Week 2 Health Assessment PDF

BACHELOR OF SCIENCE IN NURSING: HEALTH ASSESSMENT COURSE MODULE COURSE UNIT WEEK 1 2 2 Collection of Subjective Data Through Interview and Health History, Collec...

BACHELOR OF SCIENCE IN NURSING: HEALTH ASSESSMENT COURSE MODULE COURSE UNIT WEEK 1 2 2 Collection of Subjective Data Through Interview and Health History, Collection of Objective Data ✓ Read course and unit objectives ✓ Read study guide prior to class attendance ✓ Read and comprehend required learning resources ✓ Engage in classroom discussions ✓ Participate in weekly discussion board (Canvas) ✓ Answer and submit course unit tasks At the end of this unit, the students are expected to: Cognitive: 1. Discuss the role of nurses in health assessment process. 2. List and explain the types, methods, techniques and components of assessment. 3. Identify and explain the process of Physical Assessment. 4. Identify the four physical assessment techniques. 5. Understand the different guidelines involve during physical examination. 6. Enumerate the importance of physical assessment techniques. 7. Describe the nurse’s role for each of the phases involved in diagnostic testing. 8. Discuss the nursing responsibilities for specimen collection.  9. Describe how to collect and test stool specimens. 10. Describe how to collect sputum and throat specimens. 11. Demonstrate appropriate documentation and reporting of diagnostic testing information. Affective: 1. Inculcate that the assessment phase is the most important phase of the nursing process. An effective nursing care plan contains an accurate assessment. 2. Listen attentively during class discussions 3. Demonstrate tact and respect when challenging other people’s opinions and ideas 4. Accept comments and reactions of classmates on one’s opinions openly and graciously. Psychomotor: 1. Participate actively during class discussions 2. Confidently express personal opinion and thoughts in front of the class Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia: Wolters Kluwer Assessment: Step One of the Nursing Process Is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process: diagnosis, planning, implementation, and evaluation. Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all phases of the nursing process. Thus, health assessment is: o Gathering information about the health status of the client o Analyzing and synthesizing that data o Making judgments about the effectiveness of nursing interventions o Evaluating client care outcomes The nursing process should be thought of as circular, not linear. TYPES OF DATA Subjective Data o symptoms or covert data  o apparent only to the person affected Objective Data o signs or overt data o detectable by an observer o can be measured, tested SOURCES OF DATA CLIENT o Best source of data, subjective data Support people o Family members, friends and caregivers o Important source of data if the client is young o unconscious or confused Client records o Information documented by other healthcare professionals Health care professionals o verbal reports Literature o journals, reference texts, published studies DATA COLLECTION METHODS Observing o To gather data using the senses o A conscious, deliberate skill o 2 aspects ▪ Noticing the data ▪ Selecting, organizing and interpreting the data Interview o Planned communication or conversation with a purpose o To get or give information o Identify problems of mutual concern o Evaluate change, teach, provide support o Provide counselling or therapy PHASES OF THE INTERVIEW Pre -Introductory Phase o Nurse reviews the medical record before meeting with the client o If a medical record is not established, the nurse will need to rely on interview skills to elicit valid and reliable data from the client and that individual’s family or significant other Introductory Phase o The nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential  o The nurse makes sure that the client is comfortable (physically and emotionally) and has privacy o The nurse should develop trust and rapport at this point in the interview Working Phase o Longest Phase o Verbal / Nonverbal o The nurse elicits the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level o The nurse listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client o The nurse and client collaborate to identify the client’s problems and goals Summary and Closing Phase o Summarize / Restate o Clarify o The nurse summarizes information obtained during the working phase and validates problems and goals with the client o The nurse identifies and discusses possible plans to resolve the problem (nursing diagnoses and collaborative problems) with the client o Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions