Lecture 1: Introduction to Health Assessment Flashcards
Learning Objectives
*Discuss the characteristics of evidence-based practice, diagnostic reasoning, the nursing process, and critical thinking
*List the steps to cultural competency
*List elements of a complete health history
*Interview a client to gather data for a complete health history
*Analyze the client data, and record the history accurately
*Learn the assessment techniques of inspection, palpation, percussion, and auscultation
*Identify equipment needed for a complete physical examination
*Learn the method of gathering data for a general survey
What is Nursing (according to the ANA)
“the protection, promotion, and optimization of health and abilities, prevention all illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in care of individuals, families, communities, and populations”
What is Assessment
The Collection of data about an individual’s health state
Includes
- subjective data
- objective data
- patient’s record
Assessments are the starting point to making diagnoses
What are the Phases of the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
What is Assessment
The first phase of the Nursing Process where subjective and objective data is collected
What is Diagnosis
The second phase of the Nursing Process that includes the analysis of the subjective/objective data to make professional nursing judgments (diagnosis, collaboration, or referral)
What is Planning
The third phase of the nursing process where outcome criteria are defined and a plan is developed
What is Implementation
The fourth phase of the nursing process where the plan is carried out
What is Evaluation
The fifth and final step of the Nursing process where the outcome criteria are assessed and the plan is revised as necessary
What is clinical judgment
The observed outcome of critical thinking and decision making that is an iterative process that uses nursing knowledge to observe and assess presenting situation, ID client concern, and generate the best possible evidence-based solutions to deliver safe client care
Nursing model diagram
What is Diagnostic Reasoning
the analysis of health data to draw conclusions and identify diagnosis
Comparison of Health Promotion, Risk, and Actual Nursing Diagnoses (table)
Types of Assessments
Complete: includes complete health history and full physical exam
Focused (problem centered): For limited or short term problems
Follow Up: evaluate problems at regular intervals
Emergency: rapid collection of data w/ concurrent lifesaving measures
Assessment Process
Start with building rapport and trust
Use effective communication techniques: reflection (repeating what you’ve heard to encourage more detail), empathy, facilitation (encouraging patient to say more)
Spend more time listening vs talking
N.U.R.S.E. Empathy Skills
Name emotion: ( Ex: “I’m hearing that you are frustrated”
“I’m seeing that this is really upsetting you”
“If I went through that, I may feel sad. How are feeling?”)
Understand & legitimate: “Anyone in your shoes might feel the same way”
“I’m sorry you have been waiting so long” (the blameless apology)
Respect: (Ex: “You are showing tremendous courage in sharing this”
“I give you a lot of credit in getting through this”)
Support: (“I will be here with you each step of the way”
“We will work together on this”)
Explore: (“How has the impacted your life”
“What ideas might you have about what is causing this?”
“What are your hopes for this visit?”)
Open Ended v. Closed Questions
open ended: asking for a narrative response
- use more at the beginning of an interview
closed: asking specific info, yes/no questions, fills in details or moves the interview alone
Skills to Assist the Narrative
- silent attentiveness (give the pt time to think and organize what they want to say without interruption)
- reflection (echo the pt’s words, repeat & reframe what they say, focusing attention on specific phrases)
- empathy (recognize pt’s feelings and name them)
- clarification (use when pt’s words are ambiguous/confusing, asking pt to confirm or deny something)
- confrontation (if there’s discrepancy or inconsistency in the person’s narrative, give honest non-judgmental feedback)
- explanation (informative statements, factual and objective info, giving reasons for requirements or actions)
- interpretation (based on your conclusions, linking events/making associations, implies cause)
interacting with patients in emotional states (table)
Health Equity
the attainment of the highest level of health for all people
considering social determinants of health: (conditions of life that affect one’s health. age, sex, location, food insecurities, housing, habits, etc)
Cultural Competence
cultural sensitivity: possessing basic knowledge of and constructive attitudes toward diverse cultural populations
cultural competence: understanding and attending to total context of patient’s situation including beliefs about health and illness, cultural similarities and differences
Signs v. Symptoms
Sign: OBJECTIVE information
