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Nurse's Role in Health Assessment

• Assessment is important in every situation
• Managed care and internal case management increased the impact on the nurses assessment role.
• Acute, critical, ambulatory, and home health care are settings greatly impacted

Assessment Types

• Holistic nursing assessments collect subjective and objective data.
• These assessments determine a client's overall level of functioning.
• They exist to make a professional clinical judgement
• Physical medical assessments focus on a client's physiologic development status

Nursing Process Phases

• Assessment involves collecting subjective and objective data
• Diagnosis: is analyzing subjective and objective data to make a nursing judgement such as (nursing diagnosis, collaborative problem, or referral)
• planning involves determining outcome criteria and developing a plan
• Implementation is carrying out the plan
• Evaluation is assessing outcome criteria and revising the plan

Health Assessment Steps

• Preparing for the assessment includes reviewing a client's record, the client's status with other health care team members, and educating them on diagnosis and tests performed
• The collection of subjective data encompasses biographical information, history of present health concern, physical symptoms related to each body part or system, personal health history, and family history
• Health and lifestyle practices and review of systems are components of subjective data
• Collection of objective data includes: physical characteristics, body functions, appearance, behavior, measurements, and the results of laboratory testing

Second Health Assessment Steps

• Validation of assessment data
• Documentation of data
• Analysis includes identifying abnormal data and strengths, clustering the data, drawing inferences and identifying problems
• Form possible nursing diagnoses, check for defining characteristics of those diagnoses, confirm or rule out nursing diagnoses, and documenting conclusions

Types of Assessments

• Initial comprehensive assessments collect subjective data about the client's perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices
• Ongoing or partial assessments collect data after the comprehensive database is established
• Focused/problem-oriented assessments are thorough assessments of a particular client problem that doesnt cover areas unrelated to the problem.
• Emergency assessments are very rapid assessments performed in life-threatening situations
• Subjective data are sensations, symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information.
• It is elicited and verified only by the client.

Evolution of the Nurse's Role in Health Assessment: Past

• Nurses used to rely on natural senses and palpation because physical assessment was an integral part of nursing
• Health care moved from acute care settings to community care, with growth of baccalaureate and graduate education
• Advanced practice of nurses increased

Evolution of the Nurse's Role in Health Assessment: Present

• Managed care and internal case management greatly impacts the assessment role of the nurse in:
  • Acute care settings
  • Critical care outreach
  • Ambulatory care
  • Home health
  • Public health
  • School and hospice

Evolution of the Nurse's Role in Health Assessment: Future

• Rising educational costs
• Increasing complexity of acute care
• Growing aging population with complex comorbidities
• Expanding health care needs of single parents
• Increasing impact of children and the homeless
• Intensifying mental health issues
• Expanding health services network
• Increasing reimbursement for health promotion and preventative care services
• Limited number of medical students pursuing practice in primary care settings
• Aging of the baby boomer generation

Collecting Subjective Data: Interviewing

• In the Pre-introductory phase, the nurse reviews the medical record to reveal the client's past health history and reason for seeking health care
• The information from the Pre-introductory phase assists with conducting the interview
• Types of interviews include introductory, working, and summary and closing.

Interviewing- Introductory Phase

• Includes introduction, explaining the interview purpose and the types of questions to be asked
• Include explaining the reason for taking notes and assuring confidentiality of information
• Make sure the client is comfortable and has privacy
• Developing trust and rapport by using verbal and nonverbal skills

Interviewing- Working Phase

• Includes: biographical data, reasons for seeking care, history of present health concern, past health history, and family history
• Review of body systems for current health problems Includes lifestyle and health practices and developmental level
• Listen, observe cues, and use critical thinking skills to interpret/validate information received
• Collaboration with the client happens to identify the client's problems and goals

Interviewing- Summary and Closing Phase

• Summarize information obtained during the working phase
• Validate problems and goals with the client
• Identify and discuss possible plans to resolve the problem with the client
• Ask if anything else concerns the client and if there are any further questions

