AHA

Nursing Assessment

Overview of Nursing Assessment

  • Classification: General

  • Key Components of Nursing Assessment:

    • Assessment

    • Evaluation

    • Nursing Process comprises five phases:

    1. Nursing Diagnosis

    2. Planning

    3. Implementation

Types of Health Assessment

  • Classification: General

  • Types of Health Assessment with Examples:

    • Complete or Comprehensive

    • Episodic

    • Follow-up

    • Emergency

Priority Setting in Nursing Assessment

  • Classification: General

  • Levels of Priorities:

    • First-level Priorities (Emergency/Life Threatening): Immediate attention needed.

    • ABC's (Airway, Breathing, Circulation) and Vital Signs concerns

    • Examples of issues that fall under first-level priorities:

      • Airway problems

      • Breathing problems

      • Cardiac/Circulation problems

      • Vital Sign concerns

    • Second-level Priorities (Urgent): Require prompt intervention to prevent further deterioration.

    • Examples:

      • Pain management

      • Administration of antibiotics

      • Administration of insulin

      • Mental health crises

    • Third-level Priorities: Important to health and wellness but can be addressed once patients are stable.

    • Examples:

      • Dressing changes

      • Patient education

Subjective vs. Objective Data in Assessment

  • Classification: General

  • Definitions:

    • Subjective Data: Information provided by the patient about their experience and symptoms.

    • Objective Data: Observable and measurable signs collected during assessments.

Interviewing Traps in Nursing Assessment

  • Classification: General

  • 10 Common Traps to Avoid in Nursing Interviews:

    1. Providing false assurance or reassurance

    2. Giving unwanted advice

    3. Using authority

    4. Using avoidance language

    5. Engaging in distancing

    6. Overusing professional jargon or casual language

    7. Using leading or biased questions

    8. Talking too much

    9. Interrupting

    10. Using “why” questions

    • Example for each trap can enhance understanding.

Normal Values - Vital Signs

  • Classification: General

  • A summary of vital sign normal ranges:

    • Temperature: 35.8extto37.335.8 ext{ to } 37.3 °C

    • Heart Rate: 60extto10060 ext{ to } 100 beats per minute

    • Respirations: 10extto2010 ext{ to } 20 breaths per minute

    • Blood Pressure: 95extto135/(60extto85)95 ext{ to } 135 / (60 ext{ to } 85) mmHg

    • Oxygen Saturation: >95 ext{%}

Differentiating Types of Pain

  • Classification: General

  • Differentiate between types of pain:

    • Somatic Pain - Pain originating from the skin, muscles, joints, or bones, which is often described as sharp or aching and is usually localized.

    • Acute Pain - Pain that occurs suddenly and is usually sharp in quality, typically a result of injury or illness, and lasts for a short duration. It can serve as a warning for the body about potential harm.

    • Nociceptive Pain - Pain that arises from the activation of nociceptors in response to harmful stimuli, often categorized into somatic and visceral pain, and may be described as sharp, throbbing, or aching.

    • Neuropathic Pain - Pain caused by damage or disease affecting the somatosensory nervous system, which may be described as burning, shooting, or tingling, and can persist even after the original injury has healed.

    • Visceral Pain - Pain that originates from the internal organs, often presenting as deep, squeezing, or vague discomfort, and can be difficult to localize; it may be accompanied by autonomic symptoms such as nausea or sweating.

    • Chronic Pain - Pain that persists over an extended period, often lasting longer than 3 to 6 months, and may result from various factors, including underlying medical conditions, repeated injury, or psychological components, leading to significant distress and functional impairment.

    • Referred Pain -Pain perceived at a location other than the site of the painful stimulus, commonly occurring when nerve pathways for different areas converge; this can lead to confusion in diagnosing the source of pain.

    • Superficial Pain - Pain that is typically sharp, localized, and often arises from the skin or subcutaneous tissues; it is often described as a more immediate sensation, such as that from a cut or scrape, and is usually easier to identify and treat.

