Lecture 1: Vitals and Patient History Flashcards
2 Assessments for Data Collection
- History: Subjective Data - What the person says (open to interpretation, how they perceive the information)
- Physical Examination: Objective Data - What the health care provider observes (What people can see/hear, using senses to perceive data)
Types of Clinical Reasoning Models
- Diagnostic Reasoning (Clustering data, reasoning your way through)
- Nursing Process (Pull together our thoughts)
- Critical Thinking
4 Steps of Diagnostic Reasoning
- Attending to cues (ex: listening to the lungs, writing what you see, gathering data)
- Formulating hypotheses
- Gathering data
- Evaluating hypotheses + data
6 Parts of the Nursing Process
- Assessment (Focus subjective + objective data cluster data to move to nursing diagnoses
- Diagnosis (How they are adapting, what is happening)
- Outcome Identification (Exert themselves without wheezing, how do you overcome this?)
- Planning (Planning ways to help them achieve their goals)
- Implementation (Teach and show them)
- Evaluation (Did it work?)
Levels of Clinical Judgement (4)
- Novice
- Competent
- Proficient
- Expert
Examples of our Clinical Thinking Skills
- Identifying assumptions
- Identifying an organized and comprehensive approach
- Validation
- Distinguishing normal from abnormal
- Making inferences
- Clustering related cues
(We have to identify assumptions based on our experiences, is it a gut feeling, or fact based) - Distinguishing relevant from irrelevant
- Recognizing inconsistencies
- Identifying patterns
- Identifying missing information
- Promoting health
- Diagnosing actual and potential (risk) problems
- Setting priorities
- Identifying patient-centered expected outcomes
- Determining specific interventions
- Evaluating and revising thinking
- Determining a comprehensive plan
Evidence Informed Assessment
Evidence:
- What “counts” as evidence
- Assessment skills are foundational to EIP
- Importance of questioning tradition in assessment when no compelling research evidence exists to support it
Evidence Model:
- Evidence from research and evidence-informed theories
- Physical examination and assessment of patient
- Clinical expertise
- Patient preferences and values
Guidelines for Clinical Practice
- Work to build trust
- Engage through listening
- Convey respect for differences
- Pay attention to social and economic contexts of patients and families lives
- Be knowledgeable about the social and economic policies in Canada that influence provision of healthcare provincially and nationally
The Interview Process
- Subjective Data: What the patient says about himself or herself
- Results of a successful interview: Gather complete accurate data, establish trust, teach patient about their health, build rapport for a continuing therapeutic relationship, look for opportunities to engage in teaching
The Contract
- The interview as a contract between patient and examiner
Factors to consider: - Time/place
- Intro and explanation
- Purpose
- Length
- Expectations
- Presence of others
- Confidentiality
- Costs
The Process of Communication
- Sending
- Receiving
- Attending to power differentials
- Communication Skills
- Unconditional positive regard
- Empathy and active listening
Describe a Proper Physical Setting
- Ensure privacy
- Refuse interruptions
- Attention to the physical environment
- Dress
- Taking notes
- Electronic clinical documentation
- Audio recording
Challenges of Note Taking
- Impedes eye contact
- Shifts attention away from patient
- Interrupts patients narrative flow
- Impedes observation of nonverbal behaviour
- Can be threatening during discussion of sensitive issues
Communication Techniques
- Introducing the interview
- The working phase: open ended and closed ended questions
Responses: assisting the narrative - Facilitation
- Silence
- Empathy
- Clarification
- Confrontation
- Interpretation
- Explanation
- Summary
Nonverbal skills - Eye contact, physical appearance,etc
- Closing the interview
10 traps for interviewing
- Providing false assurance or false reassurance
- Giving unwanted advice
- Using authority
- Using avoidance language
- Engaging in distancing
- Using professional jargon
- Using leading or biased questions
- Talking too much
- Interrupting
- Using “why” questions
Interviewing in Challenging Situations
- Hearing-impaired patients
- Acutely ill patients
- Patients under the influence of alcohol or drugs
- Personal questions asked of the clinician
- Dealing with sexual advances
- Patients who are crying
- Angry patients
- Patients who threaten violence
- Anxious patients
Cultural and Social Considerations
- Communicating across cultures
- Perspectives on professional interactions
- Etiquette
- Space and distance
- Considerations related to gender
- Considerations related to sexual orientation
Overcoming Communication Barriers
- Differing perceptions of the roles of patient, family, and healthcare professional
- Need for reflective nursing practice and awareness of expectations of conformity and obedience
- Influence of past experiences and inequity in shaping responses in health care settings
- Use of interpreters who are trained is ideal
- Children are inappropriate interpreters
- Awareness of potential for violation of confidentiality when a relative, friend, or visitor is used for interpretation
Assessment: Subjective and Objective
Subjective: the health history
- Not measurable
- Patient experience
- “Symptoms”
Objective: the physical examination
- Measurable
- “Signs”
Med vs. nursing
- Same process, different goals
- Meds: diagnose and treat disease
- Nurses: diagnose and treat human responses to actual or potential health problems (not just physical assessment)
The Health History
- Biographical data
- Reason for seeking care
- Current health or history of chronic illness
- Past health
- Family history
- Allergies
- Meds
- Review of systems
Biological Data
- Name
- Address and phone #
- Age and DOB
- Birthplace
- Gender
- Marital status
- Ethnocultural background
- Occupation (usual and present)
- Source of information
Reason for seeking care
- Brief statement in patient’s words using quotation marks, includes health maintenance, health promotion, or wellness needs
- Symptom: Subjective sensation
- Sign: Objective abnormality, detectable on physical examination or in lab reports
Current Health or History of Current Illness (HPI) (OPQRSTU!!)
