Newborn and Adult ass. and Ethico-legal

APGAR Scoring System

• Doctors and nurses use the APGAR scoring system to assess newborns
• Assessment occurs at one minute and five minutes after birth
• Activity (Muscle Tone):
  • 0 points: Absent
  • 1 point: Flexed arms and legs
  • 2 points: Active
• Pulse:
  • 0 points: Absent
  • 1 point: Below 100 bpm
  • 2 points: Over 100 bpm
• Grimace (Reflex Irritability):
  • 0 points: Floppy
  • 1 point: Minimal response to stimulation
  • 2 points: Prompt response to stimulation
• Appearance (Skin Color):
  • 0 points: Blue; pale
  • 1 point: Pink body, blue extremities
  • 2 points: Pink body
• Respiration:
  • 0 points: Absent
  • 1 point: Slow and irregular
  • 2 points: Vigorous cry

MMDST (Infants and Children)

• The MMDST is used to identify developmental delays in children from birth to 6 years of age
• The test consists of 125 tasks
• The MMDST is adapted from the Denver Developmental Screening Test (DDST)
• It includes four areas:
  • Personal-Social: Focuses on getting along with people and caring for personal needs
  • Fine Motor-Adaptive: Involves eye-hand coordination, manipulation of small objects, and problem-solving
  • Language: Covers hearing, understanding, and using language
  • Gross Motor: Includes sitting, walking, jumping, and overall large muscle movement

Katz Index of Independence in ADL (Adults)

• The Katz Index of Independence in ADL measures an elder's ability to perform activities of daily living independently
• Bathing:
  • Independence (1 Point): Bathes self completely with no supervision, direction, or personal assistance
  • Dependence (0 Points): Needs help with bathing more than one part of the body, or needs help with bathing only a single part of the body
• Dressing:
  • Independence (1 Point): Gets clothes from closets and drawers and puts on clothes and outer garments with fasteners completely; may need help tying shoes
  • Dependence (0 Points): Needs help with dressing self or needs to be completely dressed
• Toileting:
  • Independence (1 Point): Goes to toilet, gets on and off, arranges clothes, cleans genitalia without help
  • Dependence (0 Points): Needs help transferring to the toilet, cleaning self, and uses bedpan or commode
• Transferring:
  • Independence (1 Point): Moves in and out of bed or chair unassisted; mechanical transferring aides are acceptable
  • Dependence (0 Points): Needs help in moving from bed to chair or requires a complete mechanical transfer
• Continence:
  • Independence (1 Point): Exercises complete self-control over urination and defecation
  • Dependence (0 Points): Is partially or totally incontinent of bowel or bladder
• Feeding:
  • Independence (1 Point): Gets food from plate into mouth without help; preparation of food may be done by another person
  • Dependence (0 Points): Needs partial or total help with feeding or requires parenteral feeding
• Scoring:
  • A score of 6 indicates full function
  • A score of 4 indicates moderate impairment
  • A score of 2 or less implies severe functional impairment

Assessment of Pregnancy (LMP, EDC)

• LMP (Last Menstrual Period):
  • Ask for the first day of the last menstrual cycle
• EDC (Estimated Date of Confinement/Due Date):
  • Naegele's Rule is used to calculate EDC
  • If LMP is April to December: EDC=LMP−3 months+7 days+1 year
  • If LMP is January to March: EDC=LMP+7 days+9 months
• Example 1:
  • LMP: September 8, 2018
  • Subtract 3 months: June 8, 2018
  • Add 7 days: June 15, 2018
  • Add 1 year: June 15, 2019
• Example 2:
  • LMP: January 2, 2018
  • Add 7 days: January 9, 2018
  • Add 9 months: October 9, 2018

Mental Status Assessment ("ASEPTIC")

