Health Assessment 2144
Health Assessment 2144 NURS 2144
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This 20 page Study Guide was uploaded by Victoria Sellers on Thursday September 15, 2016. The Study Guide belongs to NURS 2144 at Temple University taught by in Summer 2016. Since its upload, it has received 67 views. For similar materials see Health Assessment in NURSING at Temple University.
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Date Created: 09/15/16
HA Exam 1 Study Guide Nurse’s Role in Health Assessment, Collecting Subjective Data: Interview and History, & Collecting Objective Data: Physical Examination, Technique, and Equipment HEALTH ASSESSMENT AND THE ROLE OF THE REGISTERED NURSE Role of the Professional Registered Nurse American Nurses Association requires extensive knowledge and skills Established 4 goals for the RN: 1. Promote health 2. Prevent illness 3. Treat human response to health or illness 4. Advocate for individuals, families, communities, populations Nursing scope and standards of practice (ANA 2004) and code of ethics for nurses with interpretive statements 1. Appropriate nursing interventions to promote health and prevent disease i.e.: education, screenings 2. Manage and coordinate care 3. Utilize interprofessional communication 4. Improve patient outcomes 5. Involve scholarship and research Advocacy Represent the patient and nursing profession Responsible to protect the legal and ethical rights of patients o i.e.: making sure the patient knows what's going on Provide safe and humanistic care Values and ethical principles are beliefs to which an individual is committed Nursing Values Define and provide examples: o Altruism - selflessness o Autonomy - being able to do things for yourself o Human dignity - treat others how you want to be treated o Integrity - do the right thing and own your mistakes o Social justice - think about who gets the best of what Purpose of Health Assessment Gathering data about the health status of a patient Analyzing and synthesizing the data collected Making concrete judgments pertaining to interventions Evaluating patient care outcomes The nursing process begins with a complete and accurate health assessment o Components: Health history Review of systems (ROS) Physical assessment Other purposes: o Gain insight into a condition Establish a database Identify patterns and trends Determine if a specific condition is improving or worsening Wellness and Health Promotion Wellness is an ongoing process Role of nurses is to facilitate wellness and health promotion Collaborative effort from multidisciplines Healthy People 2020 1. Goals 2. Interventions 3. Evaluations/revisions Nursing Process Systematic problem solving approach 1. Assessment 2. Diagnose 3. Develop an individualized plan of care 4. Intervene/perform interventions 5. Evaluate goals 6. Reassess the process (ONGOING) Critical Thinking (extremely important to the nursing process) Purposeful, creative, outcome directed thinking Driven by needs of patient, family, and community o Concentrated and focused by importance Based on the nursing process Requires knowledge, skills, and experience Guided by professional standards and ethics Constantly reevaluating to improve outcomes Diagnostic Reasoning Based on a nurse's critical thinking Gathering data to conclude diagnoses o Abnormal and normal findings o Subjective and objective data o Collaborative approach Cluster data: establish patterns, themes, and relationships Interventions to Promote Healthy Change 1 Primary prevention (preventing problems) 2 Secondary prevention (diagnosis and treatment) 3 Tertiary prevention (preventing complications) Types of Physical Assessment 1 Emergency 2 Focused 3 Comprehensive Frequency of Physical Assessment Varies with the patient's needs, purpose of data collection and health care setting Examples: o ICU patient o Long term care patient o Outpatient/community o Healthy individual in the community o Different age groups Cultural and Environmental Issues Must be knowledgeable of cultural diversity Cultural competence Be aware of subcultures Spirituality and religions o Respect them all; agree to disagree Physical Assessment Frameworks Functional assessment: patterns all humans share Head to toe assessment: most organized approach in all settings Body systems approach: logical tool in organizing data when documenting and communicating findings Evidence Based Critical Thinking Minimize personal experience and own biases Identify the problem based on accurate assessment and analysis of current nursing knowledge Search literature for relevant research Establish criteria for appropriate nursing diagnoses Develop interventions and a plan of care Evaluate goals and patient outcomes Reassess (ONGOING) CHAPTER 1: NURSE'S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA Assessment: Important for Every Situation Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse o Acute care o Critical care o Ambulatory care o Home health Holistic nursing