TYPES OF INTERVIEWS Directive Interview o Highly Structured o Controlled by the Nurse o Elicits specific information o Nurse uses directive questions Non – Directive Interview o Rapport – building interview o Controlled by the client Information Gathering Interview o Combination of non – directive and directive interview TYPES OF INTERVIEW QUESTIONS Closed Questions o Used in directive interview o Answerable only by Yes or No o Often begin with where, who, what, do, is o For patients who are highly stressed and has difficulty communicating o Ex. “Do you feel pain?” Open – Ended Questions o Used in non – directive interview  o Invites client to explore, elaborate, clarify thoughts or feelings o Useful in eliciting attitudes and mental status o Often begin with what and how o Ex. “What brought you to the hospital?” Neutral Questions o A question that the client can answer without direction or pressure from the nurse Leading Questions o Closed o Directive o Persuasive FACTORS TO CONSIDER DURING THE INTERVIEW Time o When the client is physically comfortable and free of pain Place o Well – lighted, well – ventilated room, free of noise and distractions Seating Arrangement o Ideal seating arrangement: the nurse and patient sit in two chairs placed at right angles to a desk or a table or a few feet apart with no table Distance o Maintain a 2 to 3 feet distance during interview Language o Avoid medical jargon o Translators, interpreters THINGS TO AVOID DURING AN INTERVIEW Leading the patient Biasing yourself Letting family members answer for patient Asking more than one question at a time Not allowing enough response time Using medical jargon Assuming rather than clarifying and validating Taking the patient’s responses personally Feeling personally uncomfortable Using clichés Offering false reassurance Asking persistent or probing questions Changing the subject Taking things literally Giving advice Jumping to conclusions EXAMINING Physical Examination  o Carried out systematically o Cephalocaudal or head to toe approach Screening Examination o Also called review of systems o A brief review of essential functioning of various body parts or systems ACTIVITIES OF DAILY LIVING (ADL) Hygiene o bathing, grooming, shaving and oral care Continence Dressing Eating o the ability to feed oneself Toileting o the ability to use a restroom Transferring o actions such as going from a seated to standing position and getting in and out of bed INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) Finding and utilizing resources o looking up phone numbers, using a telephone, making and keeping doctors’ appointments Driving or arranging travel o either by public transportation, such as Paratransit, or private car Preparing meals o opening containers, using kitchen equipment REVIEW OF SYSTEMS Each body system is addressed o Skin, Hair, Nails – color, Temperature, etc. o Head and Neck – headache, swelling, etc. o Eyes – vision problems, etc. o Ears – Tinnitus, etc. o Mouth – lesions o Thorax and Lungs – DOB, etc. o Breast / regional lymphatics – lumps, etc. o Heart / neck vessels – BP, chest pain etc. o Peripheral vascular – edema, etc. o Abdomen – constipation, etc. o Male genitalia – urination, erection, etc. o Female genitalia – dyspareunia, etc. o Anus, rectum, prostate – bowel habits, pain o Musculoskeletal – swelling, pain o Neurologic – mood, behavior etc. COMPLETE HEALTH HISTORY Lays the groundwork for identifying nursing problems and provides a focus for the physical examination The importance lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual’s lifestyle and current health status Data from health history provide the examiner with specific cues to health problems that are most apparent to the client Modified or shortened when necessary o Eg. If the physical assessment will focus on the heart and neck vessels, the subjective data collection would be limited to the data relevant to the heart and neck vessels STEPS OF HEALTH ASSESSMENT A. Collection of Subjective Data Through Interview and Health History a. Biographical data ▪ Usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others ▪ The client is considered the primary source and all others (including the client’s medical record) are secondary sources ▪ In some cases, the client’s immediate family or caregiver may be a more accurate source of information than the client ✓ Eg. An older-adult client’s wife who has kept the client’s medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful. ▪ A format summary used to obtain biographical data may include: ✓ Name ✓ Address ✓ Phone ✓ Gender ✓ Provider of history (patient or other) ✓ Birth date ✓ Place of birth ✓ Race or ethnic background ✓ Primary and secondary