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Explain the purpose and types of health assessment.
Gathering information about the health status of the patient. The nurse then plans for appropriate nursing interventions based on this data and evaluates patient care outcomes.
- Physical Assessment: collection of objective data that provides information about changes in the patient’s body systems
- Comprehensive assessment: with a health history and completed physical examination when patient first enters a health care setting
- Ongoing partial assessment or follow-up assessment) is one that is conducted at regular intervals. This focuses on identified health problems to monitor positive or negative changes and evaluates the effectiveness of interventions
- Focused assessment: to assess a specific problem
- Emergency assessment: rapid focused assessment conducted when addressing a life-threatening or unstable situation.
Differentiate Subjective and Objective data
- Subjective data: What the person says about himself or herself
- This is the first and best chance that a person has to tell you what or she perceives his or her health state to be
Objective data: information that is collected from patients. It can be defined as the data medical professionals obtain through observations by seeing, hearing, smelling and touching
Describe the different components of a health history
- Health history: is important in beginning to identify the person’s health strengths and problems and as a bridge to the next step in data collection, the physical examination
- Biographic data: includes name; address; telephone number; age; birth date; birthplace; sex; marital or partner status; race; ethnic origin; and occupation, usual and present
- Source of history: the history may be provided by the patient or a substitute
- Reason for Seeking Care: Brief, spontaneous statement in the patient’s own words that describes the reason for the visit
- Present Health or History of Present Illness: Chronologic record of the reason for seeking care, from the time of the onset of the symptoms until now. Start when the person first noticed the symptoms and work forward to the present. Should contain (PQRSTU)
- Provocative or Palliative: What brings it on? What were you doing when you first noticed it? What makes it better? Worse?
- Quality or Quantity: How does it look, feel sound? How intense/severe is it? Region or
- Radiation: Where is it? Does it spread anywhere?
- Severity scale: How bad is it (on a scale from 1-10)? Is it getting better, worse, staying the same?
- Timing: Onset-exactly when did it first occur? Duration-How long did it last? Frequency-How often does it occur?
- Understand: patient’s perception of the problem. What do you think it means?
- Past Health Childhood Illnesses
- Accidents or injuries
- Serious or Chronic Illnesses
- Hospitalizations and Operations
- Obstetric History
- Last Examination Date
- Current Medications
- Family History: age and health
- Review of Systems: General Overall Health State
- Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, and sweats or night sweats Functional Assessment (Activities of daily living):
- Functional assessment measures a person’s self care ability in the areas of physical health; activities of daily living such as bathing and dressing; instrumental activities for independent living such as cooking; nutritional status; social relationships and resources; self concept and coping and home environment.
- Perception of Health: How do you define health?
Prepare the patient and the environment for a health assessment
- Consider and remain sensitive to the patient’s physiologic needs and psychological needs
- Explain that the first part of the assessment will involve questions about the patient’s health concerns, health habits and lifestyle and that the information will only be shared with the patient’s other health care providers
- Inform the patient that after the health history is completed, the boy structures will be examined
- Reassure assessments by explaining in detail such as draping
- Environmental Preparation
- Privacy and respect for patient are primary concerns with conducting health assessment
- Prepare examination room before health assessment and prepare by a gown and drape, gathering instruments.
- There should be enough light and warm enough
- Assist the patient with undressing
- Ask patient to empty bladder before examination to promote patient comfort during assessment
Describe the techniques of inspection, palpation, percussion, and auscultation during a physical assessment (633).
- Head-to-Toe; Body System Assesments
- Palpation (touching)
- Percussion (tapping)
- Auscultation (listening w/ stethoscope)
- inspection is close, careful scrutiny first of the person as a whole and then of each body system. Inspection begins the moment you first meet the individual and develop a “general survey.” Use each person as his or her own control and compare the right and left sides of the body. The two sides are nearly symmetric. Inspection requires good lighting, adequate exposure, and occasional use of instruments to enlarge your view.
- Ensure there is good lighting
- Perform at EVERY encounter with patient
- Observe visually, but also use hearing and smell
- Inspect each area of the body for size, color, shape, symmetry
Follows and often confirms points that you noted during inspection. Palpation applies your sense of touch to assess these factors: texture; temperature; moisture; organ location and size; and any swelling, vibrations or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses.
- The Dorsum (back) of the hand is used for detecting temperature
- Fingertips and fingerpads are used to assess texture, size, consistency
- Light: Apply pressure with fingers together and depress the skin 1cm
- Uses: rigidity, tenderness, masses
- Moderate: pressure with fingers depressing 1-2cm
- Deep: carries a risk of internal injury, should be done by experienced one
- Fingertips- best for fine tactile discrimination such as skin texture, swelling, pulsatility, and presence of lumps.
