NUR 097 1-3 PDF - Health Assessment

NUR 097 Module 1 Definition of Health Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets” Physical health- how the body words and adapts. Emotional health- positive outlook and emotions and cha...

NUR 097 Module 1 Definition of Health Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets” Physical health- how the body words and adapts. Emotional health- positive outlook and emotions and channeled in a healthy manner. Social well-being- supportive relationships with family and friends. Cultural Influence- favorable connections to promote health Spiritual Influence- living peacefully, morally, ethically Environmental Influence- favorable conditions to promote health Developmental level- how one thinks, solves problems, and make decisions. Health is a sum of these facets and not solely defines as the absence of disease or eating right, but rather by the contribution of all dimensions. Health Assessment The nursing health assessment entails both a comprehensive health history and a complete physical examination, which are used to evaluate the heath and status of a person, The nursing health assessment involve systematic data collection that provides information to facilitate a plan to deliver the best care for the patient. The first part of health assessment in a health history, which also ‘incorporates “7 facets” The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records may be also be used to collect additional information. Learning about the patient’s physical phycological issues, social and cultural associations, environment, developmental level, and spiritual beliefs contribute to the history. The second component of the health assessment is the physical examination. The nurse uses a structured head-to-toe examination to changes in the patient’s body system. An unusual or abnormal finding may support the history data or trigger additional questions.  The purpose of the nursing heath assessment is to determine the patient’s health status, risk factors, and need for education as a basis for developing a nursing plan of care. The nursing process is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan is the overall goal. The information obtained throughout the health assessment should be documented in a clear, concise manner. This information is collated in the patient’s medical records. NURSING PROCESS The nurse uses NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and develop an action plan; implement the plan; and evaluate outcome. The NURSING PROCESS steps are: Assessment Diagnosis Planning Implementation Evaluation Assessment- It is the first step of the nursing process. It is the subjective and objective data gathered during the initial health history and physical examination and collected on each patient encounter. Diagnosis- has a nursing focus and is based on real or potential health problems or human responses to health problems. The nurse uses clinical reasoning to formulate diagnosis on the assessment data and the patient’s problem list. Planning- is devising the best course of action to address the patient's diagnosis. During planning, the nurse and the patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the nursing diagnosis in order to alleviate, decrease, or prevent the problems addressed in the nursing diagnosis and the planned goals. Evaluation- is a continuing process to determine if the goals have been attained. The nursing care plan is revised based on the patient’s condition and whether the goals are realistic or appropriate for the patient. Types of Health Assessment  The admission of a new patient to a clinic hospital, long-term care facility, or visiting nurse agency usually requires a comprehensive health assessment. a. A focused or problem-oriented assessment is where the nurse focuses on gathering information about the patient’s problem. A follow-up history is a form of a focused assessment. An emergency history is a data collection which focused on the patient’s emergent problem with a systematic prioritization of a need beginning with the ABCs airway, breathing, and circulation. Module 2 INTERVIEWING AND COMMUNICATION Health History Interview − A conversation with a purpose within a free using health history format: 1. Establish a trusting and supportive relationship. 2. Gather information 3. Offer information Health History Format − Is a structure framework for organizing patient information in written, electronic, and verbal form to communicate effectively with other health care providers. − Patient’s information is concisely organized into three categories: Past Present Family history Phases of Interview 1. Pre-Interview; set the stage for a smooth interview Self-Reflection Self-Reflection is a continual part of a professional development in a clinical work. It brings a deepening personal awareness of our work with patients, which is one of the most rewarding aspects of patient care. Review Patient Record Set interview goals Review own clinical behavior and appearance  2. Introduction: put the patient at ease and establish trust Greet the patient and establish rapport Establish the agenda for the interview 3. Working: obtain patient information Invite the patient’s story Identify and respond to emotional clues Expand and clarify the patient’s story Generate and test diagnostic hypotheses Negotiate a plan, including further evaluation, treatment, education, and self- management support and prevention THE SEVEN ATTRIBUTES OF A SYMPTOM 1. Onset- When did (does) it start? Setting in which it occurs, including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 2. Location- Where is it? Does this radiate? 3. Duration- How long does it last? 4. Characteristics Symptoms- What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10) 5. Relieving/Exacerbating Factors- Is there anything that makes it better or worse? Treatment. What have you done to treat this? Was it Effective? EXPLORE SEVEN THE PATIEN’S PERSPECTIVE (FIFE) The patient’s feelings, including fears or concerns, about the problem. The patient’s Ideas about the nature and the cause of the problem The effect of the problem on the patient’s life and Function The Patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences 4. Termination: Summarize important points Discuss plan of care “So, you will take the medicine as we discussed, check your blood glucose daily, and make a follow-up appointment for 4 weeks. Do you have any  questions about this?” Address any related concerns or questions that the patient raises. Types of data: Subjective data are information from the client’s point of view (“Symptoms”). Including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (”signs") obtained through observation, physical examination, and laboratory and diagnostic testing. History of Present Illness (HPI). This section of the history is the complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments. The HPI should reveal the patient’s responses to the symptoms and the effect the illness has had on daily living. Key Elements of the History of the Present Illness: Seven attributes of each principal symptom Self-treatment for the symptom by the patient or family Past occurrences of the symptom(s) Pertinent positives and/or negatives from the review of the systems Risk factors or other pertinent information related to the symptoms SEVEN ATTRIBUTES OF A SYMPTOM OLD CART, Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment. Key Elements of the Past History: Allergies, including reactions to each medication, such as rash or nausea, must be recorded. Allergies to foods, insects, or environmental factors along with