languages (spoken and read) ✓ Marital Status ✓ Religious or Spiritual Practices ✓ Educational Level ✓ Occupation ✓ Significant others or support persons (availability) b. Reasons for seeking health care ▪ Reason for seeking health care (major health problem or concern) ▪ Feelings about seeking health care (fears and past experiences) ▪ This category includes two questions:  ✓ “What is your major health problem or concerns at this time?” o This question assists the client in focusing on the most significant health concern and answers the nurse’s question, “Why are you here?” or “How can I help you?” o Physicians call this the client’s chief complaint (CC) ✓ “How do you feel about having to seek health care?” o This question encourages the client to discuss fears or other feelings about having to see a health care provider. o This question may also draw out descriptions of previous experiences—both positive and negative—with other health care providers. c. Chief complaint ▪ Questioning the client “What is your major health problem or concerns at this time?” implies the client’s chief complaint (CC), but a more holistic approach for phrasing the question may draw out concerns that reach beyond a physical complaint and may address stress or lifestyle changes d. History of ▪ Present illness ✓ History of Present Health Concern Using COLDSPA o Character Describe the sign or symptom (feeling, appearance, sound, smell, or taste if applicable) “What does the pain feel like?” How does it feel, look, smell, sound, etc.? o Onset When did it begin; is it better, worse, or the same since it began? “When did this pain start?” o Location Where is it? Does it radiate? Does it occur anywhere else? “Where does it hurt the most? Does it radiate or go to any other part of your body? o Duration How long does it last? Does it recur? “How long does the pain last? Does it come and go or is it constant?” o Severity How bad is it on a scale of 1 (barely noticeable) to 10 (worst pain ever experienced)? How much does it bother you? “How intense is the pain? Rate it on a scale of 1 to 10.” o Pattern  What makes it better? What makes it worse? “What makes your back pain worse or better? Are there any treatments you’ve tried that relieve the pain?” o Associated factors What other symptoms do you have with it? Will you be able to continue doing your work or other activities (leisure or exercise)? What other symptoms occur with it? How does it affect you? “What do you think caused it to start? Do you have any other problems that seem related to your back pain? How does this pain affect your life and daily activities?” ▪ Past health history ✓ Ask about o Childhood illness o Childhood immunizations o Adult illnesses o Past surgeries or accidents o Experienced pain o Allergies o Hospitalizations o Pregnancies o Births o Injuries o Medications o Emotional or psychiatric problems ✓ Sample questions may include: o “What diseases did you have as a child?” o “What immunizations did you get and are you up to date now?” o “Do you have any chronic illnesses? If so, when were they diagnosed? How are they treated? How satisfied have you been with the treatment?” o “What illnesses or allergies did you have? How were the illnesses treated?” ▪ Family health history ✓ Document information in a genogram and in a list of familial diseases ✓ Nurses must be familiar with the field of genomics ▪ Current medications ✓ Sample questions may include: o “What medications have you used in the recent past and currently, both those that your doctor prescribed and those you can buy over the counter at a drug or grocery store? For what purpose did you take the medication? How much (dose) and how often did you take the medication? Do you take any medications not prescribed for you but prescribed for a family member/friend or purchased on the street?” ▪ Lifestyle and Health Practices Profile ✓ A very important section of the health history because it deals with the client’s human responses, which include o Description of typical day Elicit an overview of how the client sees his usual pattern of daily activity Encourage the client to discuss a usual day, which, for most people, includes work or school o Nutritional and weight management These questions uncover food habits that are health promoting as well as those that are less desirable Ask the client to Recall what consists of an average 24-hour intake with emphasis on what foods are eaten and in what amounts What snacks, fluid intake, and other substances they consumed Sample questions may include: “What do you usually eat during a typical day? Please tell me the kinds of foods you prefer, how often you eat throughout the day, and how much you eat?” “Do you eat out at restaurants