Characteristics of symptom:
- O: Onset (ex: 3 days ago)
- P: Provocative or palliative (ex: tylenol helps)
- Q: Quality or quantity (ex: aching pain, sharp? describe pain.)
- R: Region or radiation (ex: point where it hurts)
- S: Severity (scale 1-10)
- T: Timing (ex: worse @ night)
- U: Understanding patient’s perception (ex: any idea what it might be? “oh 3 of my roommates have strep”)
Past Health (PMHx)
- Childhood illnesses
- Accidents or injuries
- Serious or chronic illnesses
- Hospitalizations
- Operations
- Obstetrical history
- Immunizations
- Most recent examination date
- Current medications
Family History (Fam/Soc Hx)
- Family history of various conditions, such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, obesity, mental health issues, and others
- Health of close family members (spouse, children)
- Age and health or cause of death of blood relatives
Physical Examination
- Inspection
- Palpation (touching, feeling any abnormalities)
- Percussion (the hitting on fingers to feel for anything weird)
- Auscultation (listening)
What’s included in the General Survey
Physical Appearance:
- Age
- Sex
- LOC (level of consciousness)
- Skin colour
- Facial features
Body Structure:
- Stature
- Nutrition
- Symmetry
- Posture
- Position
- Body build, contour
Mobility:
- Gait
- ROM (range of motion)
Behaviour
- Facial expression
- Mood and affect
- Speech
- Dress
- Personal Hygiene
Measurement of Patient
- Weight
- Height
- Body mass index (BMI) calculation
- Waist to hip ratio
Vital Signs: Temperature
- Hypothalamus as thermostat mechanism
Influences on temperature: - Diurnal cycle
- Menstrual cycle
- Exercise
- Age
- Exposure to cold
- Surgery
- Infection
- Neurological disease
36.5-37.5
Routes of Temperature Measurement
- Oral (preferred, common, most accurate)
- Axillary (low sensitivity, reads 0.5 degree lower than oral)
- Rectal (only when other routes not practical, reads 0.5 degree higher than oral)
- Tympanic Membrane (reads quickly)
- Temporal Artery
Vital Signs - What are you looking for in your pulse
- Stroke volume
- Techniques of measurement
- Rate
- Rhythm
- Force
- Elasticity
Taking Pulse
- Using pads of your first 3 fingers palpate the radial pulse at the flexor aspect of the wrist along radius bone
- Moderate pressure
- If the rhythm is regular, count the number of beats in 30 seconds and multiply x2
- If the rhythm is irregular, count for 60 seconds
- Assess the pulse including rate, rhythm, force, and equality
- Clinical evidence suggests 95% of health persons have heart rate 50-95
- Regular vs. irregular vs. sinus arrhythmia
- Symmetrical pulses should be assessed simultaneously
- Elasticity
- Grade using 3-point scale (3+ bounding, 2+ normal, 1+ weak and thready, 0 absent)
Influences on Pulse
- Substances
- Age
- Caffeine
- Exercise
Respirations
- Normal breathing is relaxed, regular, automatic, and silent
- Do not mention to patient that you are monitoring their breathing
- Maintain position of counting radial pulse
- Count for full 30 seconds; 60 seconds if you detect an abnormality
- Count full cycle (inspiration and expiration)
- Pulse: resp rate ratio is approx 4:1
1. Rate 2. Rhythm (irregular/regular) 3. Depth (shallow/deep)
Influences on Resp Rate
- Exercise
- Illnesses
- Age
- Anxiety
- Substances
- Caffeine
Blood Pressure
Blood pressure is the force pushing against vessel wall
- Systolic pressure is the pressure against the artery during contraction
- Diastolic pressure is the elastic recoil during relaxation
Measuring Blood Pressure
- Blood pressure is measured with a stethoscope and sphygmomanometer
- Must be recalibrated once per yr
- Cuff consists of a rubber bladder inside cloth cover
- Cuffs are available in six sizes, newborn to extra large
- Position of person
- Palpate brachial artery
- Proper inflation and deflation technique
- Korotkoff sounds
*Look at lab manual checklist
BP Cuff Sizing
- Width of bladder = 40-50% of patients arm
- Length of the bladder should be 80-100% of patients arm
Using a cuff too loose -> falsely high BP
Using a cuff too narrow -> falsely low BP
Influences on BP
- Age
- Gender
- Ethnocultural background
- Diurnal rhythm (time of day)
- Weight
- Exercise
- Emotions
- Stress
Psychological Factors Influencing BP
- Cardiac output
- Peripheral vascular resistance
- Volume of circulating blood
- Viscosity
- Elasticity of vessel walls
Common Errors in BP measurement
- Patient positioning
- Cuff size
- Cuff inflation errors
- Observer errors
- Orthostatic (or postural) hypotension
Pulse Oximeter
- Noninvasive method to assess arterial oxygen saturation (SpO2)
- Healthy patient with no lung disease and no anemia normally has an SpO2 of 97 to 99%, 95% is acceptable in a patient with normal hemoglobin
- Finger, toe, and earlobe avaliable
- If you are using finger, make sure hands are warm
- At lower O2 saturation, earlobe probe is more accurate
Pulse Oximeter
- Noninvasive method to assess arterial oxygen saturation (SpO2)
- Healthy patient with no lung disease and no anemia normally has an SpO2 of 97 to 99%, 95% is acceptable in a patient with normal hemoglobin
- Finger, toe, and earlobe available
- If you are using finger, make sure hands are warm
- At lower O2 saturation, earlobe probe is more accurate
Oxygen Saturation Measurement
- Pulse Oximetry
- Sensor compares ratio of light emitted to light absorbed by hemoglobin and converts into a percentage of SpO2
- Normal range: 97-98%
