Health Assessment Overview

Health Assessment - BLUEPRINT SLIDES

• Types of Assessment:

  • Initial assessment: Performed within a set time after admission to a healthcare facility.
  • Problem-focused assessment: Ongoing process integrated into nursing care.
  • Emergency assessment: During any physiological or psychological crisis of a patient.
  • Time-lapsed reassessment: Several months after the initial assessment.

• Collecting Data:

  • Subjective (Symptom): Verbal statements from the patient (e.g., nausea, pain, fatigue, itching).
  • Objective (Signs): Observable data, measurable by an observer (e.g., what the patient says, what can be seen).

PURPOSE OF HEALTH ASSESSMENT

• Purpose: To collect baseline physical and mental health data.
• Purpose: To supplement, confirm, or question data already obtained in the nursing history.
• Purpose: To obtain data that helps establish nursing diagnoses and develop a care plan.
• Purpose: To evaluate the appropriateness of nursing actions and the physiological outcome of care.
• Purpose: To identify deviations from normal health and potential health problems, providing a foundation for a patient-centered care plan.

Open Questions

• Structure: Always start with open-ended questions like "what," "why," "when," "how," or "which."
• Purpose: Encourage conversation, find details, and give the responder control during the conversation.
• Examples: "What is your name?", "Do you smoke?", "What do you prefer, tea or coffee?"

Closed Questions

• Structure: Closed questions have short, simple answers like "yes," "no," or "don't know."
• Purpose: To gain clarification, but misplaced questions can stop or hinder conversation.
• Examples: "What is your name?", "Do you smoke?"

Leading Questions

• Structure: Questions based on assumptions that guide the patient to a specific answer.
• Purpose: To get a confirmed answer; should not be used frequently.
• Disadvantage: Can lead to unusable data.

Components of Health History

• Menstrual and Obstetrics History: Length of cycle, duration of cycle, pain, number of children, type of childbirth.
• Personal History: Hygiene habits, smoking/substance abuse, dietary preferences, and food intake, allergies.
• Functional history Rest and sleep patterns, bowel and bladder habits.

Development of Empathy

• Importance of Nurses being receptive to patients' feelings and perceptions.
• Ability of Nurses to place themselves in the patient's position to understand patient needs that patient may not freely express.
• For example, understanding a patient refusing food following a painful experience.
• Distinction from sympathy, empathy is about understanding the patient's perspective.

Some examples of Subjective & Objective data

• Examples of subjective data: Tachycardia, Dizziness, Fatigue, Nausea, Shortness of breath, Vomiting, Cough, Itching, Pain.
• Examples of objective data: Unconsciousness, Hyperthermia, Wheezing, Tenderness

Auscultation

• Diaphragm: Used for high-pitched sounds (breath sounds, normal heart sounds, bowel sounds).
• Bell: Used for low-pitched sounds (abnormal heart sounds, murmurs).

Legal and Ethical Aspects of Health Assessment

• Confidentiality and Patient Privacy (HIPAA).
• Informed Consent: Explanation of procedures and obtaining consent.
• Professional Boundaries and Ethical Conduct: Respecting patient rights and cultural differences.

Assessment Sequencing

• Head-to-toe examination: Systematic approach, starting from the head and moving to toes.
• System-wise examination: Assessments of one body system at a time.
• Emergency assessment: Rapid assessment of life-threatening conditions (ABCs).

Pulse

• Tachycardia: Pulse rate exceeding 100 beats/minute.
• Bradycardia: Pulse rate below 60 beats/minute.

Pulse Assessment Techniques

• Radial artery pulse (inner wrist).
• Apical pulse (at the apex of the heart).
• Pulse deficit: Difference between apical and radial pulse rates.

Abnormal Conditions

• Jaundice: Yellowing of skin and eyes due to excess bilirubin.
• Paronychia: Inflammation of the tissue around the nail.
• Rash: Noticeable change in skin texture or color.
• Lesion: Abnormal area of tissue.
• Vesicle: Small, fluid-filled blister.

Visual Acuity

• Snellen Chart: Progressively smaller letters to determine distance vision.
• Standard: 20/20 vision.
• Procedure: Patient positioned at a specified distance (usually 20 feet) from the chart.
• Testing order: Right eye tested first.

Pupillary Reaction to light

• Pupil response is observed concerning penlight.
• Normal pupil: Black, circular, and equal in size (2-6mm).

Cranial Nerve Testing

• Examiner observes eye movements in all directions.
• Place an object 12-14 inches from the patient's nose.
• Ask the patient to follow your finger with their eyes, making an "H" shape.

Techniques & Tools for Ear Assessment

• Weber Test: Assesses lateralization of sound.
• Rinne Test: Compares air and bone conduction.
• Whisper Voice Test: Assesses hearing acuity.

Normal Breath Sounds

• Bronchial: High pitch, loud, inspiration shorter than expiration (over trachea).
  • Bronchovesicular: Medium pitch, moderate volume, inspiration equal or slightly longer than expiration (over 1st and 2nd ICS and lateral to sternum).
  • Vesicular: Low pitch, soft, inspiration longer than expiration (over the peripheral lung fields).

Adventitious Breath Sounds/Abnormal Sounds

• Crackles (rales): Interrupted sounds (such as cellophane or Velcro ripping), often due to fluid in the airways.
• Wheezes: Continuous musical sounds, often due to airway narrowing.
• Rhonchi: Continuous snoring sounds typically related to secretions in larger airways.
• Pleural friction rub: Discontinuous creaking sound from inflamed pleura, the linings of the lungs.