assessment o Collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment Physical medical assessment o Focuses primarily on the client's physiological development status Phases of Nursing Process Assessment: collecting subjective and objective data Diagnosis: analyzing data to make a professional nursing judgment o Nursing diagnosis, collaborative problem, or referral) Planning: determining outcome criteria and developing a plan Implementation: carrying out the plan Evaluation: assessing whether outcome criteria have been met and revising the plan as necessary Steps of Health Assessment Preparing for the assessment o Review client's record o Review client's status with other health care team members o Educate about client's diagnosis and tests performed Collecting Subjective Data (what the PATIENT TELLS YOU) o Biographical info (name, DOB, ethnicity, environment, sex) o History of present health concern (physical symptoms related to each body part or system) Past health history o o Family history o Health and lifestyle practices Collecting Objective Data (what YOU SEE) o Physical characteristics o Body functions o Appearance o Behavior o Measurements o Results of laboratory testing Validation of Data o Verify that the subjective and objective data are reliable and accurate o Steps of validation 1. Decide whether data requires validation 2. Determine ways to validate the data 3. Identify areas where data are missing o Data Requiring Validation 1. Discrepancies between subjective and objective data 2. Discrepancies in what the patient says 3. Abnormal and/or inconsistent findings Methods of Validation o 1. Repeat assessment 2. Clarify data with patient 3. Clarify with other healthcare professionals Compare subjective data with objective data 4. Documentation of data (document EVERYTHING) o Document through the eyes of an attorney o Purpose of Documentation 1. Provide a chronological process of events 2. Progressive record of assessment findings 3. Documentation is easily accessible 4. Form of communication 5. Promotes the plan of care 6. Establishes a basis of screening 7. Source of information to diagnose new problems 8. Determines the educational needs 9. Support financial reimbursement and eligibility of care 10. Permanent legal record Promotes compliance with legal, accreditation, 11. reimbursement, and professional requirements o Keep all documents confidential o Document legibly and clearly o Use correct grammar o Avoid redundancy o Use phrases instead of sentences o Write entries objectively without judgment Analysis of data o Identify abnormal data and strengths o Cluster the data o Draw inferences and identify problems o Propose possible nursing diagnoses o Check for defining characteristics of those diagnoses o Confirm or rule out nursing diagnoses o Document conclusions Types of Assessment Initial comprehensive assessment: Collection of subjective data about the client’s perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices. Ongoing or partial assessment: Data collection that occurs after the comprehensive database is established. Focused/problem-oriented assessment: Thorough assessment of a particular client problem, which does not cover areas not related to the problem. Emergency assessment: Very rapid assessment performed in life- threatening situations Evolution of the Nurse's Role in Health Assessment: Past Physical assessment integral part of nursing Nurses relied on natural senses Palpation Movement of health care from acute care setting to community care and proliferation of baccalaureate and graduate education Advanced practice nurses Present Managed care and internal case management has impact on assessment role of the nurse o Acute care nurses o Critical care outreach nurses o Ambulatory care nurses o Home health nurses Public health nurses o o School and hospice nurses Future Rising educational cost Increasing complexity of acute care Growing aging population Expanding health care needs Increasing impact of children and homeless Intensifying mental health issues Expanding health services network Increasing reimbursement for health promotion and preventive care services Validating and Documenting Data Purpose of Documentation • Provide a chronological process of events • Progressive record of assessment findings • Documentation is easily accessible • Form of communication • Promotes the plan of care • Establishes a basis of screening • Source of information to diagnose new problems • Determines the educational needs • Support financial reimbursement and eligibility of care • Permanent legal record • Promotes compliance with legal, accreditation, reimbursement and professional requirements Documenting Data • Keep all documents confidential • Document legibly and clearly • Use correct grammar • Avoid redundancy • Use phrases instead of sentences • Write entries objectively without judgment Verbal Communication Findings • Use a standard method of data communication • Communicate face-to-face with eye contact • Allow time