- physical examination or lab reports
- measured/observed by a healthcare provider (ie: BP, wound drainage, heart sounds, K+ level)
Symptom: subjective informations
- can only be validated by patient
- what the patient states/feels (ie: pain, anxiety, fatigue, dizziness)
Health History
provides a database of SUBjective information consisting of a patient’s past and present health
biographical data: name, address, phone, age, DOB, race, ethnicity, occupation, marital status, gender
chief complaint
hx of present illness (use COLDSPA/ OLD CARTS for symptom analysis)
past medical hx
- childhood, accidents, serious/chronic illness, hospitalizations, OB hx, immunizations, allergies, current meds
family hx
- age health COD of relatives , genetic predisposition
ROS
Functional Assessment
-ADLs
who is giving the history? is the source reliable (consistent)
Chief Complaint (CC)
part of one’s health history
a brief statement in the person’s own words that describes the reason for the visit
COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors
OLD CARTS
Onset
Location
Duration
Characteristics
Associated Symptoms
Relieving or Aggravating factors
Temporal factors
Severity (intensity)
Review of Systems (ROS)
Subjective data. This is not the physical exam
-Evaluate the past and present health state of each body system
-Evaluate health promotion practices
-Order of systems is roughly head-to-toe
Functional Assessment for Health History
gathering information on self-care ability
Activities of Daily Living (ADLs)
Self-esteem/self-concept
Sleep/rest
Nutrition/elimination
Interpersonal relationships
Spiritual resources
Coping/stress management
Personal habits
Tobacco, alcohol, caffeine, street drugs
Physical Exam
purpose: to gather OBJECTIVE data about the patient
common equipment: Thermometer
Stethoscope
Sphygmomanometer
Scale
Visual acuity charts
Penlight
Measuring Tape
advanced equipment: Ophthalmoscope
Otoscope on model of ear
Tuning fork
Reflex hammer
Assessment Techniques (IPPA)
Inspection (vision)
Palpation (touch)
Percussion (tapping)
Auscultation (hearing)
Inspection
“careful scrutiny”
- inspect as a whole and then each body system
- Compare right and left sides of body for symmetry
-Focus on color, shape, size and movement
-Requires good lighting and adequate exposure
-Categories
*Indirect-assisted by equipment
*Direct-sight, hearing, smell
Palpation
(touch)
calm gentle approach, warm hands
assess:
-texture
-temp
-moisture
-swelling (edema), spasticity, crepitation, vibration, pulsation
-organ location and size
-presence of -lumps/masses
-presence of pain/tenderness
-Fingertips-tactile discrimination
*Skin texture, swelling, pulsation, determining presence of lumps
-Fingers and thumb
*detect position, shape, and consistency of an organ or mass
-Dorsa (backs) of hands
*used for determining temperature
-Base of fingers (metacarpophalangeal
joints) or ulnar surface of the hand-detects
*vibration
Light palpation: (one hand, dominant 1-2cm deep )
Pulse
Skin temp
Texture
Consistency
Warmth
Mobility
Tenderness
Deep palpation:
organ shape and size, rebound tenderness, abnormalities
Percussion
“to strike”- tapping
- relaxed, limp wrist to assess the location, size, and density of underlying structures and to detect tenderness (deep tension uses percussion hammer)
direct (immediate): hand or fingertip
directly on surface
indirect (mediate): used more often
blunt: reflex hammer
percussion note characteristics
*Resonance (lungs):
Clear, hollow, low-pitched sounds
*Hyperresonance (lungs):
Low, booming, longer sound than resonance
*Tympany (abdomen):
Loud, high pitched, musical or “drum like”
*Dullness (dense organs):
soft, high pitched, muffled
Flatness (muscle, bone, solid mass):
very soft, high pitched; dead stop of sound
Auscultation
“Listen to sounds produced through stethoscope”
Determines intensity, pitch, duration, recurring sounds
Warm, quiet room
Avoid artifact
Warm stethoscope end-piece
rub in palm
Never listen through a gown/over clothing!
Parts of the stethoscope
Diaphragm
- used for high pitched sounds (breath, bowel, normal heart sounds)
Bell (small side)
- used for low pitched sounds (extra heart sounds and murmurs)
Order of Physical Assessment (normal v. abnormal)
Usual: IPPA
Abdominal and Infant: IAPP
(inspection, auscultation, percussion, palpation)
Notes on charting
Assessment is on of the first things you should do after receiving report
Immediately following your assessment, start documenting your findings.
Start at the beginning of the page with date and time (military)
Use abbreviations approved by the facility, there is a list of generally medical abbreviations in syllabus.
Do not write in complete sentences, avoid slang terms unless they are direct quotes
End the paragraph with your first initial, last name and UANS.
Paper charting, when EHR down, chart in black pen ONLY!
Falsification of documentation can result in dismissal
When in doubt, ask faculty
If error is made:
One line through error and initial
Some facilities require “mistaken entry” or “error”
