3B Biophysical and Psychosociocultural Assessment

Assessment Overview and Purpose

• Assessment Components:     * Nursing Health History: Initial data collection regarding the client's past and present health.     * Physical Examination:         * Head-to-Toe Assessment: A systematic assessment starting at the head and working downward to the feet.         * Focused Assessment: A specific assessment conducted in relation to the client’s presenting problem or a specific body system.

• Purpose of Assessment:     * To obtain baseline data about the client.     * To supplement, confirm, or refute data already obtained in the nursing health history.     * To obtain data that helps establish a nursing diagnosis.     * To evaluate physiological outcomes of care.     * To make clinical judgments regarding the client’s health status.     * To identify opportunities for health promotion and disease prevention.

Biophysical Assessment Components

The biophysical assessment covers multiple domains of physical health and function:

• Level of Consciousness (LOC)

• Orientation

• Vital Signs: Including Temperature ($T$), Pulse ($P$), Respirations ($R$), Blood Pressure ($BP$), Oxygen Saturation ($O_2$ Saturation), and Pain.

• Physical Measurements: Height, Weight, and Body Mass Index ($BMI$).

• Skin Characteristics: Assessment of integrity, color, and texture.

• Mobility: Assessment of movement and gait.

• Sensory Function: Assessment of sight, hearing, touch, etc.

• Nutrition: Dietary intake and nutritional status.

• Elimination: Urinary and bowel function.

• Sexuality: Relevant health factors.

• Diagnostic Tests: Review of laboratory and imaging results.

Methods of Assessment

• Inspection: Visual examination of the body.

• Auscultation: The act of listening to sounds produced within the body, which can be direct or indirect (using a stethoscope).

• Palpation: Using the sense of touch to examine the body.

• Percussion: Striking the body surface to elicit sounds or vibrations.

Vital Signs: Principles and Monitoring

• Definition: Vital signs are known as "cardinal signs" because they reflect the most important functions of the body.

• Components:     * Body temperature.     * Pulse.     * Respirations.     * Blood Pressure.     * Pain: Recognized as the 5th vital sign.     * Oxygen Saturation ($O_2\text{ Sat}$): Considered a standard of care ($SOC$).

• Monitoring Frequency: The timing of vital sign assessment depends on:     * Physician’s specific orders.     * Hospital policy.     * Nursing Judgment: Vital signs must be taken whenever there is a change in patient status based on the nurse's assessment.     * Routine Milestones: Upon admission and discharge; before and after surgery or diagnostic procedures; before and after ambulating; and before and after administering certain medications.

• Clinical Principles:     * While any single vital sign is important, a full set is required for a clear picture of the patient’s condition.     * Assessment must be in context: Compare current findings to the baseline or previous vital signs.     * Reference the client’s prior and present health status and monitor for trends over time.

Temperature

• Definition: A measure of heat production versus heat loss occurring through conduction, convection, evaporation, or radiation.

• Physiologic Regulation: The body regulates temperature through shivering, sweating, and vasoconstriction.

• Findings and Classifications:     * Normal (Afebrile): $98.6^\circ\text{ Fahrenheit}$ or $37^\circ\text{ Centigrade}$.     * Above Normal: Referred to as Fever, Pyrexia, Hyperpyrexia, or Hyperthermia.     * Below Normal: Hypothermia.

• Temperature Scales and Conversions:     * $C = (F - 32) \times \frac{5}{9}$     * $F = (C \times \frac{9}{5}) + 32$     * Reference points:         * $98.6^\circ\text{ F} = 37^\circ\text{ C}$         * $101^\circ\text{ F} = 38.3^\circ\text{ C}$         * $103^\circ\text{ F} = 39.5^\circ\text{ C}$

• Assessment Methods:     * Devices: Glass, electronic, or disposable thermometers.     * Routes: Oral, Axillary, Rectal, Tympanic, and Temporal.