    • Deep Pain - Pain that is often described as a dull, aching sensation that can originate from deeper tissues such as muscles, joints, and bones; it may be more challenging to assess than superficial pain, often requiring more comprehensive diagnostic approaches.


General Survey Components

  • Classification: General

  • Key Elements to Assess in a General Survey:

    • Physical Appearance

    • Body Structure

    • Mobility

    • Behaviour

Respiratory Assessment

  • Classification: General

  • Identification of Clinical Red Flags in Respiratory Assessment:

    • Inspection

    • Palpation

    • Auscultation

Tactile Fremitus

  • Classification: General

  • Key aspects of Tactile Fremitus:

    • Decreased Fremitus: Indicates barriers such as obstruction, effusion, pneumothorax, or emphysema.

    • Causes: Compression or consolidation (e.g., pneumonia)

    • Increased Fremitus: More prominent over scapula and around sternum, equal bilaterally in normal conditions.

Respiratory Sounds

  • Classification: General

  • Types of Respiratory Sounds:

    1. Stridor - a high-pitched, wheezing sound caused by disrupted airflow, often indicating a medical emergency such as airway obstruction.

    2. Wheezing - a high-pitched sound produced during expiration, commonly associated with conditions such as asthma or bronchitis.

    Respiratory Sounds

    • Classification: General

    • Types of Respiratory Sounds:

      1. Stridor - a high-pitched, wheezing sound caused by disrupted airflow, often indicating a medical emergency such as airway obstruction.

      2. Wheezing - a high-pitched sound produced predominantly during expiration, commonly associated with conditions such as asthma, bronchitis, or other obstructions that narrow the airways. It can be sibilant (musical) or sonorous (snoring-like) and may sometimes be heard on inspiration in severe cases.

      3. Crackles (Rales) - often described as popping, crackling, or rattling sounds, typically heard on inspiration but can also occur on expiration. They are caused by air moving through fluid-filled airways or by the sudden opening of collapsed alveoli. They can be fine (soft, high-pitched, brief) or coarse (louder, lower-pitched, longer duration).

      4. Rhonchi - low-pitched, rumbling, snoring-like, or gurgling sounds, most prominent during expiration, but can be heard on inspiration. They are caused by secretions or mucus in larger airways and often clear or change significantly after a cough.

      5. Normal Vesicular - soft, low-pitched, breezy sounds heard over most of the lung fields, particularly during inspiration, which is typically longer than expiration. These sounds indicate healthy air movement in the alveoli. The inspiratory phase is usually about $2.5$ to $3$ times longer than the expiratory phase.

    • Descriptions of sounds:

      • Popping or crackling sounds, often heard on inspiration.

      • High-pitched musical sounds usually during expiration.

      • Low-pitched snoring-like sounds that may clear with coughing.

      • Harsh, high-pitched sound on inspiration.

      • Soft, low-pitched sounds heard over most lung fields.

    1. Wheezes

    2. Ronchi

    3. Normal Vesicular

    • Descriptions of sounds:

    • Popping or crackling sounds, often heard on inspiration.

    • High-pitched musical sounds usually during expiration.

    • Low-pitched snoring-like sounds that may clear with coughing.

    • Harsh, high-pitched sound on inspiration.

    • Soft, low-pitched sounds heard over most lung fields.

Cardiac and Peripheral Vascular Assessment

  • Classification: General

  • Distinguishing between arterial and venous issues:

Genitourinary Assessment

  • Classification: General

  • Common medical terms related to urinary problems.

Musculoskeletal Assessment

  • Classification: General

  • Key Parameters for Assessment:

    • Size

    • Tone - DEGREE OF TENSION TO RELAXED MUSCLES

    • Strength

    • Movement

    • Medical terminology used for findings in these areas.

