9.2024 Class Day 1 Health Assessment Intro.Oxygenation.ppt PDF

Introduction to Health Assessment Anne Jones-Sutton RN MSN CPNP-PC Wake Tech MMSSON 2024-2025 NUR 101, 111, 214  Purposes of Physical Assessment SLO 1 Collect baseline cues re: patient’s health status Validate, build on and/or refute historical data while...

Introduction to Health Assessment Anne Jones-Sutton RN MSN CPNP-PC Wake Tech MMSSON 2024-2025 NUR 101, 111, 214  Purposes of Physical Assessment SLO 1 Collect baseline cues re: patient’s health status Validate, build on and/or refute historical data while analyzing cues Monitor outcomes of interventions; Complete reassessments and make clinical judgments about patient’s changing health status Evaluate outcomes of care 2 3  Concept of Assessment “Assessment provides nurses with information about physical, psychological, cognitive, and emotional well- being of patients that they can use to: analyze the data critically interpret it make clinical judgements to implement interventions for the best patient outcomes.” What frameworks come to mind? 4  Health Assessment & Physical Exam Environment SLO 2 Setting should ideally include: Privacy, Dignity, Cultural Sensitivity for patient; Attentive to needs Adequate lighting Quiet Comfortable patient (warm, pain managed, toileting needs met…) Necessary equipment available Minimal interruptions Infection control precautions  Think-Pair-Share: What is good vs. not so good about the setting below? SLO 2 6  Exam Environment SLO 2 cont. Safety for patient and nurse! Conserve your patient’s energy- minimize position changes Save your back! Note positions for exam: Table 30-2 Potter & Perry  Correct Approach SLO 2 1. 2. 3. 4. 5. 6. 7 8  Correct Approach Identify Self Hand Hygiene when entering room (& after care) Two patient identifiers every time you provide ordered care Explain why you are there, what you need from the patient or need to do with the patient Identify patient concerns (pay attention to nonverbal as well as verbal!) Engineer the right environment- manage noise, privacy; physical and psychosocial comfort of patient Be systematic and organized 9  Explain – Attend SLO 2 Tell what you are doing in simple terms Address patient using proper name (Mr./Ms...) unless they tell you another preference Let patient know what they will see- hear- feel- smell... Attend to patient’s nonverbal behaviors throughout exam 10  More tips! SLO 2 Use open-ended questions Get explanations from patient as much as they are able; family may add info p.r.n. Try to go thru assessment smoothly - no abrupt moves Be systematic & organized Adjust exam to be developmentally appropriate 11 Pick up on changes in health status earlier – not later! 12 Florence Nightingale  “Most important lesson for nurses”: What to observe How to observe Which symptoms: – Indicate improvement or decline – Important or not – Evidence of neglect & what kind ~Florence Nightingale on Observation (Inspection) Techniques of Physical Assessment SLO 5 I P P A () 15 Techniques of Physical Assessment Inspection Palpation Percussion Auscultation (Olfaction) What Cues to Observe (General Survey SLO 4 & Lab SLO 1) Appearance (age, affect, grooming, comfort, do they look ill...) Environmental safety; tubes, drains Alert, oriented, “appropriate” Nonverbal behaviors - congruence with verbal Support systems evident Mobility Aroma/odors; (use all your senses)  Pay attention! Check your skills of observation: http://www.youtube.com/watch? v=Ahg6qcgoay4 Clinical scenarios 18  How to Observe Think critically about what to assess based on: – Nursing knowledge – constantly building! – Personal & clinical experience – Patient history & current concerns – Standards of practice – As a beginner it is sometimes difficult to determine what cues are significant or not. – Practice & experience make the difference! – Always assess your patient- not just the machines they are hooked to or the test values received! Observation / Inspection of Body Pay attention to detail Compare side to side for symmetry, position, color etc. Have sufficient light Expose body parts for adequate visualization, but maintain patient’s modesty 20  Palpation Use fingertips, palms or back of hand (dorsum) to make sensitive assessments Think-Pair-Share: What are some uses of palpation when assessing: – Skin: – Abdomen: – Other? PALPATE TENDER AREAS LAST!!!  Percussion Produce a vibration that travels thru tissues Determine densities of organs Used more by advanced practice nurses Example: air filled = tympanic sound fluid filled = dull sound 22  Auscultation Listening to sounds the body makes - usually with stethoscope Clothing obscures sounds- place stethoscope directly on skin surface Diaphragm best for high pitch - bowel, breath and normal heart sounds Bell best for low pitch - extra heart sounds, murmurs Requires concentration & PRACTICE! 