• Nursing Diagnoses:     * Risk for imbalanced body temperature.     * Hyperthermia.     * Hypothermia.     * Ineffective thermoregulation.     * Risk for Infection.

Management of Hyperthermia and Hypothermia

• Types of Fever (Hyperthermia):     * Intermittent.     * Remittent.     * Constant.     * Relapsing (fever that goes away and comes back).

• Phases of Fever and Clinical Manifestations:     * Onset (Cold or Chill Phase): Characterized by shivering, cold skin, and the patient feeling cold.     * Course (Plateau Phase): Characterized by drowsiness, thirst, dehydration, loss of appetite, weakness, and aching muscles.     * Abatement (Fever Abatement/Flush Phase): Characterized by flushed skin, feeling warm, sweating (diaphoresis), decreased shivering, and potential dehydration.

• Interventions for Fever:     * Monitor vital signs, skin color/warmth, fluid balance, and lab tests (e.g., $WBC$, $C \, \& \, S$).     * Provide blankets during the chill phase.     * Encourage fluid intake.     * Administer "antipyretics" (medications to reduce fever).     * Administer tepid bathing.     * Provide oral hygiene.     * Provide dry clothing and change linens as needed.

• Hypothermia Clinical Manifestations:     * Decreased temperature, pulse, respiratory rate ($RR$), and blood pressure ($BP$).     * Shivering; pale, cool, or waxy skin; potential frostbite.     * Decreased urine output and decreased muscle coordination.     * Disorientation and drowsiness, which may progress to coma.

• Nursing Interventions for Hypothermia:     * Keep the patient warm with blankets.     * Provide a warm environment.     * Provide dry clothing.     * Cover the patient's head.     * Encourage warm fluids.     * Position the patient for comfort.

Pulse

• Definition: A reflection of the heart beat per minute.

• Norms for Adults:     * Rate: $60-100\text{ beats per minute}$.     * Character: Full and strong.

• Regulation: Controlled by the Autonomic Nervous System (Sympathetic and Parasympathetic) and baroreceptors in the aorta and carotids.

• Assessment Methods: Palpation, Doppler, and Stethoscope.

• Pulse Characteristics:     * Rate:         * Tachycardia: Heart rate higher than $100\text{ bpm}$.         * Bradycardia: Heart rate lower than $60\text{ bpm}$.     * Volume (Strength/Quality): Described as Thready and weak or Full and Bounding.     * Rhythm: The pattern of beats and intervals between them.         * Regular: $NSR$ (Normal Sinus Rhythm).         * Irregular: Known as Dysrhythmia or Arrhythmia.     * Pulse Deficit: The difference between the apical and radial pulse rates.

• Pulse Sites:     * Temporal: Located above and towards the outside of the eye.     * Carotid: Located on the side of the neck.     * Brachial: Located on the inner side of the biceps.     * Radial: Located on the inner wrist under the line of the thumb.     * Femoral: Located near the pelvic bone.     * Popliteal: Located behind the knee.     * Posterior Tibial: Located on the lower limb.     * Dorsalis Pedis: Located over the instep of the foot.     * Apical Pulse:         * Location: Found at the 4th, 5th, or 6th intercostal space at the midclavicular line.         * Specific Anatomy: Midsternal line, Manubrium of sternum, Angle of Louis, Clavicle, Midclavicular line, Anterior axillary line, and Body of sternum.         * Age-Specific Placement: Before age $4$; at ages $4 \text{ to } 6$; and in adults.         * Technique: Use a stethoscope for one full minute if the radial pulse is irregular or before administering cardiac or blood pressure medications.

• Peripheral Assessment: Assessment of the most distal pulse of a lower extremity to monitor circulation.

Peripheral Vascular and Respiratory Assessment

• Peripheral Vascular Assessment (Perfusion): Used to assess blood supply to the extremities. Components include:     * Color.     * Temperature.     * Edema.     * Movement.     * Pulses (assess the most distal).     * Sensation and Capillary Refill.