Laboratory Studies

• Plasma Glucose: Normal range 60-110 mg/dL.
• Hemoglobin: Normal levels depend on sex.
• Hematocrit: Measures packed red blood cells. Low value suggests insufficient hemoglobin formation
• Cholesterol: Measures blood fat levels. Normal range (120-200 mg/dL, moderate risk 200-239 mg/dL, High risk 240 mg/dL or above)..
• Triglycerides: Measure blood fat levels, used to assess risk of CAD.
• Serum proteins: (Albumin). Used to assess nutritional status.
• Cardiac Markers: Indicators of heart damage.

Locating And Palpating Apical Pulse

• Apical pulse is typically located in the 5th intercostal space.
• Approx. 7-9cm left of the mid-line..

Murphy's Sign

• Positive Murphy's sign indicates possible cholecystitis (inflammation of the gallbladder).
• Performed by palpating the right upper quadrant (RUQ) subcostal area, asking the patient to take a deep breath when palpating.
• Pain during palpation is the positive sign.

Findings on Auscultation

• Absence of bowel sounds over a 4-minute period indicates paralytic ileus.
• Borborygmi: Loud gurgling sounds during diarrheal episodes.
• Specific findings like a bruit over the aorta should be reported.

Patient History Review

• Chief complaint: Obtain details about the patient's symptoms.
• GI system complaints: Nausea, vomiting, abdominal pain, alterations to bowel habits.
• Medical history: Medical conditions and interventions.
• Family and social history: Can reveal predispositions or risks.
• Dietary habits: Daily diet; food intolerances; fluid intake.
• Bowel habits: Frequency, consistency, and colour of stools.
• Use of laxatives/medications.

Evaluating Nutritional Disorders

• Signs and Symptoms: Evaluate patient symptoms relating to general health, skin, hair, nails, eyes, throat/mouth, cardiovascular, GI system, musculoskeletal, and neurological systems.
• Implications: Assess implications of potential nutrient deficiencies based on signs and symptoms

Diagnostic Investigations

• Urinalysis: Evaluate for kidney diseases or infections.
• Culture and Sensitivity: Identify infectious agents and appropriate antibiotics for treatment.
• Imaging Studies: Noninvasive tests used to visualize kidneys or for structural or tumor assessment.
• Post-Void Residual Measurement: Assessment of bladder emptying efficiency.
• Cystoscopy: Direct visualization of the bladder and urethra to diagnose or treat conditions.

Percussion

• Assessing for dullness in the suprapubic region to detect distended bladder.
• Assessment for tenderness or presence of infection in a particular area of the kidney using Costovertebral Angle (CVA) percussion, assessing for costovertebral tenderness

How to Assess a Patient's Pain History (PQRST)

• P (Provokes and Palliates): What triggers the pain? What makes it better or worse?
• Q (Quality): Describe the pain (sharp, dull, stabbing).
• R (Region and Radiation): Where is the pain located? Does it spread?
• S (Severity): Rate the pain on a scale (1-10).
• T (Time): When did the pain start? How long does it last?

Types of ROM Evaluation

• Passive ROM: Movement produced by an external force.
• Active-Assistive ROM: Movement assisted by another source.
• Active ROM: Movement completed by patient.
• Goniometer: Measures joint angles.
• Inclinometer: Measures spine angles.

Diagnostic Tests (Arthrocentesis, Arthroscopy, DEXA, Imaging)

• Arthrocentesis: Aspiration of joint fluid (synovial fluid) for diagnostic or therapeutic purposes.
• Arthroscopy: Internal visual inspection of a joint using a fiber-optic endoscope. (Requires small incision).
• DEXA Scan: Bone mineral density test, used in the diagnosis of osteoporosis; noninvasive procedure.
• Imaging studies: Ultrasound, CT, and MRI scans help diagnose structural issues or conditions.

Muscle Strength Scale

• Score of muscle contraction.
• 0 - No contraction.
• 1 - Trace contraction (twitch).
• 2 - Movement only against gravity removed.
• 3 - Movement against gravity, but not external resistance.
• 4 - Movement against gravity and some resistance.
• 5 - Movement against gravity and examiner's resistance.

Glasgow Coma Scale (GCS)

• Neurological assessment for the severity of brain injury.
• Uses eye opening, verbal response, and motor response.
• The GCS score ranges from 3 (deep coma) to 15 (fully awake).

Pupillary Assessment

• Direct pupillary reflex: Light shone into one eye, observes the pupil's reaction in that same eye.
• Consensual pupillary reflex: Light shone into one eye, observes the pupil's reaction in the opposite eye.

Romberg Test

• Patient instructed to stand with feet close together and eyes closed.
• Positive sign: Inability to maintain balance; patient loses balance when eyes are closed.

Hyper-Parathyroid Disorders

• Tetany: Muscle spasms due to low calcium levels.
• Chvostek sign: Facial muscle twitching when tapping over the facial nerve.

Hypoglycemia

• Blood glucose below 70 mg/dL (3.9 mmol/L).
• Symptoms: Cold, clammy skin, rapid heartbeat, headache, nervousness, hunger, faintness.

Hypersecretion of Adrenal Glands

• Cushing's Syndrome: Excessive cortisol secretion.
• Symptoms: "Moon face," "buffalo hump," edema, thin extremities, high risk of fractures.

Diabetes Mellitus

• Symptoms: Polyuria, polydipsia, polyphagia, weight loss, blurring of vision, acetone breath odor, Kussmaul's respiration.

This quiz covers the various types of health assessments and data collection methods used in nursing. It highlights initial, problem-focused, emergency, and time-lapsed assessments as well as the importance of subjective and objective data. Test your understanding of these essential concepts in health assessment.