frequently?” o Activity and exercise patterns  Assess how active the client is during an average week either at work or at home Distinguish between activity done when working, which may be stressful and fatiguing, and exercise, which is designed to reduce stress and strengthen the individual Explain to the client that regular exercise reduces the risk of heart disease, strengthens heart and lungs, reduces stress, and manages weight Sample questions may include: “What is your daily pattern of activity?” “Do you follow a regular exercise plan? What types of exercise do you do?” “Are there any reasons why you cannot follow a moderately strenuous exercise program?” o Sleep and rest patterns Questions should focus on specific sleeping patterns such as how many hours a night the person sleeps, interruptions, whether the client feels rested, problems sleeping (e.g., insomnia), rituals the client uses to promote sleep, and concerns the client may have regarding sleep habits Sleep requirements vary depending on age, health, and stress levels Sample questions may include: “Tell me about your sleeping patterns.” “Do you have trouble falling asleep or staying asleep?” “How much sleep do you get each night?” o Substance use Information provides the nurse with information concerning lifestyle and a client’s self-care ability Use of substance can affect the client’s health and cause loss of function or impaired senses Sample questions may include: “How much beer, wine, or other alcohol do you drink on average?” “Do you drink coffee or other beverages containing caffeine (e.g., cola)?” If so, how much and how often?” o Self-concept and self-care activities Assessment of how the client views herself and investigation of all behaviors that a person does to promote her health Examples of subjects to be addressed include sexual responsibility  basic hygiene practices regularity of health care checkups (i.e., dental, visual, medical) breast/testicular self-examination accident prevention hazard protection (e.g., seat belts, smoke alarms, and sunscreen) Sample questions may include “What do you see as your talents or special abilities?” “How do you feel about yourself?” About your appearance?” “Can you tell me what activities you do to keep yourself safe, healthy, or to prevent disease?” “Do you practice safe sex? o Social and community activities Help the nurse to discover what outlets the client has for support and relaxation and if the client is involved in the community beyond family and work Helps to determine the client’s current level of social development. Sample questions may include: “What do you do for fun and relaxation?” “With whom do you socialize most frequently?” “Are you involved in any community activities?” o Relationships Ask the client to describe the composition of the family into which they were born and about past and current relationships with these family members Information help assess problems and potential support from the client’s family of origin Sample questions may include: “Who is (are) the most important person (s) in your life? Describe your relationship with that person.” “What was it like growing up in your family?” “What is your relationship like with your spouse?” o Values and beliefs system Assess the client values, and discuss the clients’ philosophical, religious, and spiritual beliefs Some clients may not be comfortable discussing values or beliefs, feelings should be respected The data can help to identify important problems or strengths Sample questions may include: “What is most important to you in life?”  “What do you hope to accomplish in your life?” “What gives you strength and hope?” o Education and work Helps to identify areas of stress and satisfaction in the client’s life Questions should bring out data about the kind and amount of education the client has, whether the client enjoyed school, whether he perceives his education as satisfactory or whether there were problems, and what plans the client may have for further education, either formal or informal Sample questions may include: “Tell me about your experiences in school or about your education.” “Are you satisfied with the level of education you have?” Do you have future educational plans?” o Stress level and coping style Ask questions that address what events cause stress for the client and how they usually respond Find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive Sample questions may include: “What types of things make you angry?” “How would you describe your stress level?” “How do you manage anger or stress?” o Environment To assess health hazards unique to the client’s living situation and lifestyle Look for physical, chemical, or psychological