• Respirations:     * Definition: "External" respiration involves inspiration and expiration.     * Respiratory Rate Manifestations:         * Tachypnea: Rapid breathing.         * Bradypnea: Slow breathing.     * Depth (Tidal Volume):         * Hyperventilation: Increased depth.         * Hypoventilation: Decreased depth.         * Kussmaul: Deep, labored breathing pattern.     * Rhythm:         * Cheyne-Stokes: Gradual increase and then decrease in depth with periods of apnea.     * Effort:         * Dyspnea: Difficulty breathing.         * Orthopnea: Difficulty breathing while lying flat.     * Other Manifestations: Skin color changes, mental status changes, Anoxia (complete lack of oxygen), and Hypoxia (low oxygen levels).

• Adventitious Breath Sounds:     * Crackles.     * Rhonchi.     * Wheeze.     * Stridor.

Oxygen Saturation ($SpO_2$)

• Definition: The amount of hemoglobin saturated with oxygen ($SpO_2$).

• Norms: $95-100\%$.

• Pulse Oximeter Use:     * Sites: Finger, toe, earlobe.     * Accuracy Warnings: May be inaccurate if the patient is anemic or has a cool extremity.

• Nursing Implications for Pulse and Respiratory Status:     * Reinforce activity restrictions.     * Proper positioning.     * Teach breathing exercises.     * Administration of supplemental oxygen.     * Modification of contributing factors.

Blood Pressure

• Adult Normal Findings:     * Systolic: $\le 120$     * Diastolic: $\le 80$

• Abnormal Findings:     * Hypertension.     * Hypotension.     * Orthostatic Hypotension.

• Measuring Blood Pressure:     * Direct: Most accurate but impractical for routine use.     * Indirect: Using a sphygmomanometer.     * Cuff Selection Rules:         * Bladder width must be 20\% > \text{arm } 5\% \text{ diameter}.         * Bladder length should be $65-70\%$ of arm circumference.         * Sizes range from newborn to adult thigh.

• Factors Influencing Readings:     * Diurnal variations (time of day).     * Medications.     * Cuff Size: Too small leads to a false high reading; too large leads to a false low reading.     * Arm Support: Arm must be supported at the level of the heart.     * Patient Assessment: Check for a Pink band; assess smoking, eating, pain, and recent exercise.

• Nursing Implications for Blood Pressure changes:     * Assess other vital signs, skin, and mental status.     * Safety considerations regarding activity and positioning.     * Control of contributing factors.

Diagnostic Tests and Environment

• Laboratory Tests:     * White Blood Cells ($WBC$)     * Hemoglobin and Hematocrit     * Electrolytes: Sodium ($Na$), Potassium ($K$).     * Chemistry: Glucose, $BUN$ (Blood Urea Nitrogen), Creatinine, Albumin.     * Coagulation: $INR$, $PT$, $APTT$, Platelets.     * Other: Culture and Sensitivity ($C \, \& \, S$), Urine analysis ($UA$).

• Imaging and Specialized Tests:     * X-rays, $MRI$, $CT$ scan.     * $EKG$ (Electrocardiogram).

• Patient’s Immediate Environment: Important cues impacting care include the presence of:     * Tubes and catheters.     * Drains.     * Oxygen delivery systems.     * Intravenous ($IV$) lines.     * Feeding tubes.     * Sequential compression devices ($SCDs$).

Psychosociocultural Assessment

• Mental Status: Cognitive functioning.

• Emotional Status: Including both overt (obvious) and covert (hidden) emotions.

• Spirituality: Religious or spiritual needs.

• Effects of Hospitalization: Identification of the "sick role."

• Support Systems: Availability of family or community help.

• Customs and Beliefs: Cultural practices influencing care.

• Socioeconomic Status: Educational and financial factors affecting health.