• ASEPTIC is a mnemonic used to remember the components of a mental status assessment:
• Appearance:
  • Apparent age
  • Dress
  • Grooming
  • Hygiene
  • Eye contact
  • Abnormal movements
  • Attitude
• Speech:
  • Rate: pressured, slowed
  • Rhythm: Hesitant, long pauses
  • Tone
  • Volume: Loud, soft, yelling
  • Accent
  • Clarity
  • Pronunciation
  • Quantity: Responds to questions
• Emotion:
  • Mood
    • Quality: Depressed, euthymic
  • Affect
    • Range: Restricted or guarded
    • Stability: Fixed or easily distracted
    • Appropriateness
• Perception:
  • Hallucination: Auditory, visual, olfactory
  • Illusions: Distortions of images or sensations
  • Depersonalization: Existence isn't real
  • Derealization: Patient is not real or things are not real
• Thought:
  • Content and Process
    • Thought Process: Tend to go off topic, flight of ideas, word salad, echolalia, neologisms
    • Delusions: Paranoid, powers
    • Suicidal ideation
    • Homicidal ideation
• Insight and Judgement:
  • Insight: A deep understanding of a certain concept or illness
  • Judgment: Ability to make reasonable decisions
• Cognition:
  • LOC: Alert, confused, lethargic
  • Orientation: Name, place, time
  • Attention/Orientation: Focus is poor or ?
  • Memory: Short and long term memory
  • Intelligence

Comprehensive Geriatric Assessment

• Components of the comprehensive geriatric assessment include:
  • Medical:
    • Problem list
    • Comorbidities
    • Medication review
    • Advance care planning
    • Vision and hearing
    • Nutritional status
    • Continence
  • Psychological:
    • Mood
    • Ideas, concerns, and expectations
  • Functional:
    • Gait and balance
    • Mobility and transfers
    • Basic ADL
    • IADL
    • Advanced ADL
  • Social:
    • Social or environmental appropriateness
    • Formal care support
    • Home safety and falls risk
    • Social network providing informal support
    • Accessibility to local resources
    • Financial assessment

Nurse’s Role in Health Assessment

• First healthcare contact for patients
• Assesses patient needs, diagnoses illness
• A key player in care standards and health promotion

Ethico-Legal Guidelines in Health Assessment

• Informed Consent:
  • Based on patient autonomy
  • Involves educating patients on risks, benefits, and alternatives
  • Requires voluntary, competent decision-making
• Filipino Patient’s Bill of Rights (Key Points):
  1. Right to considerate & respectful care, regardless of socio-economic status.
  2. Right to complete, understandable info on diagnosis, treatment, and prognosis.
  3. Right to informed consent before procedures/treatments.
  4. Right to refuse treatment within legal limits; be informed of consequences.
  5. Right to privacy regarding medical care.
  6. Right to confidentiality of medical records & communication.
  7. Right to reasonable response for hospital services.
  8. Right to know hospital’s affiliations with other institutions.
  9. Right to be informed of any human experimentation involved in care.
  10. Right to continuity of care, informed scheduling, and physician availability.
  11. Right to bill examination regardless of payment source.
  12. Right to know hospital rules/regulations related to their conduct.
• Data Privacy Act (2012):
  • Protects privacy of communication.
  • Ensures free flow of info for growth/innovation.
  • Data sharing must have agreements with safeguards.
  • Reviewed by National Privacy Commission.
• Health Care Team in Health Assessment:
  • Team-based approach with clients, families, communities.
    • Nurses collaborate with patients, caregivers, and physicians/specialists
  • Promotes effective communication & patient outcomes.
• Core Nursing Values in Health Assessment:
  1. Cultural Awareness:
     • Understand and respect diverse beliefs
     • Accommodate customs, preferences, values
  2. Professionalism:
     • Actions reflect ethics & values
     • Display consistently with patients and colleagues
  3. Attention to Detail:
     • Prevents mistakes
     • Focus on active listening and non-verbal cues
  4. Critical Thinking:
     • Integrate data and experiences
     • Solve problems and plan effective care
  5. Compassion:
     • Essential but challenging
     • Understand patients, families, and system barriers
  6. Time Management:
     • Prioritize, organize, multitask
     • Use checklists, anticipate needs, delegate/supervise
  7. Communication:
     • Nurses are central communicators
     • Coordinate between patients and healthcare providers