for the individual to answer and ask questions • Summarize what was heard for validation General Status and Vital Signs General Survey First component of the assessment Begins with the first moment of the encounter Continues throughout the health history Forms global impression of the person Data types: subjective and objective General Survey Objective Data Collection Equipment needed o Scale (digital is best) o Height bar o Stethoscope (always have your own) o Thermometer o Watch the second hand (not your phone) o Sphygmomanometer (BP cuff – choose the right one for the client) o Pulse oximeter Anthropometric measurements o Height (in & ft. vs cm &m) o Weight (lbs. vs kg) o BMI Vital Signs Reflect health status, cardiopulmonary function, and overall body function Baseline Frequency – depends on the person Need to assess patient medications “Vitals” o Temperature o Pulse o Respirations o Blood pressure th o Pain is the “5 vital sign” o O2 saturation Temperature Routes: o Oral – easiest, most accessible (primary) o Rectal – 1 F higher than oral o Axillary – 1 F lower than oral o Temporal – same as oral o Tympanic membrane – same as oral How to choose route: patient safety, patient comfort, ease, accuracy Diurnal cycle – recurs every 24 hours o Normal temperature rates vary throughout the day (higher at night, lower in the morning) >103 requires immediate intervention and cooling measures Always document your findings F/C Conversion F to C: F – 32 (5/9) C to F: C + 32 (9/5) Pulse Know the arterial pulse points o Temporal o Carotid o Axillary o Radial o Ulnar o Brachial o Femoral o Popliteal o Dorsalis pedis o Posterior tibial Normal adult rate = 60-100 bpm o Tachycardia – abnormally fast o Bradycardia – abnormally slow o Asystole – no pulse Equipment: watch with a second hand Check pulse for 1 minute (if you check for 30 seconds, you can multiply it by 2) Check the rhythm and regularity Pulse deficit (apical/peripheral) Amplitude (0 to +4) o +2 is considered normal Always document your findings! Respirations Inspiration and expiration – air moving in and out of the body Eupnea = normal breathing rate = 12-20 breaths/min Dyspnea = difficulty breathing o SOB = shortness of breath o SOA = shortness of air Tachypnea = abnormally fast breathing Bradypnea = abnormally slow breathing Factors that affect respiratory rate o Drugs o Exercise o Sleeping o Anxiety o Disease/disorders Assessment – be covert – if they know you’re doing it, the patient won’t breath naturally Always document your findings! O2 Sat/Pulse Ox/SpO2 Oxygen saturation o Normal pulse oximetry is SpO2 from 92% to 100% o SpO2 of 85%-89% is acceptable with certain chronic conditions such as emphysema o Always document your findings! Blood Pressure Systolic BP (SBP) and diastolic (DBP) Normal is 120/80 Variations occur normally and are influenced by many factors o Exercise o Illness o Weight gain o Vessel elasticity o Diet o Anxiety o Smoking o Position Equipment o Sphygmomanometer (BP cuff) Choose the right size!! o Arm BP (120/80) o Thigh BP (SBP 10-40 > arm) o Wrist BP (not very accurate) o Orthostatic BP Pulse pressure = SBP – DBP (~40) Mean arterial pressure = 1/3 SBP + 2/3SBP o Organ vitality (~70) Always document your findings! Pain – technically a symptom… Subjective Why assess? o Increased comfort, decrease pain o Improve physiological, psychological, and physical function o Increased satisfaction with pain management Assess pain using COLDSPA o Character o Onset o Location o Duration o Severity o Pattern o Associated factors (illness assessment) Always document your findings! Rapid Response Team Called in for certain scenarios o An acute change in mental status o Stridor – high pitched squeaking noisy breathing o Respirations < 10 or >32 breaths/min o Increased effort to breath o Oxygen saturation < 92% o Pulse < 55 bpm or >110 bpm o SBP < 100 or >170 o Temperature < 35C or >39.5C o New onset of chest pain o Agitation or restlessness Never call them in directly as a nursing student – get a professional healthcare worker to do that Hair, Skin, Nails Structure and Function Physical barrier Protects underlying tissues and structures from microorganisms, physical trauma, UV radiation, and dehydration The skin is the largest organ Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis o It does a lot. Don’t abuse it!! Anatomy Layers of skin o Epidermis o Dermis o Subcutaneous Hair o Vellus (prepubertal) o Terminal (adult) Nails o Hard, transparent plates of keratinized epidermal cells Skin Cancer Most common of all cancers 3 types o Melanoma – fatal o Basal cell carcinoma o Squamous cell carcinoma Both more common and less serious Risk factors o Sun exposure o Nonsolar sources of UV radiation o Medical therapies o Family history o Moles and pigmentation irregularities o Fair skin that burns and freckles easily o Light hair o Age o Male > female o Chemical exposure o HPV – human papillomavirus o Xeroderma pigmentosum Rare hereditary defect of the enzyme system that repairs DNA after