Nursing Assessment Fundamentals

Objective vs. Subjective Data

• Subjective data is what the patient describes or feels.
• Objective data is what the healthcare professional observes and measures.
• Examples of subjective data include pain level, symptoms, and past medical history.
• Examples of objective data include vital signs, physical exam findings, and lab results.

Stethoscope: Uses and Parts

• A stethoscope is used for auscultation, which is listening to sounds produced by the body.
• It has two main parts:
  • Diaphragm: best for high-pitched sounds like normal heart sounds, breath and bowel sounds. Apply firmly to the skin.
  • Bell: best for low-pitched sounds like extra heart sounds or murmurs. Apply lightly to the skin to create a seal.
• Stethoscopes should be cleaned using alcohol wipes before and after each patient to prevent infection.

Cultural and Religious Assessments

• Cultural assessments are vital for a complete patient profile.
• Key domains include heritage, health practices, communication patterns, family roles, nutrition, pregnancy/child-rearing, spirituality/religion, death, and health providers.
• Do not assume anything about a patient’s culture; ask directly about their beliefs.
• The FICA tool is a helpful resource for assessing a patient's religious or spiritual beliefs:
  • F - "Do you consider yourself spiritual or religious?"
  • I - "What importance does your faith or belief have in your life?"
  • C - "Are you part of a spiritual or religious community?"
  • A - "How should I address these issues in your healthcare?"
• Be mindful of how cultural beliefs can impact healthcare decisions and may influence use of traditional or alternative therapies.

First-Level Priority Patients

• First-level priority concerns are emergent, life-threatening, and immediate needs, such as airway, breathing, and circulation.
• These conditions require immediate action to prevent further deterioration.

Proper Order of Assessment

• The typical assessment order involves:
  • Inspection: Detailed visual assessment of the patient's overall and body system.
  • Palpation: Using touch for assessing factors like texture, temperature, moisture, and organ location (swelling).
  • Percussion: Tapping the skin to feel underlying structures.
  • Auscultation: Using a stethoscope to listen to body sounds.

Suicidal Ideation

• Mental health assessment for suicidal ideation is essential for all patients.
• The HEEADSSS method can be used for adolescents to identify risk factors.

At-Risk Patients: Drugs and Alcohol

• When assessing persons under the influence of alcohol or other substances, use simple, direct questions to assess for safety.
• Identify the time of last use, amounts consumed, and types of substances used.

Elder Abuse and Elder Neglect

• Explicit information regarding elder abuse or neglect isn't provided in the given context.

Intimate Partner Violence

• No details of intimate partner violence are specifically provided in the text.
• However, the assessment should address this issue during the functional assessment, given other details in the document.

Phases and Portions of the Patient Interview

• The patient interview process involves collecting data.
• It should include:
  • Introduction – explain purpose of interview.
  • Working phase – employ open-ended questions and note verbal responses.
  • Closing – summarize key findings and thank the patient.
• Key components: Biographical data Reason for visit Present health/history of present illness (h/o p.i.) Past medical history Family history Medication reconciliation Review of systems Functional assessment

Vital Signs: Abnormalities and Causes

• Vital signs include temperature, pulse, respiratory rate, and blood pressure.
• Older adults may have reduced vital capacity and decreased responsiveness.
• Temperature - take into account variations in taking temp depending on site (oral, rectal, tympanic, temporal)
• Pulse – normal range but can be irregular in older adults.
• Respiration – may be shallower in older adults.
• Blood pressure – systolic pressure tends to increase with age, causing widened pulse pressure. Consider orthostatic hypotension when positioning changes.

Pain Assessment

• Subjective pain reports are the gold standard in pain assessment.
• Tools like numerical scales, verbal descriptor scales and visual analog scales can quantify pain during the assessment.
• The PQRSTU mnemonic (Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing, Understanding) can help clinicians to assess pain.

Skin Cancers, Decubitus Ulcers (Pressure Injuries), and Lesions

• Skin cancers have distinguishable patterns described by a simple ABCDE rule for screening:
  • Asymmetry (not symmetrical shape)
  • Border (irregular borders or margins)
  • Color (varied colors)
  • Diameter (larger than 6mm)
  • Evolving changes.
• Decubitus ulcers/pressure injuries from impaired circulation. Risk factors include immobility, thin skin, decreased sensation, altered consciousness, moisture, shearing injury, poor nutrition, and infection.
• Lesions are assessed for shape, size, location, and surrounding skin characteristics.

Medication Reconciliation

• Medication reconciliation involves comparing current and previous medication lists to reduce errors.
• This is important for patient safety and to help reduce medical errors.

SBAR Communication Tool

• SBAR is a communication tool used for clear and accurate information exchange between healthcare professionals.
• It supports providing information accurately and reducing ambiguity.
• Each letter of SBAR represents an element of the tool (Situation, Background, Assessment, Recommendation)