situations that may put the client at risk These may be found in the client’s neighborhood, home, work, or recreational environment. Controllable or uncontrollable Sample questions may include “What risks are you aware of in your environment such as your home, neighborhood, on the job, or any other activities in which you participate “Do you believe you are ever in danger of becoming a victim of violence? Explain.” ▪ Developmental level ✓ Significantly impacts client’s health assessment ✓ The primary source of data varies depending on the patient’s age and developmental level  ✓ For patients with developmental alterations, findings related to intellectual ability must be interpreted according to the assessed developmental level not the patient’s age ▪ Psychosocial history ✓ Includes the way a person thinks, feels, acts and relates to self and others ✓ It is the ability to cope and tolerate stress and the capacity for developing a value and belief system ✓ Assessment must consider the interaction of body, mind and spirit in their entirety rather than as separate body systems ✓ Factors that influence psychosocial health o Internal factors Genetics Physical health Developmental stage Physical fitness o External factors Family Culture Geography Economic status ✓ Additional factors to consider in psychosocial health o Self – concept o Role development o Sexuality o Interdependent relationships o Ability to manage stress o To cope and adapt to change o Develop a belief and value system B. Collection of Objective Data a. Physical Examination ▪ What is physical assessment? ✓ A systematic way of collecting objective data from a client using the four examination techniques ▪ Use?? ✓ to assess or identify current health status ▪ Purpose of physical assessment ✓ Obtain physical data about the client’s functional abilities ✓ Supplement, confirm, or refute data obtained in the client’s health history ✓ Obtain data that will help the nurse data establish diagnoses and plan the client’s care ✓ Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem ✓ To make clinical judgments about a client’s health status  ✓ To identify areas for health promotion and disease prevention ▪ PREPARATION GUIDELINES ✓ Preparatory phase o Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and how he could cooperate (i.e. positioning). o Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder. o Ensure privacy by closing the doors or pulling the curtains around him. o Invite a relative or a significant other to stay with the client, as necessary o Provide adequate lighting. o Gather the Materials or Equipment. o Ensure the examination table is at a comfortable working height. Perform hand hygiene. ✓ Materials / Equipment needed o height chart o weighing scale o Snellen’s chart o penlight o card board o sterile gloves o tongue depressor o 4x4 Gauze o tuning fork o stethoscope o wrist watch o tape measure o marker/pencil o record sheet o waste receptacle ✓ Positioning your patient o STANDING FOR: assessment of posture, gait & balance CONTRAINDICATION (CI): Patients who are weak, disabled, or paralyzed may need assistance or may not be able to assume this position o SITTING seated position, back unsupported and legs hanging freely FOR: Head neck posterior and anterior thorax breast Breasts axillae heart vital signs, upper extremities lower extremities and reflexes CI: Elderly and weak clients may require support o DORSAL RECUMBENT Back lying position with knees flexed and hips externally rotated; small pillow under the head; soles of the feet on the surface FOR: Head and neck, axillae, anteror thorax, lungs, breasts, heart, extremities, peripheral pulses, vital signs and vagina CI: clients with cardio pulmonary problems. Not used for abdominal testing because of the increased tension in  abdominal muscles. If patient has abdominal pain, flexing knees is usually more comfortable o SUPINE The client is lying on the back. The head and shoulders are usually elevated with a small pillow. The arms and legs are extended and the legs are slightly abducted FOR: head neck axillae, anterior thorax, lungs, abdomen, extremities, peripheral pulses CI: Tolerated poorly by clients with cardiovascular and respiratory problems o SIM’S The client is lying on the side with the body turned at 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45-to-90-degree angle. FOR: assessment of rectum and vagina CI: Difficult for elderly and people with limited joint movement o PRONE The client is lying on the abdomen with head turned to the side. FOR: Posterior thorax,  hip joint movement CI: Often not tolerated by the elderly and people with cardiovascular and respiratory problem o LITHOTOMY The client is lying on the back with the