Nursing Initial Assessment Quiz

Initial Assessment

• According to JCI Hospital Standards, all patients must have an initial assessment.
• The initial assessment includes a health history and a physical examination.
• The initial assessment provides information to understand the care the patient is seeking, form a nursing diagnosis, select the best care setting, and understand the patient's response to any previous care.

General Survey

• The general survey is a first encounter with a patient focused on obvious physical characteristics.
• It provides a first impression and helps prepare for the physical assessment.

What's your first impression?

• Physical appearance: Age, gender, level of consciousness, skin color, facial features, and overall appearance.
• Body structure: Stature, nutrition, symmetry, posture, position, body built, contour, and obvious deformities.
• Mobility: Gait and range of motion.
• Behavior: Mood, facial expression, speech, dress, and personal hygiene.

Measurements

• Weight: Instruct the patient to remove shoes and heavy outer clothing before weighing.
• Height: Use a wall-mounted device or the measuring pole on the balance scale. Align the head piece with the top of the head. The patient should be shoeless and standing straight.
• Body Mass Index (BMI): BMI = Weight (in Kilograms) / Height (in meters)^2. BMI is a practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition.

Abnormalities in Body Height and Proportion

• Hypopituitary Dwarfism: Deficiency in growth hormone results in retardation of growth, delayed puberty, and hypothyroidism.
• Achondroplastic Dwarfism: Genetic disorder resulting in short arms, legs, and stature, due to problems converting cartilage to bone.
• Gigantism: Excessive secretion of growth hormone resulting in overgrowth of the body.
• Acromegaly (Hyperpituitarism): Excessive secretion of growth hormone in adulthood, causing overgrowth of bone in the face, head, hands, and feet.

Vital Signs: Definitions

• Vital signs indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions.
• Vital signs include temperature, pulse, blood pressure, and respiratory rate.
• Vital signs are called "vital" because any difference between normal baseline measurement and present measurement may indicate the need for nursing and medical interventions.

Vital Signs: Temperature

• Cellular metabolism requires a stable core body temperature of a mean of 37.2°C.
• The body maintains a steady temperature through a feedback mechanism regulated in the hypothalamus of the brain.
• The thermostat balances heat production with heat loss.

Temperature Terms

• Afebrile: A patient who is not febrile (no fever).
• Febrile: A patient with a fever.
• Pyrexia: Temperature above normal but below 41°C.
• Hyperpyrexia: Very high temperature (41°C and above).

Nursing Diagnosis Examples - Temperature

• Hyperthermia related to exposure to a hot environment as evidenced by flushed, warm skin.
• Hypothermia related to a decreased metabolic rate as evidenced by body temperature below the normal range.

Vital Signs: Pulse

• The adult heart pumps about 70 ml of blood with every beat (stroke volume).
• The force of the blood flares arterial walls and generates a pressure wave, which is felt in the periphery as the heart rate - pulse.
• Palpating a peripheral pulse gives the rate, rhythm, and force of the heartbeat.

Palpating the Pulse

• Use the pad of the first three fingers.
• Find the pulse.
• If the beat is regular, count the beats for 30 seconds and multiply by 2.
• If the beat is irregular, count the beats for a full minute.

Where to find a pulse:

• Temporal
• Carotid
• Brachial
• Radial
• Ulnar
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis

Factors Affecting Pulse

• Age: As age increases, pulse rate decreases.
• Gender: After puberty, male pulse rate is lower than females.
• Exercise: Pulse rate increases with activity.
• Fever: PR increases due to increased BMR.
• Medications: Some medications increase pulse rate, and some decrease it.
• Hypovolemia: Loss of blood increases pulse rate.
• Stress: Increases the pulse rate and the force.
• Position changes: Pooling of blood decreases venous return, which might reduce blood pressure and increase pulse rate.

Nursing Diagnosis Examples - Pulse

• Decreased cardiac output related to altered heart rate as evidenced by arrhythmias, palpitations, and electrocardiographic changes.

Vital Signs: Respiration

• Normal respiration is relaxed.
• One respiration includes one inspiration (inhalation) and one expiration (exhalation).
• Respiration is an unaware process, so do not alert the patient to the fact that you are counting respirations. Awareness may alter their breathing pattern.

