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Collecting Objective and Subjective data Health Assessment (pg. 2) Objective Data Subjective Data ASSESSMENT-POINT OF...

Collecting Objective and Subjective data Health Assessment (pg. 2) Objective Data Subjective Data ASSESSMENT-POINT OF ENTRY IN AN see, hear, smell, feel… Says about themselves ONGOING PROCESS (symptom) IPPA Method Assessment: “collection of data about Physical Examination Techniques Subjective data is information an individual’s health Inspection (symmetry color movement) obtained from the patient and/or state.” Palpation (moisture temperature mases family members Purpose: to make a judgment or crepitus) light & deep diagnosis Percussion (gentle tapping sound?) Must be factual and complete Auscultation (listening) cardio, respiratory, & GI o Pain *** o #1 Rule for pain Assessment Includes subjective, complains: BELIEVE objective data, and o Vital signs o Temp THE PATIENT o Heart rate patient’s database; entire patient o Weight records, o Height o Respiratory rate o Blood pressure including lab studies o Physical appearance Clinic Judgment & the Diagnostic Process o Age o Sex (Evidence-bases decisions/critical thinking needed) o LOC o Skin color Diagnostic Reasoning (pg. 2-3) The process of analyzing health data and o Facial features drawing o Overall appearance o Body structure conclusions to identify diagnoses o Nutrition o Posture Clinical Judgment- allows you to make the best evidence-based decisions for o Position your o Stature patient o Symmetry o Mobility o Novice: use rules to guide performance o Gait o Competent: see actions in context of patient goals and plans o Range of motion o Proficient: Understand a patient’s situation as an whole o Behavior o Expert: has intuitive grasp of clinic situations & o Facial expression zeros o Mood & affect in on the accurate solutions Objective Vs. Subjective Data Evidence-based practice (EBP)- patient deserve to be treated with most Examples current & best practice techniques. (Florence Nightingale) Objective Data Subjective Data -research utilization Examples Examples 5 Steps to EBP o Blood pressure o Headache o Heart rate o Chest pain o Alert o Fatigue 1. Ask the clinical question o Rounded o Shortness of 2. Acquire source of evidence abdomen breath 3. Appraise & synthesize evidence o Diaphoretic o Exhausted 4. Apply relevant evidence to o Tearful o Sore practice 5. Asses the outcomes Clinical Decision Making (4 factor) 1. Best evidence in research 2. Patient’s own preferences 3. Clinician’s own experience & expertise 4. Physical examination & assessment Nursing Process (ADPIE) Assessment (recognize cues) Diagnosis (analyze cues) Planning (prioritize hypotheses/generate solutions) Implementation (take action) Evaluation (evaluate outcomes) Priority Setting: Prioritizing First, Second, and Third level priorities (pg. 4) First-level priority Second-level priority Third-level priority problems problems problems Emergency, life Prompt intervention to forestall threatening, & immediate further deterioration Important to patient health but can attend to o Change in LOC after more urgent health problems o Acute pain o Infection risk o Abnormal lab values o Lack of knowledge o Mobility problems o Elimination problems o Family coping  Collecting 4 Types of Patient Data (pg. 6) Complete (Total Health) Focused or Problem- Follow-Up Emergency Centered Database Database Database Database Collect a targeted history and Complete health history and the physical examination is Used to check status of URGENT, RAPID collection of the full physical examination catered to the area(s) of known issue to verify if info in conjunction with lifesaving (forms a base-line) concern. “mini” database change has occurred. measures. (Usually obtained in primary (Completed in all setting) (Completed in all setting) Complete database can follow care setting) once patient is stable. Concerns mainly one problem Ex: Full physical examination, current/past health problems, persons health state; perception of health; health maintenance behaviors; individual copping patterns; support system; risk factors, lifestyle changes Social Determinants of Health (SDoH) pg.7-10 Social Determinants of Health (SDoH): Factors that influence an person’s health and wellbeing o Environment o Access to health care o Community o Education o Economic stability *** Work with patient to identify modifiable SDoH to ensure best possible health outcomes Must recognize potential barriers to good health and work with the patient to determine solutions Interviewing People with Special Considerations Interpreters Hearing Impaired People: Signing, lip reading, or writing Determine client's preferred language to discuss Acutely Ill People: Be very clear with statements medical information People Under the Influence of Street Drugs/Alcohol: Simple Determine if client has a communication disability such and direct questions; remain nonthreatening as Personal Questions: Supply only