Glasgow Coma Scale

  • Classification: General

  • Remembering the Glasgow Coma Scale: ### Glasgow Coma Scale - Classification: General - **Purpose**: A neurological scale used to assess the conscious state of a person. It is commonly used in acute settings and for monitoring changes in neurological status over time, providing a standardized and objective measure of a patient's level of consciousness. - **Components and Scoring**: The scale assesses three main categories of responsiveness, with scores ranging from 33 (deep unconsciousness or unresponsive) to 1515 (fully awake and alert). 1. **Eye Opening Response (E)**: Scores from 11 to 44. - 44: Spontaneous eye opening (eyes open before stimulation) - 33: Eye opening to speech (any speech, not necessarily command) - 22: Eye opening to pain (supraorbital pressure, trapezius pinch, fingernail pressure) - 11: No eye opening (even with pain stimulation) 2. **Verbal Response (V)**: Scores from 11 to 55. - 55: Oriented to time, place, and person (correctly names self, location, date) - 44: Confused conversation (responds to questions but disoriented or incoherent) - 33: Inappropriate words (random exclamation, no sustained conversation) - 22: Incomprehensible sounds (moaning, groaning without words) - 11: No verbal response (no sounds even with pain stimulation) 3. **Motor Response (M)**: Scores from 11 to 66. - 66: Obeys commands fully (performs two-part command, e.g., 'show me two fingers') - 55: Localizes pain (purposeful movement toward painful stimulus, attempting to remove it) - 44: Withdraws from pain (flexion withdrawal, pulls limb away from stimulus) - 33: Abnormal flexion (decorticate posturing, flexion of arms, extension of legs, adduction) - 22: Abnormal extension (decerebrate posturing, extension of arms and legs, internal rotation) - 11: No motor response (flaccid, no movement even with pain stimulation) - **Total Score Interpretation**: The scores from the three components are summed (GCS=E+V+MGCS = E + V + M). The total score provides an indication of the severity of brain injury or neurological impairment. - **Severe brain injury**: 3−83-8 - **Moderate brain injury**: 9−129-12 - **Minor brain injury**: 13−1513-15 - Memory trick: - Introduce yourself: Look at the patient's eyes (Eye response) - Say hi: Evaluate verbal response - Shake their hand: Assess their motor response

    • Memory trick:

    • Introduce yourself: Look at the patient's eyes (Eye response)

    • Say hi: Evaluate verbal response

    • Shake their hand: Assess their motor response

Mental Status Exam

  • Classification: General

  • ASEPTIC Framework focuses on assessing various aspects of a patient's cognition:

    • What categories are assessed?

Screening Tools

  • Classification: General

  • Various Screening Tools Used in Assessments:


    Screening Tools

    • Classification: General

    • Various Screening Tools Used in Assessments:

      • TWEAK: A screening tool for alcohol use disorders, particularly in women. It assesses Tolerance, Worry about drinking, Eye-opener use, Amnesia (blackouts), and Kut down attempts. - USUALLY WITH PREGNANT WOMEN

      • to identify potential risks and provide early interventions to ensure the health of both the mother and the child.

      • CAGE: A brief screening questionnaire for identifying potential alcohol problems. It asks questions about Cutting down, Annoyance when criticized about drinking, Guilty feelings about drinking, and Eye-opener drinks.

      • Mini-Mental State Exam (MMSE): A widely used 30-point questionnaire used to screen for cognitive impairment, often in older adults. It assesses orientation, attention, memory, language, and visuospatial skills.

      • Mini-Cog: A brief, 3-minute screening tool for cognitive impairment that combines a 3-item recall test with a clock drawing test. It is less influenced by education and language than the MMSE.

      • MOCA (Montreal Cognitive Assessment): A rapid screening instrument for mild cognitive dysfunction that assesses several cognitive domains including attention and concentration, executive functions, memory, language, visuospatial skills, abstraction, calculation, and orientation.

      • CIWA - Clinical Institute Withdrawal Assessment for Alcohol: A standardized tool used to measure the severity of alcohol withdrawal symptoms, helping clinicians to determine the appropriate level of care and treatment.

Lung Sound Identification

  • Classification: General

  • Name That Lung Sound Quiz focuses on differentiating between normal and abnormal lung sounds.