Adult Health Assessment Study Notes

Adult Health Assessment Overview

This document covers essential information regarding the respiratory and integumentary assessments required for nursing learners as part of their finals at Bow Valley College (BVC).

General Information

  • Assessment Duration: Each learner has 30 minutes to complete their assessment, although the assigned system assessment should take 15 minutes.
  • Partnership and Scheduling:
       - Students will sign up with a partner one week in advance for testing.
       - Partners will be randomly assigned to testing weeks one or two.
       - If a learner has classes NF2 and AHA lab assessments on the same day, BVC policy permits two assessments on the same day, necessitating careful planning.

Assessment Guidelines

  • Skin Assessment Requirements:
       - Assessments must be conducted on bare skin for accurate evaluations such as heart sounds, skin temperature, pulses, and edema.
       - Patients need not remove all clothing but should wear appropriate coverings during the assessment to ensure modesty and privacy.
       - Stethoscopes must make direct contact with bare skin, without interference from clothing.
       - Exposed areas for assessment include arms (shoulders to hands), legs (knees to feet), chest, and back, which should be assessed by the nurse even if not visible to the evaluator or camera.
  • Required Attire and Supplies:
       - The nursing learner must wear the BVC uniform that includes the BVC ID, pen, stethoscope, and penlight.
       - Equipment such as a stethoscope that is unavailable must be arranged through the evaluator.
       - Learners must bring sufficient alcohol swabs to clean equipment before use, and hand sanitizer will be provided.

Participant Instructions

  • Presence and Participation:
       - Expect to be present in the testing area for up to 1 hour, allowing 30 minutes for each partner to complete their assessment and for switching roles.
       - During non-assessment time, learners will engage in an instructor-facilitated practice lab.
       - Communication is essential; partners should discuss details such as attire, order of assessment, and baseline findings.
  • Room Arrangement:
       - Discuss and arrange how to set up the room and camera prior to the assessment. Considerations include the location of the assessment (bed, chair, or standing) and conducting a timed dry run.
  • Attire for Patients:
       - Patients should wear comfortable clothing, ideally a tank top/short sleeves and shorts/capris, to avoid discomfort during the assessment. BVC scrubs are also acceptable, and optional items include shorts, loose-fitting clothing, or a towel/robe for privacy.

Preparing as a Patient

  • Engagement and Hydration:
       - Be actively engaged and cooperative during the assessment.
       - Avoid advising the nurse on tasks; this can be perceived as academic dishonesty.
       - Arrive well-rested and hydrated.
  • Personal Information:
       - Learners must provide their first and last name and learner ID for identification without disclosing personal health history or date of birth. Respond only to questions as they arise.

BVC ID Card Requirements

  • A valid BVC student ID card (with name, learner ID, and photo) is necessary on the assessment day.
  • Those without an ID can visit the registrar's office to obtain one. For clinical placements, a plastic BVC-issued ID may be required.

Frequently Asked Questions (FAQs)

  • Can I use the rubric during the assessment?
       - No, reference materials, including textbooks or personal notes, are not allowed during the assessment.
  • How do I verify the patient's ID?
       - Verification requires bringing a Bow Valley College-issued ID; if unavailable, one can be obtained from the registrar's office.
  • Can I change partners?
       - No changes are permitted once the assessment pairing is finalized.
  • Do I need to clean my equipment?
       - Yes, all equipment must be cleaned before contact with the patient after the timer starts.
  • Must I vocalize my findings?
       - Yes, all findings should be vocalized. Example:
         - For heart sounds: “I’ve listened to all four heart sounds with both the bell and diaphragm of the stethoscope, I heard s1 and s2 with no additional heart sounds or murmurs at the aortic, pulmonic, tricuspid, and mitral areas.”

Performing the Video Assessment Using iPads

  1. Log into the iPad using code 123456.
  2. Open the camera to record.
  3. Ensure that the setup does not block the camera while conducting the assessment.
  4. Press "record" when the patient is ready and your equipment is gathered.
  5. At the start of the video, display your BVC ID and announce the system being assessed.
  6. After completing the assessment, press "stop" to end the recording.
  7. Save the video with your name and the system performed (e.g., ASandhu Respiratory) in the files.
  8. Log into D2L and upload the video to the dropbox.
  9. After submission, delete the local video file and log out of D2L.
  10. If complications arise, contact an instructor, referencing the practice folder on D2L for additional help.

Respiratory and Integumentary Assessment Steps

Respiratory History

  • Each learner must ask two relevant respiratory health history questions before proceeding with the assessment.

Respiratory Inspection

Chest Assessment
  1. Symmetry: Observe the symmetry of the chest.
  2. Shape and Configuration: Assess the shape and configuration of the chest while looking at bare skin.
  3. AP to Transverse Diameter Ratio: Evaluate the ratio of the anterior-posterior (AP) diameter to the transverse diameter, which should ideally reflect a 1:2 ratio.
  4. Breathing Quality and Pattern: Assess the quality and pattern of breathing.
  5. Cyanosis/Pallor Presence: Check for signs of cyanosis (bluish skin) or pallor (pale skin).
  6. Nail Bed Inspection: Inspect nail beds for indications of clubbing.