damage from ultraviolet rays, resulting in extreme sensitivity to sunlight o Long-term skin inflammation or injury o Alcohol and smoking o Inadequate niacin in diet Health Teaching Mantra for Risk Reduction SLIP on a shirt SLOP on sunscreen SLAP on a hat WRAP on sunglasses Cultural Considerations Lowest rate – Asians Highest rate – white Australians Most susceptible o Pale Caucasians o Freckled skin o Red hair Suspicious Lesions Examine the skin for suspected lesions using the ABCDE mnemonic o Asymmetry o Border o Color o Diameter o Elevation Lab tests o Scraping of the lesion o Culture and sensitivity o Woods light – sees under the skin o Biopsy (for problems in ABCDE) Hair Assessment Inspection and palpation o General color and condition, cleanliness, dryness or oiliness, parasites, and lesions o Amount and distribution of scalp, body, axillae, and pubic hair Nails Can tell a lot about a person’s overall health Inspection: nail grooming and cleanliness, nail color and markings, shape Palpation: assess texture and consistency, capillary refill Risk Factors o Nails in moist environment, walking in damp public locales or continuously wearing closed shoes; excessive perspiration o Nail injury, trauma, or irritation o Repeated irritation (especially from water/detergents) o Immune system disorders – diabetes mellitus and AIDS or on immunosuppressive meds o Skin conditions – psoriasis or lichen o Some trades or professions o Contagion from one digit to another or one person to another Self-Assessment – Review Box 14-1 – Use this to teach patients Pressure Ulcers Vast majority are nurse-caused o Move your patient! o 3 P’s: decrease Pressure, increase Protein, wash off Pee Caused by o Pressure o Poor nutrition o Excretions Stage 1 – redness 2 – little blister 3 – deeper; tunneling starts 4 – bone and tendon visible Unstageable – slough Deep tissue injury Common sites – anywhere bony (prominences) o Most commonly happen at home o **float the heels o The skinnier the patient, the more likely they’ll happen Primary Skin Lesions Macule Patch Papule Plaque Nodule Cyst Vesicle Bullae Pustule Lichenification Induration Erythema Purpura Secondary Skin Lesions Erosion – loss of epidermis; heals quickly on its own Ulcer – (see pressure ulcers) Scar – fibrous tissue replaces normal tissue Fissure – small very thin linear tears in skin Vesicular Lesions Petechia Ecchymosis Hematoma Cherry angioma Spider angioma Telangiectasis Head, Neck Structure and Function The head o Cranium Frontal, parietal, temporal, occipital, ethmoid, sphenoid o Face Maxilla, zygomatic, inferior conchae, nasal, lacrimal, palatine, vomer, mandible The neck o Hyoid bone and cricoid cartilage o Several major blood vessels (jugular veins, carotid arteries) o Larynx (voice box) o Trachea (windpipe) o Esophagus (digestive tract) o Thyroid gland – largest endocrine gland in the body; releases thyroid hormone which increase metabolic rate of most body cells Cervical vertebrae 1 = atlas 2 = axis 7 total Lymph Nodes Filter lymph, a clear substance composed mainly of excess tissue fluid Filtering removes bacteria and tumor cells from lymph Produce lymphocytes and antibodies as a defense against invasion by foreign substances Normally they aren’t palpable, or else they’re very small When overwhelmed by microorganisms (infection), they swell and become painful o Glands = body’s defense against infection Locations o Pre- and postauricular o Tonsillar o Occipital o Submandibular o Submental o Superficial/posterior/deep cervical o Supraclavicular Traumatic Brain Injury Presence of transportation accidents o Cars, motorcycles, bikes, pedestrians Presence of violence o Firearm assaults and child abuse or self-inflicted wounds Falling Excessive alcohol consumption o DON’T STALL JUST CALL!! Infants and elderly injured by caregivers o Shaken baby syndrome Health Assessment Interview Approach COLDSPA History of current health problem, past health, family history Lifestyle and health practices Headache impact Testing (just know that it’s a thing) Head Assessment Inspect the size, shape, and configuration Consistency Involuntary movement Palpate the head Facial Assessment Inspect the face for o Symmetry o Features o Movement o Expression o Skin condition Palpate o Temporal artery: assess tenderness and elasticity o Temporomandibular joint (TMJ): assess range of motion, swelling, tenderness, crepitation (crackling or rattling) Neck Assessment Assess the neck from behind – easier and more comfortable Inspect movement of neck structures o Cervical vertebrae o Neck range of motion (ROM) Palpate o Trachea – check swallowing o Thyroid gland – check thyroid and cricoid cartilage Auscultate enlarged thyroid gland Palpate lymph nodes of head and neck o Pre- and postauricular o Occipital o Tonsillar o Submandibular o Submental o Superficial/posterior/deep cervical o Supraclavicular Age-related Considerations Arthritis or osteoporosis = neck pain and a decreased range of motion Wrinkles are prominent because subcutaneous