- A grasping action of the fingers and thumb- to detect the position, shape, and consistency of an organ or mass
- The dorsa of hands and fingers—best for determining temperature because the skin here is thinner than the palms
- Base of fingers or ulnar surface of the hand- to detect vibrations.
Technique low and systematic Warm your hands by kneading them together or holding them under warm water Identify any tender areas and palpate them last Start with light palpation to detect surface characteristics and accustom the person to being touched When deep palpation is needed (abdominal content), intermittent pressure is better than one long, continuous palpation Avoid any situation in which continuous or deep palpation could cause internal injury or pain.
Bimanual palpation requires the use of both hands to envelope or capture certain body parts or organs
Percussion (Tapping): ***
The act of striking one object against another Involves tapping the person’s skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ
- The fingertips are used to tap the body over body tissues to produce vibrations and sound waves
- Characteristics of the sounds produced are used to assess the location, shape, size, and density
- Abnormal sounds suggest alteration of tissues
- ex: Abdominal Tumor
- The stationary hand
- Hyperextend the middle finger of your non-dominant hand and place its distal portion firmly against the person’s skin
- Avoid the ribs and scapulae
- Percussing over a bone yields no data because it always sounds “dull”
- Lift the rest of the stationary hand up off the person’s skin; otherwise the resting hand will dampen off the produced vibrations just as a drummer uses the hands to halt a drum roll.
- The striking hand
- Use the middle finger of your dominant hand as the striking finger
- Hold your forearm close to the skin surface with your upper arm and shoulder steady, but not rigid
- The action is all in the wrist and it must be relaxed
- Bounce your middle finger off the stationary one
- Aim for just behind the nail bed
- Flex the striking finger so that its tip not the finger makes contact It hits directly at right angles to the stationary finger
- Percuss two times in this location using even, staccato blows. Lift the striking finger off quickly
- A resting finger dampens vibrations
- Then move to a new body location and repeat, keeping your technique even.
Auscultation (Listening w/stethoscope) ***
- The act of listening to sounds with a stethoscope
- Listening to sounds produced by the body such as the heart, blood vessels, lungs, and abdomen through a stethoscope.
- Choose a stethoscope with two end pieces- a diaphragm and a bell. The diaphragm has a flat edge and is best for high-pitched sounds breath bowel, and a normal heart sounds.
- Diaphragm – high pitched sounds: Heart, Lungs, Abdomen
- Bell – low pitched sounds: Blood vessels
- Hold the diaphragm firmly against the person’s skin, firm enough to leave a slight ring afterward
- The bell end piece has a deep, hollow, cuplike shape
- It is best for soft, low-pitched sounds such as extra heart sounds or murmurs
- Hold it lightly against the person’s skin, just enough so it forms a perfect seal
- Pressing harder causes the skin to act as a diaphragm, obliterating the low pitched sounds.
Successfully conduct a physical assessment practicum in a systematic manner Look into Jarvis Book Chapters 1-4
Document significant health assessment findings in a concise and descriptive manner (670-671)
- Collect Health History and physical assessment
- Identify actual and potential problems
- Document Data with each system recorded individually
- Ex: Vital Signs
- Collect health history and physical assessment
- Identify nursing diagnosis
- Plan appropriate care
- Evaluate patient’s response to nursing interventions
- Complete Health History Includes:
- Biographical Data:
- Marital status
- Reason for Seeking Care: symptoms and duration
- History of Present Illness: symptoms in chronological order
- Analysis of Symptoms:
- P: Provocative
- Q: Quality
- R: Region/ is it radiating
- S: Severity
- T: Time
Review the structure and function of the neurological system
- CNS: brain & spine
- Cerebral cortex is cerebrum’s outer layer of nerve cell bodies
- Center for humans’ highest functions, governing thought, memory, reasoning, sensation, and voluntary movement
- Contains four lobes; damage to them – loss of function: motor deficit, paralysis, loss of sensation, or impaired ability to understand and process language
- Thalamus: Main relay station for incoming sensory pathways
- Hypothalamus: Controls temperature, sleep, emotions, autonomic activity, pituitary gland
- Cerebellum: Motor coordination, equilibrium, muscle tone
- Midbrain and pons: Motor neurons and motor and sensory tracts
- Medulla: Fiber tracts and vital autonomic centers for respiration, heart, and GI function
- PNS: 12 pairs cranial nerves, 31 pairs of spinal & all branches
- Carries sensory message to CNS from sensory receptors; motor message from CNS to muscle & glands; ANS messages govern internal organ & blood vessels
- 12 pairs of cranial nerves
- Spinal nerves: 31 nerves 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
- Dermatome: circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve
Specific assessments performed during examination of a patient’s cognition and sensory perception status.
