Physical/Health Assessments Exam Review

Exam 1 Review Notes on Physical/Health Assessments

Chapter 26 - Health Assessment Overview

Health Assessment involves the systematic collection of OBJECTIVE data about the patient's health. The client is considered the primary source of information during this process. Privacy and respect for the patient are emphasized as primary concerns when conducting health assessments. It is essential to note that assessments cannot be delegated; they should exclusively be performed by Registered Nurses (RNs).

Patient Positions

• Supine: Patient is lying flat on their back.

• Prone: Patient is lying on their stomach, with the head turned to the side.

• High Fowlers: Patient is sitting upright at a 90-degree angle.

• Fowlers: Patient is sitting at about a 45-degree angle.

• Semi-Fowlers: Patient is sitting at about a 15-degree angle.

• SIMs: Patient is lying on either side, with the lower arm positioned below the body and the upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed.

Skin Color Changes

• Erythema: Redness of the skin.

• Cyanosis: A bluish skin color indicating decreased oxygenation.

• Jaundice: Yellowish tint due to increased bilirubin levels, often related to liver disease.

• Pallor: Paleness of the skin, associated with conditions such as anemia, decreased hemoglobin levels, shock, or decreased blood volume.

Levels of Consciousness

• Lethargic: The patient is drowsy or asleep and must be aroused through gentle shaking or calling their name.

• Stuporous: The patient must be shaken or shouted at to become aroused.

• Comatose: The patient cannot be aroused.

• Glasgow Coma Scale: A clinical tool used to assess the level of consciousness in patients.

Additional Assessments

• Skin Turgor: This assessment checks for hydration, with the best sites being the back of the hand or below the clavicle. Normal skin turgor shows a capillary refill time of less than 3 seconds.

• PERRLA: An acronym for Pupils Equal, Round, Reactive to Light and Accommodation, used to describe normal pupil function.

Abnormal Breath Sounds

• Wheezing: A high-pitched sound that indicates narrowing of the airway, often seen in asthma patients.

• Rhonchi: A low-pitched snoring sound that may clear with coughing.

• Crackles: Bubbling or popping noises heard typically in the lower lobes, often described as a sound similar to Rice Crispy cereal.

Older Adults Normalities

• Kyphosis: An increased dorsal spinal curve that makes it harder to take deep breaths and increases the risk of pneumonia or respiratory distress.

• Lordosis: A normal condition in children where the buttocks appear to stick out.

• Edema: Swelling, which can be classified as pitting or non-pitting.

Bowel Sounds Assessment

Bowel sounds reflect peristalsis movement and are assessed by listening for 5 to 34 seconds in each quadrant, starting in the lower right quadrant and moving around the abdomen.

• Hyperactive Bowel Sounds: Indicate conditions like diarrhea or Clostridium difficile (C. Diff) infection.

• Hypoactive Bowel Sounds: May suggest constipation or post-surgical status.

• Absent Bowel Sounds: If there are no sounds after 2 minutes, the nurse must notify the medical doctor (MD).

Nursing Process Overview

Chapters 13–18 outline the nursing process:

1. Assessing (A): The collection and validation of patient data, which comprises both subjective and objective information.

2. Diagnosing (D): The analysis of the collected patient data leading to a NANDA (North American Nursing Diagnosis Association) diagnosis.

3. Planning (P): Establishing expected outcomes/goals and interventions, distinguishing between independent and collaborative interventions.

4. Implementing (I): Carrying out the care plan, monitoring the patient's responses, and properly delegating tasks.

5. Evaluating (E): Assessing whether the patient has achieved the established goals.

• The Medical Diagnosis (Dx) identifies diseases and is typically performed by a physician, while the Nursing Diagnosis focuses on the patient's response to health problems, which is the domain of the RN.

• Outcomes/goals should be established to be SMART (Specific, Measurable, Attainable, Realistic, Time-framed).

• The categories of outcomes include cognitive, psychomotor, affective, and physiologic outcomes.

Delegation Principles

The Five Rights of Delegation are:

1. Right Task: Ensuring the task is appropriate to delegate.

2. Right Circumstance: Assessing the context and circumstances for delegation.

3. Right Person: Delegating to a qualified individual for the task.

4. Right Direction/Communication: Providing clear instructions for the task.

5. Right Supervision/Evaluation: Periodically supervising and evaluating the performance of the delegated task.

Documentation Practices

Chapter 19 emphasizes documentation as critical for communication among the healthcare team, serving as a legal record and ensuring continuity of care. Notable points include:

• HIPAA (Health Insurance Portability and Accountability Act): A federal law protecting patient privacy.

• Telephone Orders: Protocols require verifying the accuracy of telephone orders by repeating them back.

• SBAR: An acronym used for effective communication which stands for Situation, Background, Assessment, Recommendation.