Counting Respirations

• Maintain the same position while counting the radial pulse and unobtrusively count the respirations.
• Count respirations for 30 seconds and multiply by two.
• If you suspect an irregularity, then count for a full minute.
• Avoid the 15-second interval.

Factors Affecting Respirations

• Exercise: Increases respiratory rate.
• Acute pain: Increases respiratory rate.
• Anxiety: Increases respiratory rate.
• Smoking: Can cause chronic respiratory issues.
• Medications: Can affect respiration.
• Brain stem/spinal cord injury: Impacts the respiratory system.
• Hemoglobin function: If compromised, respiration is affected.

Components of Respiratory Assessment

• Rate: Tachypnea (fast), Bradypnea (slow), Apnea (no breathing), Hyperventilation, Hypoventilation.
• Rhythm: Regular or irregular inspirations & expirations.
• Depth: Normal, effortless, silent breathing.
• Effort: Labored with abnormal sounds.

Measurement of Oxygen Saturation

• Pulse Oximeter: Non-invasive method to assess arterial oxygen saturation (SpO2).
• A sensor attached to the finger or earlobe emits light and detects the amount of light absorbed by oxyhemoglobin and un-oxygenated hemoglobin.
• Healthy people have an SpO2 of 97% to 100%.

Nursing Diagnosis Examples - Respiration

• Ineffective airway clearance related to allergic airways as evidenced by diminished breath sounds.
• Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by abnormal respiratory rate, rhythm, and depth.

Vital Signs: Blood Pressure

• Blood pressure (BP) is the force of the blood pushing against the vessel wall.
• The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole.
• The diastolic pressure is the minimum pressure felt while the ventricles are relaxing and refilling, or diastole.

Factors Affecting Blood Pressure

• Age: Increases with age (after 40)
• Gender: After puberty, women have lower BP than men.
• Race: African Americans are more likely than Caucasians to have hypertension.
• Exercise: BP may increase during exercise.
• Weight: Elevated weight increases BP.
• Stress: Can cause transient BP elevation.
• Medications: Some medications elevate or lower BP.
• Smoking: Nicotine elevates BP.
• Caffeine: Increases BP.
• Alcohol: May initially lower BP but can elevate it in long-term consumption.
• Medications: Many medications can affect BP.

Nursing Diagnosis Examples - Blood Pressure

• Ineffective peripheral tissue perfusion related to inadequate blood flow as evidenced by diminished pulse, pale or cyanotic, skin temperature.
• Decreased cardiac output related to decreased or altered heart rate as evidenced by fatigue, weakness, dizziness, orthostatic hypotension

Documentation Guidelines

• Current: Made at the time or shortly after an event.
• Factual: Objective & subjective observations.
• Accurate: Use of exact measurements.
• Legible: Black ink, use of standard abbreviations as per local policy.
• Concise: Clear and easy to understand data. Use abbreviations carefully.
• Complete: Information must contain appropriate and essential information.
• Organized: Communicate information in a logical order.

Applying Critical Thinking Skills

• When assessing vital signs, it's vital to consider:
  • The patient's medical history.
  • Their current medications.
  • Any recent changes in their health status.
  • Any other relevant factors that may influence their vital signs.

References

• Jarvis, C (2016). Physical Examination and Health Assessment (7th ed.). Philadelphia: W.B. Saunders, USA.
• Perry, A. & Potter, P. (2010). Clinical nursing skills & techniques. (7th ed.). Mosby, Elsevier.
• Kozier, B., Erb, G., Berman, A., Snyder.S., Abdarhman.M., Abu-Mogli, F., Saleh, M. (2012). Fundamentals of nursing, concept, process, & practice. The Arab world edition. (1st ed.). Edinburgh: Pearson Education Limited.
• Holtzclaw, b. (2014). Monitoring Body Temperature in Critical and Acute --care Settings. Safe.
• Joint commission International Accreditation and Standards for Hospitals (2014) (5th ed.).
• https://www.nursetogether.com/

Additional Readings

• tCD_EBA-GOC
• Recognizing & responding to clinical deterioration -- Australian Commission on Safety & Quality in Healthcare
• The Oxford University Pain internet site
• Clinical Practice/Hypertension/Pages/default.aspx Australian Heart Foundation facts & recommendations

Test your knowledge about the initial assessment process in nursing, based on the JCI Hospital Standards. This quiz covers the components of health history, general survey, and factors influencing first impressions in patient assessments.