfortable you may make referral

Seductive clients

set firm limits, encourage more appropriate methods

complete health history

identify relevant problem

blueprint for physical exam

explain purpose.

what to get out of health history

bio data, reasons for seeking health care, history of present health car, past health history, family history, review of system, lifestyle, developmental level

Biographical data

name, address, DOB, phone, gender, PCP, race, languages, educational level, occupation, significant others, religion or spiritual practices,

COLDSPA - Character

Description (what does it feel like)

COLDSPA - Onset

When did it start

COLDSPA - Location

Where is it? Does it radiate?

COLDSPA - Duration

How long does it last? does it recur and is it constant/intermittent?

COLDSPA - Severity

Intensity, how much does it bother you

0-10 on pain scale

Associated factors/affect the client

Other symptoms/ how does it affect ADLS

Past history

Childhood - present

illnesses, chronic illnesses, medications, surgeries/ hospitalizations, accidents/injuries, history of ain, emotional or mental problems.

Family history

Genetic condition and others, as many relatives as possible, draw genogram if possible

Review body systems

skin/nails/hair, head and neck, eyes, ears, mouth/throat/nose/sinuses, thorax/lungs, breats/lymph/heart/neck vessels, abdomen, genitlia, anus/rectum/prostate, musculoskeletal, neuro

SUBJECTIVE DAYA ONLY and use lay (common) terminology

document description of health status and denial of any problems

Lifestyle and health practices

weight management and nutrition, sleep and rest, relationships, stress levels, education and work, meds/tobacco/alcohol/substance use, self-care

Collecting objective data exam prep

Provide comfort, warm tempature, free of interruption, quiet area with adequate lighting, firm examination table or bed, waist height bed to prevent stooping/bending, bedside table/tray to hold equipment

Standard precautions

Hand hygine, PPE for blood/bodily fluids

Gloves and gown

Client approach and prep

establish nurse-client relationship. Explain procedure/steps of physical exam. Respect clients requests/desires; sequence may vary with age or patient acuity

explain importance of exam

reassure client “i will listen in a number of places; that does not mean there is a problem”

Leave room and provide privacy, provide necessary container in case of need for sample

being with invasive procedures

explain procedure being with performed

explain why position change necessary, be organized, unnecessary position changes

Sitting position

Allows full expansion of lungs, good position for vitlas and exampining head, neck, lungs, chest, back, breasts, axillae, heart, vitals and upper extremities

Supine

allows abdominal muscles to relax and provides easy access to peripheral pulse sites

Dorsal recumbent

More comfortable than supine for clients with pain in back or abdomen. DO NOT ASSESS ABDOMEN IN THIS POSITION because abdominal muscles are contracted

Sims position

Assess rectal and vaginal areas. Clients with joint problems and elderly may have difficulty assuming and maintaining this position

Standing position

Assess posture, balance and gait. Also useful for examining male genitalia

Prone

Assess hip joint. Clients with cardiac and respiratory problems cannot tolerate this position.

Knee Chest

examine rectum. Should be kept in this position for limited time as it can be embarrassing and uncomfortable. Elderly and clients with respiratory and cardiac problems cannot tolerate this.

Lithotomy

Examine female genitalia, reproductive tracts and the rectum. Elderly can not assume this position. Keep client draped until needed and keep for limited time.

order of assessment? what is the one exception and why

Inspect-palpate-percuss- Auscultate

Abdomen is Inspection-Auscultate and palpate because if you palpate first you could increase gastric motility leading to false assessment.

Fingerpads for palpating

Fine discriminations like pulse, texture, size, consistency and crepitus.

Ulnar or palmar surface for palpating

Vibrations, thrills and fremitus

Doral (back) surface

temperature

Inspection

Have good lighting (sunlight best), loop and observe before touching, only expose oart being examine (drape other areas), note colo/patters/size/location, compare body parts for symmetry

Purpose of percussion

Elicit pain, determine location/size/shape, determine density (air, fluid or solid) detect abnormal masses, elicit reflexed using percussion hammer)

Hyper-resonance is heard

lung with emphysema

Resonance is heard

hollow sound heard over NORMAL LUNG

tympany is heard

drum sound heard over GASTRIC BUBBLE LIKE STOMACH

dullness is heard

thud like sound heard over ORGAN(NORMAL) OR PLEURAL EFFUSION (!!ABNORMAL!!)

flatness is heard over

bone or muscle

Diaphragm is used for

high-pitched sounds, Firm pressure (LUNG, BOWEL AND NORMAL HEART SOUNDS)

Bell is used for

low pitched sounds, light pressure (ABNORMAL HEART SOUNDS → MURMURS AND BRUITS)

Blunt percussion

Detect tenderness of organs (e.g kidney by placing one hand flat on body surface and using fist of other hand to strike the back of the hand. on the body surface.