appropriate information Sexually Aggressive People: Set appropriate verbal vision, hearing, or speech boundaries Use trained interpreters when available Crying: Acknowledge them and provide time for patients to Americans with Disabilities (ADA) Act: express their sadness https://www.ada.gov/resources/effective-communication/ Anger: Hear the person out; don’t take it personally and remain calm Threats of Violence: Act calm, diffuse the situation and seek support Anxiety: Take time to listen, and avoid the “traps” Complete Health History pg.41  The Health History- The Adult Biographic Data Healthy History Sequence Reason for Seeking Care Source of hx o Brief, spontaneous statement in the person’s o Name o Who is own words that describes the reason for the 1.Biographic data o Address providing the visit 2.Reason for seeking care o Phone number info? Includes 1-2 signs/symptoms: 3.Present health or history or present illness o Age o How reliable Symptom: Subjective 4.Past health history o Birthdate are they? Symptom: Objective 5.Medication reconciliation 6.Family history o Birthplace o Do they o Record whatever the person says is the o Gender appear well or reason 7.Review of systems o Preferred ill? for 8.Functional assessment or activities of daily pronoun seeking care living (ADLs) o Relationship o Not a diagnostic statement Status o If multiple concerns- focus on most pressing o Race concern by asking which prompted their visit o Ethnic origin today o Occupation o Primary language Past History of Present Illness Well Person Ill Person Short statement about the general Chronologic record of the reason for state of health: “I feel healthy right seeking care, Final summary of any symptom the now.” “I am healthy and active.” from the time the symptom first person has should include these eight started until now critical characteristics: Location Character or Quality Quantity or Severity Timing (Onset, Duration, Frequency) Setting Aggravating or Relieving Factors Associated Factors Patient’s Perception Medication Reconciliation Family History Review of Symptoms o A comparison of a list of current medications o An accurate family history Purpose with a previous list highlights diseases and o Evaluate the past and present o Done at every hospitalization and every clinic conditions for which a particular health state of each body system, visit patient may be at increased risk o Double-check in case any significant o Purpose is to reduce errors and promote o A pedigree or genogram is a data were omitted in the Present Illness patient safety graphic family tree that uses section o Include prescribed meds, OTC, and herbal symbols to depict the gender, o Evaluate health promotion practices meds relationship, and age of o Prescribed Medications immediate blood relatives in at Data Collection o Name (generic or trade) least three generations such as o Order of the examination of body systems is o Dose parents, grandparents, and roughly head to toe o Schedule sibling o Record the presence or absence of all SS o What is it for? o Should be limited to patient statements or o How long have you been taking? o subjective data—factors that the person o Any side effects? says were or were not present o Taking as prescribed? Functional Assessment (ADLs) Measures a person’s self-care ability in the areas of general physical health o ADLs (bathing, dressing, eating, etc.) o iADLs (cleaning, shopping, cooking, etc.) o Nutrition (including elimination) o Social relationships (family, friends, etc.) o Resources (functional, spiritual) o Self-concept o Coping (Stress management, tobacco, alcohol, etc.) o Home environment (housing, neighborhood, intimate partner violence, etc.) o Perception of Health  IPPA Method Physical Examination Techniques Inspection concentrated watching can be done without touching (ALWAYS 1ST step) Palpation light and deep can be done w/ hands, fingers, ulnar or dorsa surfaces Percussion tapping to elicit audible vibrations (air, fluid or solid) Auscultation (listening to sound) cardio, respiratory, & GI (typically through an stethoscope) Stethoscope: does NOT magnify, simply blocks extraneous room sounds. ALWAYS LISTEN ON SKIN Bell: soft, low-pitched sounds Diaphragm: high- pitched sounds Pain Assessment Pain Assessment Tools Sources & Types of Pain #1 Rule for pain complaints: BELIEVE THE PATIENT (everyone experiences and copes with pain differently) 1. Find out details of Pain Sources of Pain Types of Pain 2. Have patient rate pain Visceral: from internal organs-dull Acute pain: short-term, often 3. Document and treat accordingly Somatic: from musculoskeletal tissues dissipates DETAILS: or body surface after healing O: Onset P: Provo-Palli L: Location Q: Quan/Qual Deep somatic: from blood vessels, Chronic pain: pain continues D: Duration R: joints, tendons, muscles, bone for 6+ months Region/Rad C: Character S: Severity Cutaneous: from skin surface and Breakthrough pain: transient scale subcutaneous tissues pain that A: Aggravating