HA Week 1 Lecture Fa24 (Students) PDF

Nurse’s Role in Health Assessment Holistic Nursing Health Assessment ►Purpose American Nurses Association ►Method Nursing Process (ADPIE) ►Assessment Data collection Types of data 2 The Nursing Process (ADPIE)...

Nurse’s Role in Health Assessment Holistic Nursing Health Assessment ►Purpose American Nurses Association ►Method Nursing Process (ADPIE) ►Assessment Data collection Types of data 2 The Nursing Process (ADPIE) ► Assessment Collecting subjective/objective data ► Diagnosis/Analysis Analyzing data and prioritizing clinical judgments ► Planning Generating a solution, developing a plan, and then determining your outcomes criteria ► Implementation Taking action – implementing your plan. ► Evaluation Have outcomes been met? Revise if not. 3 Phases of the Nursing Interview ►Pre-introductory ►Introductory ►Working ►Closing 4 Communication Open-ended questions Closed-ended questions ► Communication to Laundry list AVOID: Verbal Rephrasing Well-placed phrases Excessive or insufficient eye contact Inferring Distractions and distance Providing information Standing or walking Biased or leading questions Appearance Rushing through the interview Demeanor Reading questions from a form Nonverbal Facial expression Attitude Silence Listening 5 WIPE Subjective Data Collection: Chief Complaint (CC) History of Present Illness (HPI) C O L D S P A Associated Character Onset Location Duration Severity Pattern factors 7 4 Major Steps in Health Assessment Subjective data Objective data Data Validation Data collection collection Documentation 8 4 Types of Assessments Initial Comprehensive Collect subjective/objective data of all body systems, past Assessment health history, family history, and lifestyle/health practices Ongoing/Partial Assessment Overview of body systems and health patterns (follow-up) Focused/Problem- oriented Assessment Thorough assessment of a specific health concern Emergency Assessment Very rapid assessment in life-threatening situations 9 Framework for Assessments: Focused ▶ Focused subjective data collection is about the chief complaint: CC (Chief Complaint) and HPI (history of present illness) Personal health history Family history Lifestyle and Health practices 10 Framework for Assessments: Comprehensive ► Comprehensive subjective assessment addresses all systems Biographic PMH PSH Psychosocial Family Social/Lifestyle/Health practices Review of Systems (ROS) 11 Screening Tools for Health Assessment Social Determinants of Health 13 Social Determinants of Health What can Nursing do? Gain a holistic perspective of the person, family, community and population Recognize impact of health disparities and SDOH Advocate for social justice and health equity Have a plan for needs that are identified Identify resources Recognize that one size does not fit all 14 Adverse Childhood Experiences Study (ACE study) 15 SBIRT: CAGE and AUDIT tools for Alcohol Use Disorder SBIRT CAGE AUDIT 1. How often do you have a Screening C. Have you ever felt the need to cut drink containing alcohol? down on your drinking? A. Have people annoyed you by Brief Intervention criticizing your drinking? 2. How many units of alcohol do you drink on a typical day G. Have you ever felt guilty about when you are drinking? Referral to Treatment your drinking? E. Do you ever drink an Eye-opener 3. How often have you had 6 in the morning to relive the shakes? or more units if female, or 8 or more if male, on a single occasion in the last year? 16 PHQ-2 Depression Screening Tool 17 Objective Data Collection: ► Direct Observation General Survey ► Measurements Vital Signs Labs and Imaging ► Physical Exam Inspection Palpation Percussion Auscultation 18 General Survey ► “AAOX4” ▶Physical Appearance ► “Dressed appropriately for the season/situation” ► “Smooth, coordinated range of motion (ROM)” ► “Weight within range for height and build” ▶Body Structure ► “Gait smooth, even, well-balanced” ► “Posture erect” ▶Mobility ► “Facial features symmetric” ► “Clean, well-groomed” ▶Behavior ► “Sits comfortably, relaxed” ► “Uniform coloring, no lesions” 19 Physical Exam Techniques INSPECTION PALPATION PERCUSSION AUSCULTATION 20 A few words about Percussion and Auscultation The bell is held lightly against the skin to pick up low-pitched sounds such as extra heart sounds, murmurs, or bruits. The diaphragm firmly against the skin to pick up high- pitched sounds such as breath, bowel, and normal heart sounds. 