- 2-point discrimination
Glasgow Coma Scale
- Best eyes response
- Best verbal response
- Best motor response
Subjective data necessary to obtain a health hx of pt’s cognition, sensory perception, mobility status
- Headache: Weakness or incoordination
- Head injury : Numbness or tingling
- Dizziness : Difficulty swallowing
- Seizures : Difficulty speaking
- Tremors - Significant neurologic past hx
Identify and describe sensory function tests and motor examination
- Sensory Function Tests (Ch. 25, pp. 669-670)
- Touch: Light touch first, then Pain and Temperature USE A SOFT OBJECT and a SHARP OBJECT Patient should be able to distinguish between a sharp (painful) touch and a soft dull touch
- Vibration: A tuning fork is placed on bony prominences for vibratory sensation Do you feel the vibration or not?
- Kinesthesia/Proprioception: Position sense (Ch. 43, pp. 631) Awareness of positioning of body parts and body movement
- Stereognosis: The sense that perceives the solidity of objects, their size, shape, and texture
- Graphesthesia: The ability to recognize writing on the skin purely by the sensation of touch Example: drawing circles in the palm of your hands or lines down your arm or leg
- 2-point discrimination: The ability to discern that two nearby objects touching the skin are TRULY TWO DISTICNT POINTS, NOT ONE Often tested with two sharp points
Motor Examination Tests
- Gait: A person's manner of walking
- How to assess Have patient walk across the room on the toes, on the heels, hop on one foot, and heel to toe Observe posture, balance, and arm and leg movements Posture should be erect (upright), with slight swaying in the standing position
- Asses for… Normal standing position should is feet are as wide as shoulder width Foot placement during walk, should be accurate and in line The walk is SMOOTH, EVEN, and WELL BALANCED Symmetric arm swing are present during walk
Range of Motion (ROM) Assess for full mobility of each joint Movements should be DELIBERATE, ACCURATE REFER TO RANGE OF JOINT MOTION EVALUATION CHART
- Coordination and Motor Function Have patient touch finger with the thumb Rapidly pat the hand on the thigh Tap foot on the floor (or against your hand,, if the patient is supine) Repeat on opposite limb.
- Assessment Movements should be coordinated If patient is unable to do these movements, it may indicate disease of the upper motor neurons or cerebellum
Strength against resistance
Pupils response to light (Visceral reflexes)
- Deep tendon reflexes (DTRs)
- Position limb so muscle is slight stretched
- Reflex hammer should strike tendon briskly to stretch tendon
- Get patient to relax
- Normal sties for DTRs Brachioradials Biceps Triceps Patellar Achilles/Plantar
- Grading of DTRs
- 4+ = very brisk
- 3+ brisker than average
- 2+ average, normal
- 1+ diminished, low normal
- 0 no response
Describe specific assessments performed during examination of a patients mobility status (Check Cognition, Sensory, Perception, and Mobility Powerpoint)
- Obtain health history
Inspect for… Swelling Mass or deformities Stiffness Instability of joints, limbs, and body regions Palpate for temperature, tenderness surrounding joint
Range of Motion (ROM) Passive and active Have PT perform active ROM If unable to, USE PASSEIVE ROM Palpate for unusual joint movement during ROM
- Muscular strength
- Assess… : Muscle tone and strength Strength against gravity/resistance Note as 0/5 - 5/5 5/5 = NORMAL
Identify the specific subjective data necessary to obtain a health history of a patients mobility status (Ch. 32, pp. 1054, Focus Assessment Guide 32-1)
- Daily activity level: What activities do you normally carry out on a routine day?
- Type, frequency, duration of exercise
- Description of lifestyle
- Past history of activity and exercise; recent changes
- Endurance: Describe how much and what type of activity makes you tired
- History of dizziness, dyspnea, etc.
- Exercise/fitness goals: What exercise or fitness goals are you currently working on?
- Attitudes about exercise and physical fitness
- Knowledge of the benefits of exercise
- Motivations to exercise
- Fitness goals
- Mobility problems: Do you experience any problems with movement or with more vigorous activity or exercise? If yes, please describe these problems
- Nature of problem (symptoms)
- Known causes
- Physical or mental health alterations: Are there any physical or mental health problems that may be affecting your mobility? Tell me about them.
- Pain or discomfort
- Depression or sever anxiety
- External factors affecting mobility: Is there anything else you can think of that limits your ability to get around?
- Environmental factors
- Financial resources