factors T: Timing occurs in between times of no R: Relieving factors Referred: from another body location pain T: Treatment (originated from another area). Both sites S: Severity are innervated by the same spinal nerve Therapeutic Communication The Process of Communication Sending Use of preferred title name and gender o Verbal and nonverbal communication pronoun Receiving active or attentive listening o words or gestures may be templated differently guided questioning Internal Factors empathetic response o liking others empathy and ability to listen and self-awareness summarizing External Factors o physical setting (office or clinic) transitions o privacy empowering the patient o refuse interruptions reassurance o equal setting appropriate nonverbal communication Dress o Appropriate appearance/ clothing Note-Taking o Avoid excessive not taking EHR o Electronic health record  Techniques of Communication Introducing the interview o Introduce yourself and state your role in the agency give a reason for interview The working phase o Data gathering phase combination of open and closed ended questions Open-ended questions o Tell me how I can help you? o What brings you to the hospital ? o you mentioned shortness of breath tell me more about that? Closed or direct questions o Yes or no questions Verbal response- assisting the narrative o Encourage free expression while keeping the person focused Assessing Mental Status: ABCT Appearance Behavior Cognitive Functions Thought Process Posture LOC awake alert and aware of Orientation time place & Perception Is erect and position stimuli person Thought process is relaxed Facial expressions looks Attention Span does this Body movements appropriate for situation person's ability to person make voluntary deliberate Speech pace and articulation concentrate sense? coordinated smooth Mood & Affect how do you feel Recent memory access Thought content and even today how? How do you usually recent memory Should be concise Dress feel? Remote memory ask and logical appropriate for person verifiable past Perceptions person setting events should Grooming & Hygiene New Learning- 4 be aware of reality clean and well unrelated word test Screen for Anxiety groomed Disorders Pupils pupil size and reactive to light Culture Cultural Assessment Importance Culture Related Concepts National minority is becoming the emerging majority (40% of the Culture: includes attitudes, values, beliefs, norms total population) and roles o Conceptual issue: nurses and other healthcare * learned from birth – language acquisition and providers are expected to know, understand, and socialization meet the health needs of people from culturally * shared by all group members diverse backgrounds with minimal preparation in * adapted to environmental factors cultural competence. * always changing * Sub-cultures may share different beliefs, Health assessment is a critical point to perform cultural values, attitudes, norms assessments Socialization (enculturation): raised within a culture o People from varying cultures may interpret symptoms and differently acquiring the norms, values and behaviors of that o Errors may occur due to a lack of cultural group competence (example: medication interactions with herbal remedies) Ethnicity: social group that may share traits – geographic origin, religion, language, values, traditions Acculturation: adopting culture and behaviors of the major culture Race: reflects self-identification. Construct of groups of people who share similar physical characteristics – Social Construct  Completing a Cultural Assessment Spiritual Assessment: FICA Spirituality Tool (p. 20) Cultural Self-Assessment: always the first step. You need to know F: FAITH where your beliefs and values lie before assessing others. Remember: “Do you have spiritual beliefs, values or being a nurse means you leave your judgments at home practices that help you cope with stress?” Cultural Assessment: Do not assume understanding – ALWAYS ask I: IMPORTANCE/INFLUENCE about cultural practices that may impact care “Do you have specific beliefs that Health practices: use of traditional healers, influence your health care decisions?” complementary/alternative therapies, any UNACCEPTABLE C: COMMUNITY practices? (blood transfusions) “Are you part of a spiritual or religious Communication: Preferred language? CERTIFIED interpreter community?” Family roles and social orientation: Who makes healthcare A: ADDRESS/ACTION decisions within the family? “How should I address these issues in Nutrition needs – any forbidden foods, fasting rituals? your health care?” Religious affiliation – need for services? Healers – need to be called in for treatment options/considerations? Death – rituals in preparation for death; meaning for death Health providers – same sex provider Item Normal Findings Abnormal Findings Age appears stated age looks older / younger than stated age Sex sexual development is appropriate for delayed or rapid puberty age and sex Level