Types of Communication

• Nonverbal communication is as important as verbal communication
• Appearance, demeanor, posture, facial expression and attitudes influence how the client perceives questioning

Non-Verbal Communication specifics

• Appearance-Clients expect a professional look
• Facial Expression- Show your true feelings and are an often overlooked form of communication
• Attitude- a non-judgemental attitude is one of the most important non-verbal skills to develop
• Clients should be accepted regardless of beliefs, ethnicity, lifestyle, and health care practices
• Periods of silence allow you and the client to reflect and organize thoughts This facilitates more accurate reporting and data collection
• Listening- Develop full skill to collect complete and valid data

Non-Verbal Communication to Avoid

• Excessive or insufficient eye contact
• Distraction and distance
• Standing

Verbal Communication specifics

• Effective communication is essential to the interview to elicit as much data as possible
• Use open-ended questions to elicit the client's feelings (how or what) Examples like how have you been feeling lately?
• Close-ended questions focus on specific information like "When did the pain start?"
• Provide a laundry list of words to choose like "Is the pain severe/dull/sharp?"
• Use well-placed phrases like um-um, yes, or I agree to encourage the patient to continue
• Rephrase to clarify information and enable reflection on information
• Ex. "You are thinking that you have a serious illness"
• Provide information throughout to address questions and concerns

Verbal Communication to Avoid

• Biased or leading questions
• Rushing through the interview
• Reading the questions

Communication- Special Considerations

• Special considerations must be made for:
  • Gerontologic variations
  • Cultural variations
  • Emotional variations

Interacting with Clients

• Anxious clients need simple, organized information, explanation of your role, simple questions, and minimal stimuli, without hurrying
• Act calmly, allow the client to vent if angry, and avoid arguments and touching, while getting help from other professionals if needed
• Maintain space so they don't feel cornered, and never allow the client to position themselves between you and the door
• Express interest, understanding, and neutrality with depressed clients, without being too upbeat
• Set limits and structure with manipulative clients, differentiating manipulation from reasonable requests, and obtaining objective opinions
• Set limits on overt sexual behavior for seductive clients and avoid subtle responsiveness
• Encourage appropriate coping, avoid one-on-one meetings if overt sexuality continues, and report inappropriate behavior

Discussing Sensitive Issues

• Be aware of thoughts and feelings regarding dying, spirituality, and sexuality
• Ask simple, nonjudgmental questions
• Allow ventilation of feelings and offer referrals to a competent professional if needed

Interview Question Types

Several types and techniques to use during an interview:

• Health History Interviewing:
  • Biographical data
  • Reasons for seeking health care
  • History of present health concern
  • Past health history
  • Family health history
  • Review of systems for current health problems
  • Lifestyle and health practices
  • Developmental level

Biographical Data includes things like:

• Name
• Address
• Phone
• Gender
• Provider of history (patient or other)
• Birth date
• Place of birth
• Race or ethnic background
• Primary and secondary languages (spoken and read)
• Marital status
• Religious or spiritual practices
• Educational level
• Occupation
• Significant others or support persons (availability)

Interview- Sources of Data

• Primary data comes from the patient themselves
• Secondary data sources include a spouse or children if the client shows forgetfulness or is mentally incapacitated
• Ask 2 questions to get a reason for a healthcare visit

2 Questions to ask

• What is your major health problem or concern at this time? Assist the client to focus on his most significant health concern
• “Why are you here? Or how can I help you?” Encourages the client to discuss fears or other feeling about having to seek a health care provider

The client's present health and symptoms should then be explored

• Ask the client to explain a their health problems, symptoms and related issues in as much detail as possible by focusing in the onset, progression, and duration.
• Because there are many characteristics to be explored for each symptom, a memory helper-known as a mnemonic—can help the nurse to complete the assessment of the sign, symptom, or health concern