• RN Responsibilities: Only Registered Nurses are authorized to interpret data, conduct assessments, develop plans, and evaluate patient outcomes. In contrast, Unlicensed Assistive Personnel (UAP) may perform basic care tasks such as taking vital signs, recording intake and output (I&O), weighing patients, executing simple dressings, assisting in transfers, and handling post-mortem care.

Chapter 27 - Safety Principles

• Introduction to Patient Interaction: Always knock before entering, perform hand hygiene, introduce yourself, and verify patient identification using two identifiers.

• QSEN (Quality and Safety Education for Nurses): Emphasizes patient-centered care, teamwork, evidence-based practice, safety, informatics, and quality improvement in nursing practice.

• Gait Belt: Utilized for patients with weakened physique when ambulating.

• Restraints: Should be a last resort measure requiring a medical doctor's order; they can be classified as either physical or chemical restraints.

• Incident Reports: Must be completed immediately following an adverse event; they are not part of the patient's medical record, serving instead a preventative purpose.

• RACE Protocol: Acronym that refers to the steps in case of a fire: Rescue, Activate, Confine, Evacuate.

• Range of Motion (ROM):

  • Active ROM: The patient performs the movements independently.

  • Passive ROM: The nurse actively assists in the movements.

Chapter 24 - Infection Control

• Chain of Infection: Understanding the six elements of infection transmission—Agent, Reservoir, Portal of Exit, Transmission, Portal of Entry, and Host—is crucial for infection control.

• Signs of Infection: Common indications include redness, swelling, heat, pain, and loss of function in the affected area.

• A White Blood Cell (WBC) count exceeding 10,000 typically indicates an infection.

• Hand Hygiene: There are Five Moments for Hand Hygiene, and washing should be completed for 20 seconds or using hand sanitizer when appropriate.

• Hospital-Acquired Infections (HAIs): The most common types include catheter-associated urinary tract infections (CAUTIs), surgical site infections, central line-associated bloodstream infections, and ventilator-associated pneumonia.

• Precautions in Infection Control:

  • Airborne Precautions: Involve negative pressure rooms and N95 respirators for diseases such as tuberculosis (TB), varicella, and measles.

  • Droplet Precautions: Require a private room and a surgical mask, as seen with illnesses like influenza and rubella.

  • Contact Precautions: Utilize barriers such as gloves and gowns for infections like MRSA and C. difficile.

• Asepsis Categories: Distinguish between medical asepsis (clean techniques) and sterile techniques (which kill all microorganisms).

Chapter 25 - Vital Signs

Normal ranges for vital signs are crucial for assessing patient health:

• Temperature: Ranges from 97 °F to 100.5 °F.

• Pulse Rate: Typically falls between 60 and 100 beats per minute, noting that this range may be lower in older adults.

• Respirations: Normal respiratory rate is 12 to 20 breaths per minute.

• Blood Pressure: Normal is generally 120/80 mmHg.

• Oxygen Saturation (O2 Sat): Expected values range from 95% to 100%.

Abnormalities in Vital Signs

• Fever (hyperthermia) and hypothermia represent abnormal temperature variations.

• Tachycardia refers to an elevated heart rate, while bradycardia indicates a lower heart rate.

• Tachypnea signifies increased respiratory rate, whereas bradypnea indicates a reduced respiratory rate.

• Apnea refers to the absence of breathing, while dyspnea denotes difficulty in breathing.

• Orthopnea indicates difficulty breathing when lying flat.

• Cheyne-Stokes Respirations: Characterized by alternating episodes of rapid breathing followed by apnea, typically observed in patients approaching death.

• Pulse Deficit: This represents the difference between the apical pulse and the radial pulse.

• Orthostatic Hypotension: A condition where there is a reduction in blood pressure upon changing positions.

• Pain: Often termed the fifth vital sign due to its significance in patient assessment and care.

Nursing Roles and Responsibilities

Chapters 1–2 detail the ethical and practical standards guiding nursing practice:

• American Nurses Association (ANA): Establishes standards of practice, ethics, and guidelines for nursing.

• Nurse Practice Act: This is state legislation that defines the scope of practice for nurses and outlines disciplinary actions for violations of practice standards.

• Aims of Nursing: Nurses are dedicated to engaging in promoting health, preventing illness, restoring health, and facilitating patients' coping mechanisms in managing disability and death.

• Maslow's Hierarchy of Needs: A foundational psychological theory that prioritizes the human needs.

• Hans Selye: Developed the General Adaptation Syndrome, which describes the physiological response to stress in three phases: Alarm, Resistance, and Exhaustion.

• Nursing Theorists:

  • Dorothea Orem: Proposed the Self-Care Deficit Theory, which underscores the necessity for nursing intervention when an individual cannot meet their self-care needs.

  • Sister Callista Roy: Introduced the Adaptation Theory, where ineffective adaptive responses necessitate nursing intervention to promote health and recovery.