Quiz 1 - week 1 + 2 content Flashcards
Define Health Assessment
it’s collective and holistic -> making a judgement and having a conversation with the patient about their history
Forms of data collection
Subjective: patient’s perception about their health probelm
Objective: physical examination, results of diagnostic test and measurements
What does SOAPIE stand for?
S - Subjective
O - Objective
A - Assessment
P - Plan
I - Intervention
E - Evaluate
What is involved in the health assessment interview?
- a meeting b/w you and the patient
- record a complete person-centred health history
- gather subjective data
What is health history?
provides info abt the perosn’s health strengths + problems
- combined with objective data
make a clinical judgement abt their state of health
Level of measurements
nominal scale: categories
ordinal scale: ordered categories
interval scale: differences in measurements; no absolute 0
ratio level: differences in measurements; has abosulte 0
Nursing and Technology
technique: not only one thing -> describes the approach to thinking
artefacts + resources: greater ability to communicate with more immediacy
knowledge + skills: need it to meet the needs of patients
What are the considerations of instruments (BP module)?
Validation: checking the presure gauge of a monitor against a reference manometer
Calibration: comparing the pressure guage agaisnt a known accurate reference manometer + adjsting the pressure guage to have the same readings
What human variations need to be considered?
- coexisting disease/injury
- drug therapy
- pre-existing state of health
- age
- rapidity of a health state
What is interpersonal communication?
- agjust and accommodate the use of effective communication skills in response to specfic clinical contexts
- spoken, written and non-verbal
- non-judgemental
- active listening
What is the purpose of performing health assessment?
- the collection of data
- performed frequently to detect subtle changes -> inidicate deterioriation
What is primary and secondary assessment?
Primary
- A-G approach
- 1st elemetn in every patient encounter
- identify threats
Secondary
- head to toe
- more focused
- body systems
What are the assessment approaches for different situations?
Primary Survey
- done in emergency + non-emergency situations
- A-G used
Comprehensive Survey
- preformed on patient’s initial admission to the hospital
- includes complete health hisotry + relevant physical examination
- describes current + past health state
Focused (episodic) assessment
- short-term problem
- shorter health assessment
- concerns mainly one problem
Ongoing Assessment
- evaluate at regular and appropiate intervals
- acute care setting: monitoring following a surgical procedure, one frequent neurological observation
- primary care setting: ongoing monitoring
What are the frameworks for assessment?
- head-toe assessment
- body systems approach
- functional health approach -> focused on the whole person, explores the impact of health issues, identify potential health risks
Describe the physical examination techniques
IAPPA
I - Inspection
- detailed and purposive obervation
- watch all movements + non-verbal cues
- pay attention to detail
P - Palpation
- compare both sides
- make delicate and sensitive measurements e.g. roughness/temp.
P- Percussion
- tapping the body with fingertips
- sigalling the density of a structure
- direct percussion - striking hand directly contacting the body to produce a sound
- indirect percussion - striking hand contacts the stationary hand fixed on the person’s skin
A- Auscultation
- listening to sounds
- loudness
- qaulity
- duration
Airway (LLF)
supports the free exchange of air b/w the external environment and lungs
LOOK
- signs of obstruction
- evidence of mouth/neck swealling/haematoma
- secuirity of aritifical airway
LISTEN
- nosiy breathing e.g. gurgling, snoring, stridor
FEEL
- presence of air movement
- security of artificial airway
Breathing (LLF)
mechanism used by the body to exchange gases b/w the atmosphere, blood and cells -> observed for 1 min
LOOK
- chest wall movement -> normal + symmetrical
- using their shoulders + neck
- measure their respiratory rate
LISTEN
- can they complete full sentences
- noisy breathing e.e. wheezing or stridor
FEEL
- is their trachea central
CIRCULATION (LLF)
assessment of the circulatory status
LOOK
- skin colour -> pallor or peripheral cyanosis
- capillary refill time
- central venous pressure + jugular venous pressure
LISTEN
- complaints of dizziness/headaches
- blood pressure + heart sounds
FEEL
- hands/ feet -> warm or cold?
- peripheral pulses for pressure, rate, qaulity, regularity + equality
DISABILITY (LLF)
assessment of conscious state via the AVPUC tool
A - alert
V - responds to verbal stimulus
P - responds to pain stimulus
U - unresponsive
C - confusion
LOOK
- level of consicousness
- facial symmetry, abnormal movements, patients mobility
- pupil size, eqaulity and reaction to light
LISTEN
- response to external stimuli + pain
- slurred speech
- oreination to place, time and person
FEEL
- response to external stimuli
- muscle power + strength
EXPOSURE (LLF)
measurement of body temp (normal: 36-37) -> head to toe scan
LOOK
- skin integrity -> elasticity
- signs of pressure injury
- bleeding
LISTEN
- air leaks in drains
- bowl sounds
FEEL
- abdomen
FLUIDS (LLF)
assessment of fluid status
LOOK
- fluid input and output
- losses from all drains + tubes
- amount + colour of patient’s urine
LISTEN
- complaints of thirst
FEEL
- skin turgor
GLUCOSE (LLF)
signs/sympt of hypo/hyperglycaemia
LOOK
- blood glucose levels
- signs of low glucose -> confusion + decreased conscious state
- medication chart for insulin + oral hypoglycamics
LISTEN
- compliants of thirst
- orientation to person, time and place
FEEL
- diaphoretic (sweaty, cold, clammy)
Vital Signs
body temp
pulse rate + rhythm
respiratiry rate
blood pressure
oxygen saturation
level of consciousness
pain score
Differences b/w primary and secondary
Primary
- A-G approach
- 1st element in every patient encounter
- identify threats
Secondary
- head to toe
- more focused
- body systems
Name the 7 body systems
- neurological
- cardiovascular
- respiratory
- gastrointestinal
- renal
- integummentary
- musculoskeletal
nutrition
Neurological System
- assess level of consciousness
- evaluate speech
- assess muscle strength
- pupil eqaulity + reaction to light
Cardiovascular System
- inspect + palpate for skin colour and temp
- palpate capillary refill
- palpate extremities for distal pulses + oedema
- palpate calves for tenderness
- auscultate heart sounds + apical pulse
- perform and interpret ECG for abnormal changes
Respiratory System
- access airway patency
- auscultate bowel sounds
- palpate abdomen
- assess bowl movements
Renal System
- measure 24hr fluid balance
- measure daily weight
- assess urine output
- palpate bladder
- perfom and interpret urinanalysis
Integummentary System
- inspect skin integrity
- inspect and palpate skin for signs of pressure injury
- observe any wounds, dressings or drains, invasive lines
- venous straining - dark purple or rusty discolouration
Musculoskeletal System
- observe ability to transfer and mobolise
- observe gait
- insepct major joints for range of motion
Nutrition
- inspect oral cavity
- assess ability to swallow
- estimate amount of meals eaten
- measure blood glucose levels
- measure body weight
- measure BMI
Assessment Considerations
- family-centred practice
- developmental considerations
- assessing ppl w/ special needs and challenging behaviours
- acutely ill patient
- communication barrier
- skin assessment for dark skin
- cultural considerations
What are the zones of personal space?
Intimate Zone (0-45min)
- performing physical assessment
- bathing, grooming, dressing, etc
- carrying an infant
Personal Zone (45cm to 1.2m)
- sitting at a bedside
- taking client’s history
- teaching/exchanging info
What are the zones of touch?
- social zone
- content zone (ask for permission)
- vulnerable zone (special care)
- intimate zone (great sensibility needed)
