Health Assessment and Patient Care

History Taking and Physical Examination

• Recognize cues to determine if patient condition is normal or abnormal for the patient
• Identify warning signs and changes in patient condition
• Subjective Data: Symptoms reported by the patient
• Objective Data: Signs observed or measured, including assessment findings and medical records
• Health History: Includes current medical condition, family history, lifestyle factors, and medications
• Purpose of health history: To understand baseline health, risk factors, and medical history
• Functional Assessment: Evaluates patient's daily activities and ability to live independently assessing physical, emotional, and social functioning
• Cultural Assessment: Understands cultural beliefs, practices, and SDOH (social determinants of health), including financial, language, transportation barriers, and important cultural practices, e.g., dietary restrictions, preferences that influence health and care
• Therapeutic Communication: Establishes trust, rapport, and empathy using active listening and open-ended questions
• Avoid nontherapeutic communication techniques (e.g., giving advice, judgmental comments)

Vital Signs

• Temperature: Axillary (preferred for babies), temporal or tympanic (common for children and adults), rectal(for core temp measurement)
• Pulse: Newborn (110-160 bpm), Adult (60-100 bpm)
• Respiratory Rate: Count for 1 full minute. Observe rate, depth, patterns, and effort
• Increased Pulse/Respiration: Fever, pain, anxiety, activity, stimulants
• Decreased Pulse/Respiration: Sleep, medication, certain conditions (e.g., heart block)
• Blood Pressure: Increased: Pain, stimulant use, fluid overload; Decreased: Fluid volume deficit, dehydration, shock
• O2 Saturation: Measure for oxygen sufficiency
• Pain (6th Vital Sign): Use OPQRST Assessment, where O=onset, P=provocation/palliation, Q=quality, R=radiation, S=severity, and T=timing

Physical Assessment

• Purpose: To gather data on the patient's health status, identify abnormalities, and guide care planning
• Techniques:
  • Inspection: Observe the patient for visible signs
  • Palpation: Feel for abnormal masses, tenderness, or changes in temperature
  • Percussion: Tap areas to assess underlying structures (e.g., dullness, tympany)
  • Auscultation: Listen to heart, lung, and bowel sounds
• Abdomen: Inspect, auscultate, percuss, palpate (important order to avoid altering bowel sounds)
• General Impression: Appearance, posture, facial expression, hygiene, tone, position, distress level, mental status
• HEENOT (Head, Eyes, Ears, Nose, Throat):
  • PEARRLA: Pupils Equal and Reactive to Light and Accommodation.
  • EOMI: Extraocular Movements Intact.
  • Tongue and mucosa: Indicators of hydration
  • Palate: Check for pallor (anemia), jaundice
• Chest/Thorax: Cardiac (S1, S2, S3, S4, murmurs, PMI), chest wall (crepitus, tactile fremitus, chest expansion)
• Lungs: Auscultate for abnormal sounds (rhonchi, wheezes, crackles, pleural friction rub)
• Abdomen: Inspect and palpate for abnormalities in 4 quadrants
• Percussion Sounds: Flat (bone), dull (solid organ), tympany (hollow organ).

Focused Assessments

• Purpose: Focus on specific complaints, injuries, or problems. Prioritize care based on urgency
• Common Assessments: Check pulses and perfusion, assess pain, inspect injuries before palpation to avoid worsening damage

Shock vs. Increased ICP

• Shock: Tachycardia, tachypnea, hypotension, restlessness, anxiety, pale, cool, clammy skin, decreased urine output
• Increased ICP: Bradycardia, bradypnea, hypertension with widening pulse pressure, unequal or dilated pupils, anxiety, restlessness, headache (Cushing's Triad: Hypertension, bradycardia, irregular respirations)

Fluid Volume Balance

• Fluid Volume Deficit (FVD): Tenting/poor turgor, dry cracked tongue, tachycardia, tachypnea, hypotension, sunken fontanelles, sunken orbits in pediatric cases
• Fluid Volume Overload (FVO): Edema, crackles, JVD, weight gain, tachycardia, tachypnea, hypertension

Other Topics

• Psychiatric Mental Health Nursing: Mental illness occurs when a person cannot adapt to stress, causing functional impairment; includes ego defense mechanisms: Denial, displacement, rationalization, repression; therapeutic communication - SOLER Technique (sit, open posture, lean forward, eye contact, relax); Suicide Risk assessment (asking about thoughts, intentions, plans, and means); bipolar disorder (Lithium management, safety, monitoring for hyperactivity and poor judgment); schizophrenia (major disturbances in thought, hallucinations); Anxiety and phobias; substance use; personality disorders (Cluster A, B, and C)
• Maternal Newborn Nursing: Antepartal care (inquire about safety, habits, drug use, immunizations, offer genetic testing, TORCH infections, and teratogens), monitor fetal growth). Intrapartal Care (Labor stages: 1st stage; Cervix effaces and dilates; 2nd stage; Pushing and delivery; 3rd stage; Placenta delivery); preterm labor(steroids, antibiotics); postpartum care(Hemorrhage risk, infection); newborn care(APGAR scores, preterm baby concerns; NAS babies, withdrawal symptoms monitoring).

This quiz focuses on the essential skills of history taking and physical examination in a healthcare setting. It covers recognizing normal vs. abnormal patient conditions, understanding subjective and objective data, and the importance of health and cultural assessments. Test your knowledge on effective communication and patient evaluation techniques.