hips and knees flexed at right angles and feet in stirrups. FOR: assessment of female rectum and vagina. (for a brief period only) CI: May be uncomfortable and tiring for elderly people. Often embarrassing o KNEE CHEST assessment of rectal area assessment of rectal area (for brief period only) Jack Knife ✓ Techniques in Physical Assessment o ADULT Cephalocaudal o PEDIA Least invasive to more invasive areas o ASSESSMENT TECHNIQUES Inspection (I)  Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner Careful observation Proper tangential lighting is necessary Begins with the initial contact and continues all throughout the assessment Moisture, color and texture of the body surfaces, as well as shape, position, size, color, and symmetry of the body Palpation (P) sense of touch The use of hand to touch and feel the patient’s skin, organs, mass, and other delineated structures in the body The pads of the fingers are used Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, consistency and mobility of organ or masses; distention; pulsation; and the presence pain upon pressure Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation, such as texture, vibration, presence of fluid, or size and consistency of a mass The dorsum, or back of the hand, is used to assess surface temperature LIGHT PALPATION ▪ Place the hand with fingers together parallel ▪ moving the hand in circle. ▪ 1/2 inch (1 cm) ▪ muscle tone ▪ tenderness DEEP PALPATION ▪ 1 inch (2 cm). ▪ abdominal organs and abdominal masses. ▪ Two – handed deep palpation place the fingers ▪ of one hand on top of those of the other. ▪ The top hand applies pressure while the lower ▪ hand remains relaxed to perceive the tactile  ▪ sensation. ▪ pressure can damage internal organs. BIMANUAL DEEP PALPATION ▪ Deep Palpation is done with two hands (bimanually) or one hand Percussion (P) Striking of the body surface with short, sharp strokes Palpable vibrations and characteristic sound location, size, shape density of underlying structures to detect the presence of air or fluid in a body space elicit tenderness Types: ▪ DIRECT PERCUSSION ▪ using sharp rapid movements from the wrist, strike the body surface to be percussed with the pads of two, three, or four fingers or middle finger alone ▪ Primarily used to assess sinuses in the adult ▪ Using one hand to strike the surface of the body ▪ INDIRECT PERCUSSION ▪ percussion in which two hands are used and the plexor strikes the finger of the examiner’s other hand, which is in contact with the body surface being percussed (pleximeter- the middle finger of the nondominant hand) ▪ Using the finger of the one hand to tap the finger of the other hand Percussion is used to access the location, shape, size, and density of tissues (Left) The nondominant hand is placed directly on the area to be percussed, and the middle finger is placed firmly on the body surface (Right) The tip of the middle finger of the dominant hand strikes the joint of the middle finger of the opposite hand  TECHNIQUE ▪ Strike at a right angle to the pleximeter using quick, sharp but relaxed wrist motion ▪ Withdraw the plexor immediately after the strike to avoid damping the vibration. Strike each are twice and then move to a new area Types Of Sounds Heard When Percussing ▪ FLAT – soft ▪ DULL – medium ▪ RESONANCE - loud ▪ HYPER RESONANCE – very loud ▪ TYMPANY – loud Auscultation (A) Listening to sounds produced within the body Characteristics of sound heard during auscultation ▪ PITCH – ranging from high to low ▪ LOUDNESS – ranging from soft to loud ▪ QUALITY – gurgling or swishing ▪ DURATION – short, medium or long BELL ▪ Use the bell of the stethoscope to detect low- pitched sounds ▪ The bell should be at least 1 inch wide. ▪ Hold the bell lightly against the body part being auscultated DIAPHRAGM ▪ Use the diaphragm of the stethoscope to detect high-pitched sounds ▪ The diaphragm should be at least 1.5 inches wide for adults and smaller for children ▪ Hold the diaphragm firmly against the body part being auscultated b. Diagnostic Tests and Procedures ▪ DIAGNOSTIC TESTS ✓ Commonly called laboratory tests ✓ Used for basic screening as part of wellness check ✓ Used to help confirm diagnosis, monitor an illness, and provide valuable information about the client’s response to treatment ▪ Diagnostic Testing Phases ✓ PRETEST o client preparation  o A throughout assessment and data collection (biological, psychologic, sociological, cultural and spiritual) assist the nurse in determining communication and teaching strategies. ✓ INTRATEST o specimen collection and performing or assisting with certain diagnostic testing. o The nurse uses standard precaution, sterile technique, provides emotional and physical support