Direct percussion

tapping of a body part using one or two fingertips to elicit possible tenderness (e.g tenderness over the sinuses)

indirect percussion

Most common and tapping done to feel for density of underlying structure.

solid tissue produces a soft tone, fluid produced louder tone and air is the loudest.

Temperature

Oral —> under tounge and next to frenulum, wait until a beep is heard

Axillary —> hold thermometer under axilla until beep

Temporal —> place thermometer on forehad while pressing scan, gently stroke across the temporal artery, then point to behind the ear

Bodu temperature is lowest in the morning and and highest in evening.

Hypothermia (cold , hypoglycemia, hypothyroidism or starvation) is less than 96 and hyperthermia (bacterial infections, malignancies, trauma and various blood/endocrine/immune disorders) is more than 100.

Pulse rate

Radia pulse —> use pads of 1st and 2nd fingers and lightly palpate radial artery on lateral aspect of wrist. Count for full minute if irregular

Apical —> use stethescope in mitral position on 5th intercoastal space, left midclavicular line for 1 minute

0 = absent

1+ = weak (easy to obliterate)

2+ = normal (obliterate with moderate pressure)

3+ = bounding (unable to obliterate or firm prssure_

Respirations

Count rise and fall of chest for 30 seconds and multiply x2. Acknowledge rate, rhythym and depth

Vitals BP

Dominant arm first or arm with no IV acess. Pt in sitting position, legs uncrossed. Papate brachial artery. Measure BP cuff (80% of arm circumference and wrap cuff on brachial artery. Use stethoscope with diagphram. with bulb in dominant hand inflate until beat disappears. listen for systolic and then diastolic.

Factors affecting BP

Cardiac output (more the heart pumps the greater the pressure)

Peripheral vascular resistance (increase in resistance in vascular system like people with circulatory disorders will increase BP)

Circulating blood volume (an increase in volume will increase blood pressure. Sudden drop in blood pressure may indicate a sudden blood loss like internal bleeding.

Viscosity (thicker blood = increased BP like polycythemia)

Elasticity of vessell walls (Increase in stiffness of walls will increase BP like athlersclerosis)

5th vitals

pain

order of BP

first tempature → pulse rate → respirations →blood pressure →pain

choosing correct route of measuring tempature

temporal unless sweating profusely

tympanic unless ear infection and pain

rectal ONLY for adults who need very accurate temperature

Oral unless pT just consumed hot or cold drink

Axillary for everyone especially with an altered immune system

Avoid before taking BP

High reading = smoking, caffine, upto 1 hour prior, excercise, anxiety, anger, cuff too small or lose, arm belofw heart level, legs crossed, client holding arm up

low reading = Noisy environment, cuff to large, poor placement of stethescope, arm placed above heart

older adult considerations for vitals

can have same normal tempature but they will feel cold

RR will be 15-22

have higher bP

Function of skin

protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration.

temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

1st layer of sin

Epidermis: Completely replaced every 3-4 weeks; Contains melanin and keratin-forming cells

2nd layer of skin

Dermis: Very vascular, thin, supportive layer consisting mainly of collagen; Enables skin to resist tearing; Resilient elastic tissue

3rd layer of skin

Subcutaneous: Loose connective tissue; Stores fat as an energy reserve; Provides insulation to conserve internal body heat

Sebaceous glands

Attached to hair follicls and secrete a oily substance that waterproofs the hair/skin.

Eccrine vs aprocrine sweat glands

Eccrine —> secretes sweat and thermoregulation

Aprocrine —> associated with hair follicles in axillae, perineum and breast areolae; Nonfunctional until puberty they Secrete a milky sweat; Interaction of sweat and skin bacteria produces body odor

vellus vs terminal hair

vellus hair is “peach hair” all over the body

terminal hair is longer, darker, and coarser like the scalp and eyebrows. Puberty initiates. the growth of terminal hair over the axillae, perineum, and legs.

Nails

Hard, transparent plates of keratinized epidermal cells

Melanoma

most serious type of skin cancer; biggest risk is sun exposure or UV radiation

Basal cell carcinoma

skin cancer that is Most commonly seen on sites with moderate skin exposure (e.g upper trunk or womens lower leg)