of consciousness Alert & oriented to person, place, time , Confused, lethargic, obtunded situation Skin Color color tone is even Pallor, cyanosis, jaundice, erythema Facial features Symmetric Masklike, immobile, asymmetrical Overall appearance No Acute distress Signs of distress: pain, shortness of breath, clutching chest  Item Normal Findings Abnormal Findings Stature Height within normal range Excessively short / tall Nutrition W eight within normal limits Obesity, emaciated Symmetry Body parts equal bilaterally A symmetry present Rigid spine/neck, Posture Stands erect hunches Curled in fetal position, Position Sitting relaxed, arms at side tripod Body build A rm span = height Elongated arm span Item Normal Findings Abnormal Findings Feet shoulder width apart, walk is Stumbling, shuffling, Gait even bilaterally, symmetrical arm asymmetrical arm sw ing swing Range of Motion Full mobility in each joint Limited mobility in a joint Item Normal Findings Abnormal Findings W eight Normal weight, BMI Abnormal BMI Item Normal Findings Abnormal Findings Flat expression, Maintains eye contact, expression Facial expression depressed, angry, appropriate for conversation anxious Mood and affect Cooperative, pleasant Hostile, crying Speech Clear, understandable Dysphasia, aphasia A ppropriate verbiage, even Speech pattern Constant talking pacing Inappropriate for climate, Dress A ppropriate for climate, clean unkempt  Respirations Adult Range: 16-25 bpm Average: 20 bpm Tachypnea (rapid respirations): >25 bpm Bradypnea (↓respirations): < 8-12 bpm Newborn Range: 30-50 bpm a fairly constant ratio of pulse rate to respiratory rate exists, which is about 4:1. Blood Pressure Performing Blood Pressure Reading Systolic = maximum pressure during left ventricular 1. Ensure cuff is correct size contraction (systole) – TOP READING 2. Place around arm as directed (practice in lab) Diastolic = recoil/resting pressure between each 3. Inflate to maximum level contraction – BOTTOM READING 4. Deflate cuff slowly and evenly 5. Listen for Korotkoff sounds Pulse pressure = difference between systolic and diastolic a) Systolic = 1st sound you hear pressures and reflects stroke volume b) Diastolic = last sound you hear before silence Causes of abnormalities: 6. Readings should always be even **medical diagnoses, medications, current state (under numbered stress, exercising, emotional) 7. Do NOT obtain BP on mastectomy arm  Assessment of the skin, hair, and nails: Subjective and Objective data Skin: Structure and Layers Epidermis - rugged protective barrier Dermis - consisting of connective tissue, or collagen Subcutaneous Layer- Composed of adipose tissue – fat cells Appendages Hair Sebaceous glands Sweat glands Nails Skin Assessment: Collecting Subjective Data Skin Assessment: Collecting Subjective Past and/or family history of skin disease (allergies, Data Population-Specific Additional History psoriasis, hives, eczema) Infants and Children: Changes in pigmentation Birthmarks, any change in skin color at birth Changes in mole (size and/or color) Rash or sores Excessive dryness or moisture Diaper rash, diaper care, hygiene Pruritus Burns and/bruises Excessive bruising Exposure to contagious skin conditions Rash or lesion Use of sunscreen Medications Adolescent: Hair loss Skin problems, such as acne or blackheads Change in nails Aging Adult: Environmental or occupational hazards Skin changes or pain and delays in wound healing Patient-centered care Changes in feet, toenails, bunions. Any falls History of diabetes, peripheral vascular disease Skin care habits  Skin Assessment: Collecting Objective Data ABCDEF Information about nutritional status, circulation, Asymmetry systemic diseases can be picked up in a skin Border Irregularity assessment. Color Variation Diameter greater than 6mm Skin folds are perfect conditions for moisture, irritation and infection Elevation or Evolution Large breast, abdomen and groin Funny looking “ugly duckling sign” Always remove shoes and socks to complete a thorough skin assessment! Inspect feet, toenails, and between the toes Mucous membranes are also included in this assessment Skin Assessment: Collecting Objective Data Skin Assessment: Collecting Objective Data Inspection Normal Findings Abnormal Findings General Pigmentation Vitiligo – absence of Skin tone even and consistent with genetic melanin pigment in patchy areas background May be darker in sun-exposed areas Benign pigmented areas may also occur: Freckles, moles, birthmarks Skin Assessment: Collecting Objective Data Skin Assessment: Collecting Objective Data Widespread color change – any color change over the whole body Cyanosis (blue) Pallor (white) Bluish mottled color from decreased perfusion/high Common in high-acute stress (i.e. anxiety or fear) levels of from peripheral vasoconstriction deoxygenated blood Vasoconstriction from cold and cigarette smoking Lips, nose, cheeks, ears, and oral mucous Presence of edema membranes For darker skinned individuals, assess mucous