while monitoring the client. Also the nurse ensures correct labelling, storage, and transportation of specimen to avoid invalid test result. ✓ POST-TEST o on nursing care of the client and follow-up activities and observation. o The nurse compares the previous and current test result and report this to appropriate health team members. ▪ Nursing Diagnosis Appropriate for Client’s Who Will Undergo Diagnostic Testing ✓ Anxiety or Fear related to possible diagnosis of acute or chronic illness pending conclusion of diagnostic testing ✓ Impaired Physical Mobility related to prescribed bed rest and restricted movement of involved extremity after testing ✓ Deficient Knowledge (state diagnostic test) related to misperceptions received from others regarding process for test ▪ Common Diagnostic Tests ✓ BLOOD TESTS o commonly used diagnostic tests that can provide valuable information about the hematologic system o venipuncture (puncture of a vein for collection of a blood specimen) is peformed ✓ Complete Blood Count o includes hemoglobin and hematocrit measurements, erythrocyte (red blood cells) count, red blood cell indices, leukocyte (white blood cell) count, and a differential white cell count o CBC is a basic screening test and one of the most frequently ordered blood tests ▪ Serum Electrolytes ✓ often routinely ordered for any client admitted to a hospital as a screening test for electrolyte and acid–base imbalances ✓ also routinely assessed for clients at risk in the community, for example, clients who are being treated with a diuretic for hypertension or heart failure ✓ The most commonly ordered serum tests are for sodium, potassium, chloride, and bicarbonate ions ▪ Arterial Blood Gases ✓ Specialty nurses, medical technicians, and respiratory therapists normally take specimens of arterial blood from the radial, brachial, or femoral arteries o Check institutional policies also ✓ Because of the relatively great pressure of the blood in these arteries, it is important to prevent hemorrhaging by applying pressure to the puncture side for about 5 to 10 minutes after removing the needle ✓ Normal Values for Arterial Blood Gases o pH ▪ 7.35 – 7.45 o PCO2 ▪ 35 – 45 mm Hg o PO2 ▪ >80 mm Hg o HCO3 ▪ 22 – 26 mEq/L o O2 saturation ▪ >94% ▪ Blood Chemistry ✓ include determining certain enzymes that may be present (including lactic dehydrogenase [LDH], creatine kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferase [ALT]), serum glucose, hormones  such as thyroid hormone, and other substances such as cholesterol and triglycerides ✓ a common laboratory test is the glycosylated hemoglobin or hemoglobin A1C (HbA1C) test ▪ Metabolic Screening ✓ routinely screened for congenital metabolic conditions for newborns ✓ conditions that are frequently screened for include sickle cell disease and galactosemia ✓ screening involves collecting peripheral venous blood (via a heel-stick) on prepared blotting paper and sending the specimen to the state laboratory for analysis ✓ discovered abnormalities allow the provider and parents to plan early care (e.g., special diets for children with PKU) that can prevent long-term complications ▪ Capillary Blood Glucose ✓ a capillary blood specimen is taken to measure the current blood glucose level ✓ less painful than a venipuncture and easily performed ▪ STOOL SPECIMENS ✓ Some of the reasons for testing feces include the following: ✓ To determine the presence of occult (hidden) blood (guaiac test) ✓ To analyze for dietary products and digestive secretions ✓ excessive amount of fat in the stool (steatorrhea) can indicate faulty absorption of fat from the small intestine ✓ decreased amount of bile can indicate obstruction of bile flow from the liver and gallbladder into the intestine ✓ To detect the presence of ova and parasites ✓ To detect the presence of bacteria or viruses ▪ URINE SPECIMENS ✓ Clean Voided Urine Specimen o A clean voided specimen is usually adequate for routine examination o Routine urine examination is usually done on the first voided specimen in the morning because it tends to have a higher, more uniform concentration and a more acidic pH than specimens later in the day o 10 mL of urine is sufficient ✓ Clean-Catch or Midstream Urine Specimen o Clean-catch or midstream voided specimens are collected when a urine culture is ordered to identify microorganisms causing a urinary tract infection o Care is taken to ensure that the specimen is as free as possible from contamination by microorganisms around the urinary meatus  o Clean-catch specimens are collected in a sterile specimen container with a lid ✓ Timed Urine Specimen o collection of all urine produced and voided over a specific period of time, ranging from 1 to 2 hours to 24 