Respiratory Palpation

  • Evaluate chest expansion at both anterior and posterior areas, verbalizing landmarks and findings.

Respiratory Auscultation

Anterior Auscultation
  • Minimum of 5 locations bilaterally must be auscultated, ranging from the supraclavicular region to the 6th rib, during full inspiration and expiration at each site.
       - Location 1: Supraclavicular bilaterally.
       - Location 2: To be auscultated bilaterally.
       - Location 3: To be auscultated bilaterally.
       - Location 4: To be auscultated bilaterally.
       - Location 5: At the 6th rib bilaterally.
Posterior Auscultation
  • Minimum of 7 locations bilaterally must be auscultated, ranging from C7 to T10, with comparisons made at each location during full inspiration and expiration.
       - Location 1: At C7 area bilaterally.
       - Location 2: To be auscultated bilaterally.
       - Location 3: To be auscultated bilaterally.
       - Location 4: To be auscultated bilaterally.
       - Location 5: To be auscultated bilaterally.
       - Location 6: To be auscultated bilaterally.
       - Location 7: At T10 area bilaterally.
Lateral Auscultation
  • Assess the lateral chest bilaterally, with two locations on each side (four total) from the axilla to the 7th or 8th rib.

Integumentary History

  • Learners must also ask two relevant integumentary health history questions.

Integumentary Inspection

  • Evaluate for skin abnormalities, such as lesions, moles, and discoloration.
  • Assess for uniformity in skin tone and examine bony prominences for signs of pressure points, redness, or skin breakdown.

Detailed Assessment Procedure

Before Beginning the Assessment
  • Prepare equipment including stethoscope, alcohol swab, and pen.
  • Ensure patient privacy is maintained with appropriate draping techniques.
Initial Introduction
  1. Greet the Patient:
       - Example: “Hi, my name is Carlos, and today I will be performing a respiratory and integumentary assessment.”
  2. Conduct Hand Hygiene:
       - Sanitize hands and clean the stethoscope.
  3. Patient Verification:
       - Ask for the patient’s full name and learner ID to verify identity using the BVC ID.
  4. Obtain Consent:
       - Explain the assessment process, including the need for bare skin exposure and assurance of privacy. Confirm consent to proceed.
Focused Health History
  • Respiratory Questions:
       - “Do you have any cough, shortness of breath, or chest pain with breathing?”
       - “Do you have a history of respiratory conditions such as asthma, bronchitis, or smoking history?”
  • Integumentary Questions:
       - “Have you noticed any changes in your skin such as rashes, lesions, dryness, or wounds?”
       - “Have you noticed any changes in moles, itching, or skin breakdown?”
Physical Assessment Steps
  1. Chest Inspection:
       - Inspect the chest for shape, configuration, symmetry, and effort of respiration, and verbalize observations (e.g., symmetrical thorax).
  2. Posterior Palpation for Expansion:
       - Palpate the posterior chest, focusing thumbs at the T9-T10 area, instruct patient to inhale deeply to evaluate chest expansion.
  3. Assessment of Tactile Fremitus:
       - Perform tactile fremitus with the ulnar edges of hands, asking the patient to say “ninety-nine.”
  4. Percussion:
       - Percuss down the posterior lung fields in a zig-zag pattern, ensuring to avoid the scapula.
  5. Auscultation of Posterior Lung Fields:
       - Instruct the patient to breathe in through the mouth slightly deeper than normal while auscultating.
  6. Lateral Assessment:
       - Auscultate the lateral lung fields below the axilla, comparing both sides.
  7. Anterior Chest Techniques:
       - Similar steps (palpation, percussion, and auscultation) performed on the anterior chest area while maintaining engagement and clear communication with results.
Integumentary Assessment
  1. General Skin Inspection:
       - Assess skin for color, temperature, moisture, lesions, and integrity.
  2. Skin Palpation:
       - Use the back of the hand to feel for temperature, moisture, and texture.
  3. Check for Lesions/Abnormalities:
       - Inspect specifically for lesions, rashes, or wounds.
  4. Examine Bony Prominences:
       - Assess areas like the sacrum, elbows, and heels for any signs of pressure injuries.
Final Summary
  • Closing Summary of Findings:
      - Conclude your findings clearly and confidently, stating:
       - “Respiratory and integumentary assessment is within normal limits.”
       - “Respirations are even, regular, and unlabored. Chest expansion is symmetrical with resonant percussion and clear breath sounds bilaterally in posterior, lateral, and anterior lung fields with no adventitious sounds.”
       - “Skin is intact, warm, and dry, with appropriate color for ethnicity. No lesions or pressure injuries are noted.”
       - “That completes my assessment.”

These guidelines facilitate a thorough and structured assessment while ensuring the comfort and privacy of the patient. Learners are encouraged to practice these steps to increase confidence and proficiency in performing assessments effectively in clinical settings.