Difficult to observe in darker skin tones membranes, lips, and nail beds. Can be nonspecific sign (i.e., anemia) Erythema (red) Most conditions causing cyanosis also cause Intense redness of the skin from dilated superficial decreased capillaries oxygenation to the brain Expected as a result of fever, local inflammation, Observe for signs of change in level of consciousness or emotional reactions (blushing) and/or resp. distress Increased skin temperature as a result of Jaundice (yellow) increased blood flow. Results from increased levels of bilirubin in the blood For darker skin, palpate skin for NOT a normal finding outside of newborn cases increased warmth or skin tautness First noted in the hard/soft palate junction and in (edema) sclera **Can be confused with normal finding of sub conjunctival fatty deposits of dark-skinned individuals Jaundice may be present in skin covering the body – late sign as levels rise Skin Assessment: Collecting Objective Data Skin Assessment: Collecting Objective Data Temperature Moisture Palpate skin – should be warm and equal bilaterally Normal perspiration – face, hands, axillae and skinfolds in Warmth is indicative of normal circulation response Hands and feet may be cool in cooler to stress, heat, or activity environment Diaphoresis – abnormal finding of profuse perspiration with Hypothermia increased Generalized – may be induced (surgery or with high metabolic rate (heavy activity or fever) fever) More severe – heart attack, anxiety, fear Also shock, cardiac arrest Dehydration Localized – immobilized extremity or intravenous (IV) Observe oral mucosa – should be smooth and moist fluids Dry, cracked lips are signs of dehydration. Arterial insufficiency Extreme cases appear as fissures Hyperthermia Darker skin may appear dry and flaky – not always Generalized – increased metabolic rate (fever or sign of exercise) systemic dehydration Localized – trauma, infection, sunburn Texture Normal = smooth, firm and even surface  Skin Assessment: Collecting Objective Data Skin Assessment: Collecting Objective Data Thickness Uniformly thin, may have callused areas Vascularity and Bruising Callus – overgrowth of epidermis as Cherry angiomas adaptation Edema: Fluid accumulation in the interstitial space. Usually, benign overgrowth of NOT a normal finding capillaries May alter normal skin tone or abnormal presentations Bruising (jaundice, cyanosis) Be concerned for bruising in multiple Assessment: imprint thumbs firmly for 3-4 seconds stages against the ankle malleolus or tibia. Normal finding – of healing and/or excessive bruising skin stays smooth. Abnormal finding – imprint left behind (“pitting edema”) around Mobility & Turgor – both assess elasticity of the skin. Pinch up a knees or elbows. fold of skin. Could be signs of abuse or falls in the Mobility: Ease of skin to rise elderly Turgor: Measures how skin returns to place when Needle marks or “tracks” may be visible in released antecubital fossae, forearms, hands or feet in patients with history of IV drug abuse. Tattoos? Skin lesions: ABCDEF and pressure injuries Skin Assessment: Lesions Pressure Injuries (Pressure Ulcer, Decubitus Traumatic or pathologic changes in previously normal Ulcer) structures. Usually found over bony prominences Primary: Develops on previous unaltered or “normal” skin Occur as a result of decreased blood circulation – Secondary: When a lesion changes over time or results from ischemia, scratching, infection which leads to cell death. Important assessment findings (Inspection): Color Common sites: Heel, ischium, sacrum, elbow, scapula, Elevation: flat, raised, pedunculated? vertebra, Pattern or shape: grouped, linear? ankle, heel, rib, shoulder Size – be specific, use wound measurement tool to measure in centimeters Risk factors: Impaired mobility, thin fragile skin with Location and distribution aging, Any exudate – color and/or odor decreased sensory perception, impaired level of Palpate, note surrounding temperature consciousness, moisture, incontinence, wound drainage and excessive perspiration, shearing, poor nutrition, and infection. Measured by staging system **Always assess your patient's skin fully when they are first admitted to the acute care setting. If anything is discovered, follow procedure/policy. Measure wound size, photograph, document  Pressure Injuries (Pressure Ulcer, Decubitus Ulcer) Stage 1 Stage 2 Stage 3 Non-blanchable Partial-thickness Full-thickness skin loss erythema skin loss Extends into subcutaneous tissue, Skin is intact Loss of resembles crater but reddened epidermis Fat, granulation tissue and rolled and does not with edges blanch (turn exposed seen light with dermis No bone, tendon or muscle visible fingertip Superficial, pressure) appears like Light skin appears an open pink or reddened blister Dark skin appears darker and also does not blanch Stage 4 Full-thickness skin/tissue loss Involves all skin layers, and extends to bone, tendon and muscle. May have eschar (black/necrotic tissue)