hours o generally, either are refrigerated or contain a preservative to prevent bacterial growth or decomposition of urine components o purposes To assess the ability of the kidney to concentrate and dilute urine. To determine disorders of glucose metabolism, for example, diabetes mellitus To determine levels of specific constituents, for example, albumin, amylase, creatinine, urobilinogen, or certain hormones (e.g., estriol or corticosteroids), in the urine ▪ Indwelling Catheter Specimen ✓ Sterile urine specimens obtained from closed drainage systems by inserting a sterile needle attached to a syringe through a drainage port in the tubing ▪ SPUTUM SPECIMENS ✓ Sputum is the mucous secretion from the lungs, bronchi, and trachea o It is important to differentiate it from saliva, the clear liquid secreted by the salivary glands in the mouth, sometimes referred to as “spit” ✓ Healthy individuals do not produce sputum ✓ Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to expectorate it into a collecting container ✓ Collected for the following reasons: o For culture and sensitivity to identify a specific microorganism and its drug sensitivities o For cytology to identify the origin, structure, function, and pathology of cells o For acid-fast bacillus (AFB), which requires serial collection, often for 3 consecutive days, to identify the presence of tuberculosis (TB) o To assess the effectiveness of therapy ✓ often collected in the morning o upon awakening, the client can cough up the secretions that have accumulated during the night ✓ sometimes collected during postural drainage o when the client can usually produce sputum ✓ when a client cannot cough, the nurse sometimes use pharyngeal suctioning to obtain a specimen ▪ THROAT CULTURE ✓ collected from the mucosa of the oropharynx and tonsillar regions using a culture swab  ✓ sample is cultured and examined for the presence of disease-producing microorganisms ✓ To obtain a throat culture specimen, the nurse follows these steps: o Nurse applies clean gloves, then inserts the swab into the oropharynx and runs the swab along the tonsils and areas on the pharynx that are reddened or contain exudate o The gag reflex, active in some clients, may be decreased by having the client sit upright if health permits, open the mouth, extend the tongue, and say “ah,” and by taking the specimen quickly o The sitting position and extension of the tongue help expose the pharynx; saying “ah” relaxes the throat muscles and helps minimize contraction of the constrictor muscle of the pharynx (the gag reflex) o If the posterior pharynx cannot be seen, use a light and depress the tongue with a tongue blade ▪ Imaging studies ✓ Chest X-ray o Detects densities produced by fluid, tumors, foreign bodies and other pathologic conditions present on a normal radiolucent pulmonary tissue o Routine CXR consists of 2 views: ▪ Posteroanterior projection ▪ Lateral projection o Obtained after full inspiration because the lungs are best visualized when they are well aerated o Patients are instructed to take a deep breath and hold it without discomfort because the diaphragm is at its lowest level and the largest expanse of lung is visible o Contraindicated in pregnant women c. Other sources ▪ Client chart / medical or health record ✓ Contains information about what other health care professionals (ie. Nurses, physicians, physical therapists, dietitians, social workers, etc.) observed about the client ▪ Family or significant others observations about the client D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition, Singapore: Pearson Education, Inc. https://www.slideshare.net/ShaellsJoshi/nursing-assessment-13173390 https://www.slideshare.net/shantapeter/nursing-health-assessment-48824855 https://www.healthline.com/health/physical-examination https://www.healthline.com/find-care/articles/primary-care-doctors/getting-physical- examination#screening-tests https://nurse.org/articles/how-to-conduct-head-to-toe-assessment/ https://nurseslabs.com/nursing-assessment-cheat-sheet/ https://nurseslabs.com/category/nursing-notes/diagnostic-tests/ https://www.registerednursing.org/nclex/diagnostic- tests/#:~:text=Nurses%20educate%20clients%20about%20the,all%20laboratory%20tests%20and %20testing. Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia: Wolters Kluwer Berman, A.; Snyder S.J.; Frandsen, G.; (2016) Fundamentals of Nursing, 10th Edition, Harlow, England, Pearson Education *Kozier, Fundamentals of Nursing, 8th Edition Hinkle, J.L., and Cheever, K.H., (2018) Brunner & Suddarth’s Textbook of Medical – Surgical Nursing, 14th Edition, Philadelphia: Wolters Kluwer D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition, Singapore: Pearson Education, Inc.