Pain Assessment

• In assessment (COLDSPA) stands for:
  • Character
  • Onset
  • Location
  • Duration
  • Severity
  • Pattern
  • Associated Factors
• In assessment (PQRST) stands for:
  • Precipitating/Alleviating Factors
  • Quality
  • Region
  • Severity
  • Timing

Past Health History

• It focuses on questions related to the client's past and the earliest beginnings to present
• Gained information assists the nurse in identifying risk factors from previous problems

Family Health History

• Asumes importance because other health problems may be caused from having grown up in the family
• Assess the:
  • Skin, hair, nails
  • Head, neck
  • Eyes
  • Ears
  • Mouth, throat, nose, sinuses
  • Thorax, lungs
  • Breasts, regional lymphatics
  • Heart, neck vessels
  • Peripheral vascular
  • Abdomen
  • Genitalia
  • Anus, rectum, prostate
  • Musculoskeletal
  • Neurologic

Lifestyle and Health Practices

• Clients describe their awareness of healthy versus toxic living patterns and the strengths and supports they have or use
• Use open-ended questions to promote dialogue:
  • Description of Typical Day
  • Nutrition and Weight Management
  • Activity Level and Exercise
  • Sleep and Rest
  • Substance Use Self-Concept and
  • Self-Care Responsibilities
  • Social Activities
  • Relationships Values and Belief System
  • Education and Work
  • Stress Levels and Coping Styles
  • Environment

Physical Exam Settings Should Be:

• Comfortable, the room temp:

  • Comfort room temperature and have a warm blanket incase the room temp cannot be adjusted

• Private, a free area of interruptions:

  • Have a private area free of interruptions from others such closing the door or pulling the curtains if possible

• Quiet, area free of distractions:

  • With no distractions by turning off the radio, television, or other noisy equipment

• Adequate lighting:

  • Use Sunlight if allowable, adequate over lighting or a portable lamp is helpful

• Firm examination table or bed:

  • A table/bed at a height that prevents stooping-A roll-up stool may be useful when it is necessary for the examiner to sit for parts of the assessment. A bedside table/tray to hold the equipment needed for the examinatio

Physical Exam- Preparations

• Requires careful preparation to gather objective data to elicit sound clinical judgements
• Prevents transmission of infectious agents and establish Rapport and trust
• Explain each step, when and where the examination will take place, why it is important , what will happen, Privacy and Confidentiality. Nurse should determine in advance any positions that are contraindications for a particular client
• Support any client needs, client should empty their before examination

Positioning a Patient

• Take in to account the clients ability, physical condition, energy level, and age

Position Types

• Head, chest, back, lungs, neck, breast, axilla, heart, vital signs and upper extremities need the sitting position.
• Head, neck, chest, breast, axillae, abdomen, heart, lungs, and all extremities need the supine position.
• Head, neck, chest, axillae, lungs, heart, extremities, breast and peripheral pulses need the dorsal recumbent position.
• Rectal and vaginal areas need the sim's position
• Posture, balance, gait and male genital need the standing position
• Hip joints need the prone position
  • Clients w/ Cardiac and respiratory cannot tolerate this position
• Rectums need the knee-chest position -* use for limited time as possible because it is an embarrassing position
• Female genitalia, reproductive tracts, and the rectum need the lithotomy position

Equipments and Instruments

• Prior to the examination, collect the necessary equipment and place it in the area where the examination will be performed.
• Promotes organization and prevents you from leaving
• Each part of the physical examination requires specific pieces of equipment