23  Familiarity With Stethoscope Practice most effective position of earpieces for listening Identify factors that interfere with hearing body noises with stethoscope Rethink wearing your stethoscope like a necklace! Infection control considerations for stethoscope 24  Olfaction Detect metabolic disorders, infection, draining wounds as well Any odor associated with this wound? Significance? as need for hygiene care Basically in assessment nurses use all of their senses (except taste!) Assessment skills improve with experience and practice! 25  Approaches to Physical Assessment (SLO 6) Head to Toe: Focused/System: Emergency: Periodic Reassessment/Monitoring 26 Head to Toe vs. Focused Approach Head to toe includes all body systems starting at the head and working down Focused assessment includes more detail re: area/system of concern if abnormalities are noted or suspected Emergency: “ABC’s” Airway, Breathing, Circulation 27 Which assessment approach needed most? 28 29  Vital Signs SLO 7 When can they be delegated to CNA?- (RN must always interpret & determine significance) Baseline values help detect changes over time Illness or Medication effects on V/S? When are more frequent V/S needed? Environmental modifications (temp, orthostatic changes...) 30  Recognize Vital Signs Norms and Deviations Consider norms for developmental level, fitness level… Identify variations based on health status Analyze equipment problems or user errors that should be considered Electronic BP and pulse ox contextual factors that can lead to error: 31  Integumentary Assessment SLO 8 and Lab SLO 1 Think-Pair-Share: What cues to other systems’ abnormalities can the skin signal? What types of patients are at risk for skin problems during hospitalization? 32  Skin, continued Color: What sites best to assess pallor, cyanosis, Turgor Assessment: jaundice, erythema... Temperature: Use back of hand Moisture/Turgor: Check mucous membranes & skin for clues to hydration Skin tears, bruises, nonaccidental trauma Pressure Points; Braden Scale 33  Jaundice Circumor al cyanosis Pallor Erythema 34 35  Describe primary skin lesions (SLO 8, 10) Practice describing lesions at these links in class Common Childhood Skin Disorders Eight Skin Rashes You Need to Know (medscape.com) 10 Erythema Conditions You Should Know (medscape.com) Review ABCDE screening for skin cancers Melanoma Warning Signs and Images (Skin Cancer Foundation) Wound appearance Think-Pair-Share: Write down components of a wound assessment you would think about charting. Compare to drop down list in documentation system at clinical. Review list BEFORE you assist with a dressing change! Drains/ IV sites Areas where tubing might impact skin integrity (Examples??) 36 Primary Skin Lesions Particularly macule, papule, vesicle, pustule 37 Describe the characteristics & distribution of lesions: 38  Hair & Scalp Note hair distribution and texture (on extremities as well as head!) Note hirsutism (excess in women) or alopecia (hair loss or thinning) Check scalp for lesions, lumps, moles, psoriasis/dandruff Check hair on scalp (& pubic areas prn!) for parasites such as lice, tinea. 39  Nails SLO 8, 9, 10 Reflect general health 15 Fingernail and Toenail Abnormalities (medscape.com) Clubbing of nails Check capillary refill while examining nail beds What else can you be observing/assessing at this time? 40 Checking Cap Refill 41 Oxygenation Assessment SLO 8, 9, 10; Lab SLO 1 42 Oxygenation Structures 43  Thorax & Lungs Assessment of the lungs and thorax 11 44 Bronchioles and Alveoli 45 Posterior Chest Landmarks 46  Normal Breath Sounds- Table 30-20 Compare Location, Loudness/Intensity, I:E ratio of: Vesicular Bronchovesicular Bronchial Comparison of 3 Normal Breath Sounds One minute paper: “What is the significance of hearing bronchial breath sounds over right lower lobe?” 47  Listening Pattern Posterior chest Anterior chest 48 Don’t forget Right Middle Lobe! 49  Airway/Oxygenation Assessment Cues Rate, Rhythm, Effort Symmetrical chest expansion Breath Sounds in all lung fields Cough, Productive? Ability to take deep breath comfortably 50  Additional Resources History/Interview skills http://meded.ucsd.edu/clinicalmed/history.htm Head to toe outpatient physical exam http://meded.ucsd.edu/clinicalmed/together.htm Respiratory Assessment http://meded.ucsd.edu/clinicalmed/lung.htm Lower extremity exam http://meded.ucsd.edu/clinicalmed/extremities.htm Melanoma study Dermatologic Signs of Nutritional Deficiencies (medscape.com) Abraham Verghese TED Talk- Use of Touch in Assessment ajs 9/2024 51