fat decreases with age Lower face may shrink and mouth may be drawn in as a result of resorption of mandibular bone o Also causes teeth to fall out The strength of the pulsation of the temporal artery may be decre4ased (due to weakened blood vessels) Cervical curvature may increase – kyphosis of the spine Fat may accumulate around the cervical vertebrae (especially in women) – “dowager’s hump” Decreased flexion, extension, lateral bending, and rotation of the neck due to arthritis If palpable, thyroid may feel more nodular because of fibrotic changes that occur with aging Thyroid may be felt lower in the neck because of age related structural changes Mouth, Nose, Sinus, Throat Anatomy Nose o Nerves Trigeminal – V Facial – VII Glossopharyngeal – IX Vagus – X o Blood supply: internal and external carotid artery Nose bleeds start from the Kiesselbach plexus o Lymph drainage Preauricular Submandibular Cervical Retropharyngeal o Osteomeatal complex (channel that links the frontal sinus, anterior and middle ethmoid sinuses and the maxillary sinus to the middle meatus that allows air flow and mucociliary drainage) Frontal and maxillary sinuses open into nasal cavity Polyps cause difficulty breathing through the nose Sinuses o Bony, hollow, produce mucus, drain into nasal cavity o Decrease weight of skull and give resonance to speech o Torus tubarius – adjacent to Eustachian tube o Rosenmullers fossa – nasopharyngeal tumor Posterior torus tubarius a long, deep, shallow and narrow depression found in one of the furthest sections of the nasal cavity better known as the lateral pharyngeal recess due to its proximity to the pharynx o Adenoids – roof of nasopharynx (highly vascular) Mouth (oral cavity) o Vermillion border: where the lips and skin meet o Palatine arches: lateral over the buccinators muscles of the cheek o Floor of mouth and base of tongue are very vascular o Hard palate – anterior roof of oral cavity o Soft palate – posterior roof of oral cavity o Uvula – extension of the soft palate which hangs in the posterior midline of the oropharynx Tongue (a muscle) o Lingual frenulum – attaches it to floor of oral cavity o Highly vascular Salivary glands o Begin digestive process with enzymes o Transmits taste o Protects oral cavity o Xerostomia = dry mouth o Enervated by cranial nerves VII, IX, and X o 3 major glands: Parotid duct – largest zygomatic arch to jaw Submandibular gland – under jaw Sublingual gland – under tongue Teeth and Gums o Crown, neck and root o 32 permanent teeth o Gums = gingiva Throat o Nasopharynx, oropharynx, and laryngopharynx o Palatine tonsils – back of throat between anterior and posterior pillars Immunological defense along with adenoids(^^^) Acute vs. chronic tonsillitis Tonsillitis vs. strep throat Lifespan Considerations Pregnant women – rhinitis (hay fever), nosebleeds Older adults o Gustatory rhinitis – runny nose w/ clear, watery discharge o Malocclusion – abnormal arrangement of upper/lower teeth – or tooth loss o < taste o <saliva Cultural and environmental considerations o Gingivitis – low socioeconomic status o Cleft lip/palate – more common in Native and Asian Americans (1/1,000) o Oral and pharyngeal cancers – more common in Caucasians and AA Subjective Data Collection History of present health concern Past health history Family history Lifestyle and health practices Assessment of risk factors Medications and supplements Dental health (Ludwig’s, abscesses, trauma) Psychosocial history Risk Assessment/Teaching Smoking is a major risk Ask how often they brush and floss their teeth Dietary nutrition Common Mouth and Upper Respiratory Symptoms: Assess what they are and use critical thinking: o Facial pressure, pain, headache o Snoring and sleep apnea o Obstructive breathing o Nasal congestion o Epistaxis (nosebleed) o Halitosis (bad breath) o Anosmia (loss of sense of smell) o Cough (acute vs. chronic) o Pharyngitis o Dysphagia (difficulty or discomfort swallowing) (acute vs. chronic) o Odynophagia (painful swallowing) o Dental pain o Voice changes o Oral lesions – viral/bacterial, benign/malignant Focused Health History Documentation of normal/abnormal findings Lifespan considerations o Older adult – edentulous (lacking teeth) o Angular cheilitis (inflammation and small cracks in one or both corners of the mouth) Older adults – wearing dentures Adults – wearing face masks Children – using pacifiers o Scrotal tongue (wrinkles and fissures appear) People are usually born with it Might appear with age Collecting Objective Data Equipment needed Preparation Common specialty or advanced techniques Comprehensive physical exam Use appropriate medical terminology Address buccal mucosa and area under tongue Mention posterior palate and tonsils Address both inspection and palpation Common lab and diagnostic testing Diagnostic reasoning o Nursing diagnosis, outcomes, and interventions Analyze findings Collaborate with other healthcare professionals Pull it all together
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