21 Approach to Physical Exam ▶ Preparing the patient Establish nurse-client relationship BEFORE physical exam Explain the process and reasons Respect client desires and requests Examination gown Begin with less intrusive procedures first 22 Vital Signs ►Temperature 98.6F = 37C ►Pulse (HR) 110 ►Respiration rate (RR) 16 ►Oxygen saturation (SpO2) 88% ►Blood pressure (BP) 120/76 ►Pain 6/10 23 Pain Scales Behavioral Pain Scale 24 Types of Pain ► Acute: Sudden and resolves with healing ► Chronic: Persists > 3-6 months with debilitation ► Nociceptive: Nerve receptors react to noxious stimuli causing damage Somatic - Tissues Visceral - Organs Radicular– Nerve root ► Neuropathic: Damage to Nervous tissues 25 Question 1 ► Thenurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? a) A focused assessment covers the body head to toe, unlike a comprehensive assessment b) A focused assessment occurs only in the clinic area, unlike a comprehensive assessment c) A focused assessment involves all body systems, unlike a comprehensive assessment d) A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment 26 Question 2 ► Thenurse is assessing a client’s complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? a) Character b) Onset c) Severity d) Pattern 27 Question 3 ► A clienthas presented for care with complaints of persistent lower back pain. When assessing the client’s pain, which statement, made by the nurse, would be most appropriate? a) “What makes your pain better or worse?” b) “Does this pain really bother you every day?” c) “Did either of your parents have back pain?” d) “Heating pads usually help relieve my pain.” 28 Question 4 ► To adhere to standard precautions, the nurse should remember to do which? Select all that apply. a) Perform hand hygiene before and after direct client contact. b) Remove any personal protective equipment (PPE) before leaving client’s room. c) Wear gloves for each client contact. d) When a gown is required, reuse gown when reinitiating contact with the same client. 29 Question 5 ► A nurse reviews the vital signs of a 77-year-old client: temperature 99.2 F (37.33 C), heart rate 90 beats/min, blood pressure 130/70 mmHg, respiratory rate 22 breaths/min and shallow, and oxygen saturation 90% on room air. Which action should the nurse take next? a) Apply oxygen b) Chart findings as normal c) Assess the client for infection d) Notify the health care provider regarding tachypnea 30 Case Study A 42 yo female presents for an annual check-up. The MA takes her VS and enters them in the chart for you to review before you enter the room. T: 37.5C HR: 106 RR: 20 BP: 148/86 SpO2: 96% The description from the MA is: “Mrs. D does not seem like herself today. Her clothes are mismatched, her hair doesn’t look like it’s been brushed, and she seems distracted.” Your initial assessment before meeting the patient is…? a. Mrs. D is depressed b. Mrs. D is taking drugs c. Mrs. D needs BP medication d. Mrs. D is stressed 31 Case Study You walk in the patient room and see this… How might your assessment change or stay the same? a. Mrs. D is depressed b. Mrs. D is taking drugs c. Mrs. D needs BP medication d. Mrs. D is stressed 32 Case Study While interviewing the patient, she tells you about her current circumstances: - She has 3 young children at home - Her husband had back surgery—he’s home now, but is on bedrest - Her mother usually helps but has been visiting friends out of state - School just started back this week. Two children attend elementary school around the corner, and the youngest goes to daycare, but it is closed this week because two of the employees contracted Covid-19. Based on the general survey, VS assessment, and patient communication, what assessment do you want to do next? a. Repeat Temp, HR, BP b. Evaluate her typical lifestyle vs current in more detail c. Ask about coping mechanisms d. Screen for Covid-19 33 Module One Quiz ► The Module One quiz will open Thursday for all sections. ► You may use any of your course resources. There are 20 questions: 15 on Module One and 5 on the Syllabus. ► You may take the quiz 3 times. ► You must obtain an 80% to be awarded the 3 points toward your final grade. ► This Quiz will help prepare you for the 3 exams. ► Remember, any information in the modules, in the E-book readings, and in the class presentations are fair game for the exams. 34 Moving into Lab… 1. The norm is for students to take each other’s history and conduct exams on one another. But we want to model trauma informed care for all people and that means getting consent 2. If you feel this will not be acceptable to you, please let your lab instructor or lab coordinator know so we can employ accommodations. 3. If you do not reach out to discuss your preferences, we will assume you are comfortable participating as described. 35