NSB103 Health Assessment Lecture Notes PDF

NSB103 Health Assessment Lecture: Normal vs Abnormal Assessment Data ACKNOWLEDGEMENT OF TRADITIONAL OWNERS QUT acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We pay respect to their Elders, lores, customs and creation spirits. We recognise...

NSB103 Health Assessment Lecture: Normal vs Abnormal Assessment Data ACKNOWLEDGEMENT OF TRADITIONAL OWNERS QUT acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We pay respect to their Elders, lores, customs and creation spirits. We recognise that these lands have always been places of teaching, research and learning. QUT acknowledges the important role Aboriginal and Torres Strait Islander people play within the QUT community.  Learning this Week Normal vs abnormal General survey data (subjective) Normal vs abnormal Primary survey data (ABCDE) Normal vs abnormal vital signs Normal vs abnormal cardiovascular system assessment data Normal vs abnormal respiratory system assessment data Normal vs abnormal neurological assessment data https://www.freepik.es/vector-premium/gente-sentada- en-la-computadora-portatil-grande_1253706.htm  Defining Key Terms Objective assessment data: is the physical data we can observe using our senses. Objective findings come in either a measurement or a direct observation. Objective data cannot be argued, as it is measured and observed through vital signs, tests, and physical examination. Subjective assessment data: information obtained from the patient or from a carer or significant other, such as how they are feeling, what their symptoms are, or what their current concerns are. Abnormal assessment data: health assessment data that deviates from what is normal eg outside normal vital sign ranges or parameters. Acute patient deterioration: Acute deterioration includes physiological changes as well as acute changes in cognition and mental state (Australian Commission on Safety and Quality in Health Care, 2021). *National Safety and Quality Health Service (NSQHS) Standard 8: Recognising and Responding to Acute Deterioration.  The General Survey The general survey is a way of ascertaining your impression of the person, includes the general health state and any obvious physical characteristics and usually forms the first part of objective data collection.  The General Survey: Physical Status Data Normal Abnormal Stated age versus apparent age Person’s stated age should be congruent Not ageing well; child larger or smaller than with their apparent age. Ageing well age General appearance Body should be symmetrical; no obvious Visible disabilities/anomalies; distinctive deformity; tatoo’s/piercings (normal/cultural); markings (?normal); facial asymmetry- eg should have a look of wellness (colour etc) drooping- causes?; Body fat muscle, body fat should be fairly evenly BMI category- underweight, overweight, distributed, different types of body shapes; obese? Uneven weight distribution- linked to specific diseases Body conformation and posture Erect posture; arms and legs in proportion Posture slumped, humpbacked, kyphosis to body height Motor activity Movement and gait should be smooth and Slow movement; limping; shuffling gait; effortless; all body parts have controlled tremors purposeful movement. Body and breath odours Reasonably odour free, can be dependent Bad breath (halitosis) - sweet smelling on type of diet; Eg foods, spicy, garlicky?- breath, cigarettes, alcohol etc; these are normal Body odour- severe body odour, sweat  The General Survey: Psychological Status Data Normal Abnormal Mental status and Appear awake and alert, orientated to person, Altered level of consciousness; confusion, lethargy, cognitive function place and date/time stupor, coma; altered attention, memory, (level of (AVPU- Alert; GCS- 15; MMSE- normal judgement; Dementia, Delirium, neurological injury consciousness) memory and function) etc Facial expression Facial expression should be appropriate for the Lack of expression, apathy; unchanging or flat facial circumstances and should change naturally expression, inappropriate facial expression, tremors, tics Dress, grooming, Presents clean and neatly dressed; dressed Disheveled, unkempt appearance or unclean personal hygiene appropriately for the weather. clothes; unclean, unshaven; clothes not appropriate for weather Mood and manner Presents as cooperative, and pleasant Uncooperative, hostile, tearful, unusual elation, mood swings, flat effect or mood, euphoria Speech and Should be clear and understandable, responds Speech that is slow, slurred, mumbled, not communication to questions and commands easily. Pitch, rate, articulate, very loud or rapid volume and content should be appropriate to circumstances Distress Signs of distress absent, breathing effortless, Shortness of breath, laboured speech, wheezing, face relaxed coughing, facial expressions showing pain  The Primary Survey Systematic assessment of a patient Assessing for injuries or medical conditions Quick and comprehensive The Purpose of a Primary Survey is to identify: any abnormalities or issues/concerns any deterioration in your patient any modifications to the patient’s current care plan  The Primary Survey: A and B Normal Abnormal A- Airway Clear/patent; patient should be able to speak Noisy breathing; obstruction normally B- Breathing Eupnoea; Respiration rate: 12-20 breaths per Inspiration/expiration irregular; shallow min for adult; regular; no abnormal sounds; breathing; use of accessory muscles; symmetrical breathing; work of breathing- tracheal tug, nasal flaring normal Abnormal lung sounds on auscultation O2 saturations: 95-100% Tachypnoea/bradypnoea/apnoea Hypoxaemia; hypoxia O2 sats 2 seconds. Capiliary refill: 170bpm 115bpm 110bpm 100bpm 100bpm 50 resps per min 20 resps per min 20 resps per min 20 resps per min 20 resps per min