Instruments For Examination

• Gloves
• Sphygmomanometer - measures diastolic and systolic blood pressure
• Stethoscope - auscultate blood sound when measuring blood pressure and lung/breath sounds
• Thermometer (oral/rectal/axilla) - measure body temperature
• Watch with second hand - time heart rate, pulse rate and cycles of respiration
  • Skin Fold Caliper - measure skin fold thickness of subcutaneous tissue
  • Flexible tape measure - measure circumference Platform Scale with weight attachment - measure height and weight
• Penlight - test pupillary constriction
• Snellen Chart - tests distance and vision
• Ophthalmoscope - view the red reflex and to examine the retina the eye
• Newspaper or Rosenbaum Pocket Screener - tests near vision
• Otoscope - view the ear canal and tympanic membrane
• Tuning Fork - test for bone and air conduction of sound
• Tongue depressor
• Gauze
• Bell and Diaphragm of Stethoscope
• Vaginal Speculum and lubricant - inspect cervix through dilation of the vaginal canal
• Slides or Specimen Container - obtain endocervical swab and cervical scrape and vaginal pool sample
• Lubricating Jelly - promotes comfort to client

Inspection Techniques

• Make sure the room has temperature
• Use good lighting and preferably sunlight
• Look and observe before touching
• Completely expose the body part while draping the rest
• Notes characteristic, pattern, size, consistency, behavior, or sounds
• Compare symmetric body parts

Palpation

• Consist of using parts of the hand touch and feel

Characteristics to palpitate

• Texture
• Temperature
• Moisture
• Mobility
• Consistency
• Strength
• Size
• Shape
• Degree of tenderness

Palpation Type Hand Placement

• The finger pad is sensitive to find discriminations/pulses, texture, sizes,crepitus
• Dorsal surfaces (back) feel temperature
• Ulnar or palmar surface/ vibrations, thrills, fremitus

Types of Palpation

• Light Palpitation - place dominant hand with little no depressions
• Moderate Depress Depress the skin 1 to 2 with your dominant hand in a circular motion and palpate body organs and masses
• Depress skins with dominant and non dominant to feel deep organs
• Bimanual Palpation-2 hands by using both sides

Percussion

• Involves tapping body

Percussion types

• Direct Percussion-direct tapping the body with tips
• Blunt Percussion detect -Tendeness by using hands and fingers to strike ones back
• Indirect or Media tones-tones become quiet

Auscultation-

Require the use of stethoscope hear body movements

Auscultation- how to apply

• Eliminate noises
• Expose body
• Use diagram to measure breath sounds
• Use bell for love pitch sound- hold lightly and record any abnormalities.

Verifying and Documenting Data Includes

• Verifying that subjective and objective data are reliable and accurate
• Decide whether requires validation
• Identifying areas where data are missing Data Requiring Validation
• Discrepancies or gaps between subjective and objective data Discrepancies in
• What the say at one point
• Abnormal and/or inconsistent findings

Method of validations

• Repeat assessment Clarify data with client •

• Verify with another health care •
• Compare objective findings with subjective findings

Purposes for Documentation Includes

• Provides source of assessment data and progression
• The client's family is easily accessible to the healthcare team -Provides communication,
• Establishes a Screening -validate diagnoses
• Acts as a source for help with new problems •
• Offers a basis for the client family
• • Provides • Constitutes a permanent legal • Forms Provides access

Promoting Legal Documentation

• Keep confidential all the document
• Use correct grammar
• Record objective and subjective observations

Assessment Forms for Documentation

• Initial assessment form: nursing admission • Frequent or ongoing assessment form: flow charts that • Focused or specialty area assessment form: focused

Interdisciplinary Communication

• Uses standardized methods for data

• SBAR (Situation, Background, Assessment, Recer) • Communicate face • Allow time for the receiver • Validate what the receiver has Chapter 5

Analysis of analysis data Includes

• Diagnostic and clinical reasonings • End
• Needs of heal professional • Critical Thinking
• Way the nurse processes to
• Formulate conclusion or diagnosis
• Characteristics a nurse must develop to be able to think critically

Questions to ask when writing to get data

• -Opinion or questions based on collected information- Do •

• Ask clarifying question
• Do you avoid being bias · Is there strength included when formulaing diagnosics•
• Write down the conclusions based on the information • Draw cluster -assess possible diagnosis