the patient’s reaction should also be noted. Medications, including name, dose/ route, and frequency of use, are included. Also list remedies, nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family members or friends. If the patient is unsure, ask him or her to bring in all medications to see exactly what is taken. Childhood illness, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illness, such as asthma. Adult illness in each of the following areas: Medical: illness such as diabetes, hypertension, hepatitis, asthma, or HIV; hospitalizations Surgical: Dates, reasons for surgery, and types of operations or treatments. Accidents: type, dates, treatment and residual disability of major accidents Psychiatric: illness and time frame, hospitalizations, and treatments Health Maintenance Immunizations: Ask whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles, mumps influenza, varicella, hepatitis B, Haemophilus influenza type B, Neisseria meningitides, and pneumococci. Include the dates of the original and booster immunizations. Screening tests: Such as tuberculin tests, cholesterol tests, cholesterol tests, stool for occult blood, Pap smears, and mammograms. Include the results and the dates the tests were performed. Alternatively, screening tests maybe asked about during and documented in the review systems. Safety Measures: Seat belts in cars, smoke/carbon monoxide detectors, sports helmets pr padding, etc. Risk Factors: ✓ Tobacco: Do you use or have you ever used tobacco? At what age did you start? How many packs per day? (Pd) do you smoke? How many Ppd in the past? ✓ Environemtal Hazards: In home or work environment? ✓ Substance abuse: Do you used marijuana, cocaine, heroin, or other recreational drugs? ✓ Alcohol: How much alcohol do you drink per sitting and per week? Free History outlines or diagrams on a genogram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, siblings, children, and grandchildren. Review of systems, Understanding and using Review of Systems questions are often challenging for beginning students. Think about asking a series of questions going from “head-to-toe". It is helpful to prepare the patient for the questions to come by saying, “The next part of the history may feel like a hundred questions, but they are important and I want to be thorough. “Most Review of Systems questions pertain to symptoms, but on occasion some nurses also include diseases like pneumonia or tuberculosis. Health Patterns provide a guide for gathering personal/social history from the patient and daily living routines that may influence health and illness. Metal health history. Cultural constructs of mental and physical illness vary widely, causing marked differences in acceptance and attitudes. Think how easy it is for patients to talk about diabetes and taking insulin compared with discussing schizophrenia and using psychotropic medications. Ask open-ended questions initially. “Have you ever had any problem with emotional or mental illnesses?” Then move to more specific questions initially. “Have you ever had any problem with emotional or mental illnesses?” Then move to more specific questions such as: “Have you ever visited a counselor or psychotherapists?” “Have you ever been prescribed medication for emotional issues?” “Have you or has anyone in your family ever been hospitalized for an emotional or mental health problems?” Module 3 Physical Examination A process to obtain objective data from the patient Each body system connects to another The purpose of the physical examination is to determine changes in a patient’s health status and how to respond to a problem as well as promote healthy lifestyles and wellbeing. THE COMPREHENSIVE ADULT PHYSICAL EXAMINATION Beginning the Examination: Setting the Stage Preparing for the Physical Examination: Reflect on your approach to the patient Adjust the lighting and the environment Make the patient comfortable Check your equipment Choose the sequence of examination Reflect your Approach to the Patient: Identify yourself as a nursing as a nursing student.  Try to appear calm, organized, and a competent. Most patients view the physical examination with some anxiety. Avoid interpreting your findings-if you find anything that is unusual or disturbing, always talk with your clinical instructor. Adjust the Lighting and Environment “Set the stage” so that both you and the patient are comfortable. Good lighting and a quiet environment make important contributions to what you see and hear but maybe hard to arrange. Tangential lighting optimal for inspecting structures such as jugular venous pulse, the thyroid gland, and the apical impulse of the heart Make the Patient Comfortable: Showing your concern for privacy and patient modesty must be ingrained in your professional behavior. Close nearby doors and draw the curtains in the hospital or examining room before examination begins Wash your hands Draping the patient- goal is to visualize one area of the body at a time keep the patient informed, especially when you anticipate embarrassment or discomfort checking vital signs, tell the patient the results the examination is completed, tell the patient your general impressions and what to expect next. Observe Standard and Universal Precautions Standard and MRSA precautions: Based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Hand hygiene, use of protective equipment, safe injection practices, safe handling of contaminated equipment. Universal Precautions Set of guidelines designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood-borne pathogens when providing first aid or health care.  Following fluids are considered potentially infectious: ✓ All blood and other body fluids containing visible blood ✓ Semen and vaginal secretions ✓ Cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Protective barriers include: Gloves, gowns, aprons, masks, and protective eyewear. All health care workers should observe the important precautions for safe injections and prevention of injury from needle sticks, scalpels, and other sharp instruments and devices. Make Privacy and Comfortable Patient Privacy and Comfort: Close nearby doors, draw the curtains in the hospital or examining rooms, wash your hands thoroughly. During the examination be aware of the patient’s feelings and any discomfort. Draping the Patient: Goal: to visualize one are of the body at a time. When patient is sitting, auscultate the lungs with the gown unties in the back. Breast examination, uncover the right breast and keep the left chest draped. Abdominal examination, only the abdomen should be exposed. Cardinal Technique of Examination: Note: abdominal examination, the pattern will be inspection, auscultation, percussion, and palpation. INSPECTION Close observation of the details of the patient’s appearance, behavior, and movement such as:  ✓ Facial expression, mood, body build and conditioning, skin conditions such as petechiae or ecchymosis, eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait. PALPATION Tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, or tenderness; lymph nodes: pulses: contours and sizes and organs and masses: and crepitus in the joints. Metacarpal/phalangeal joint or ulnar surface of the hand is used to detect vibration. PERCUSSION Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand lay against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger. AUSCULTATION Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For the heart this involves sounds from closing of the four valves and flow into ventricles as well as murmurs. Auscultation also permits detection of bruits, i.e., turbulence over arterial vessels.