Lecture 1.pdf

BSN211 Clinical Health Assessment Introduction to Clinical Health Assessment History Taking 2024/2025 Week 1  Learning Objectives By the end of this lecture the students will be able to: 1. Define evidence-based health assess...

BSN211 Clinical Health Assessment Introduction to Clinical Health Assessment History Taking 2024/2025 Week 1  Learning Objectives By the end of this lecture the students will be able to: 1. Define evidence-based health assessment 2. Outline different methods for data collection 3. Define cultural competence and explain ways to assist in cultural care 4. Identify and summarize different assessment techniques 5. Describe safety and infection control measures Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 2  Evidence Based Assessment Subjective & objective data Assessment is the collection of data about the individual’s health state Data is divided into: Subjective data: what the person says about him/herself during history taking. Objective data: what you observe by inspecting, percussing, palpation and auscultating during the physical examination. PATIENT RECORD Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 3  SUBJECTIVE DATA SUBJECTIVE DATA Verbal information evident to the patient, family member or friend - Symptoms or sensations The major areas of subjective data include: Biographical information (e.g. name, age, religion, occupation) Physical symptoms related to each system Past health and family history Health & lifestyle practices Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 4  OBJECTIVE DATA OBJECTIVE DATA Information obtained through the senses and hands on examination- - Signs directly observed by the examiner The major areas of objective data include: Physical characteristics ( e.g. skin color, posture) Body functions (e.g. heart rate, respiratory rate) Appearance (e.g. dress & hygiene) Behavior (e.g. mood, affect) Measurements (e.g. blood pressure, temperature, height) Results of lab testing (e.g. platelet count, x-ray finding) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 5  Signs & Symptoms A symptom is any subjective evidence of disease. A phenomenon that is experienced by the individual affected by the disease,(sweating) A sign is any objective evidence of disease. A phenomenon that can be detected by someone other than the individual affected by the disease. (raised temperature) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 6  Signs & Symptoms Any examples? Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 7  Validating Assessment Data VALIDATING ASSESSMENT DATA Confirming that the subjective and objective data are reliable and accurate Ways to validate data: Recheck your own data through a repeat assessment (e.g. re-check client’s temp with a different thermometers.) Clarify data by asking additional questions Verifying the data with another health care professional Compare your objective findings with your subjective findings to uncover discrepancies Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 8  Evidence Based Assessment Subjective and Objective data DATABASE Clinical Judgement & Nursing Diagnosis Laboratory studies Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 9 Evidence Based Assessment Example Sweating, high temperature DATABASE Pneumonia Impaired gas exchange X ray shows white spots (infiltrates) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 10  Data Collection Types Four types of data collection (depends on clinical situation) 1. Complete (total health) database 2. Focused (problem centered) database 3. Follow up database 4. Emergency database Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 11  Data Collection Types Complete database: full physical examination and health history. Current and past health state, forms a baseline to measure changes Focused database: limited or short-term problem, Concerns mainly one problem or one body system. Follow up database: Evaluate the status of an already identified problem. Emergency database: urgent-rapid collection of crucial data that is compiled with lifesaving measures. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 12  Evidence Based Practice Evidence based practice (EBP) is a systematic approach to nursing practice that emphasizes on: 1. Critical review of research literature 2. Patient own preference 3. Clinician’s experience & Expertise 4. Physical examination and assessment (relating sings and symptoms) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 13  Diagnostic Reasoning Diagnostic reasoning: analyzing health data, draw conclusions to identify diagnosis. Easy guide to diagnostic reasoning: 1. Develop a list of significant signs and symptoms (objective & subjective data) 2. Cluster information together that appear associated 3. Critically think- ask why, how etc.? 4. Validate data (test them to make sure they are correct) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 14  Diagnostic Reasoning : Example “Miss Sara is 23 years old. She is complaining of cough and chest pain when she is coughing. Sara has difficulty breathing since the last 2 days. She has 38° C temperature, her respiratory rate is 20/ min” 1. What are the signs? (objective data) What are her symptoms? (subjective data) 2. Cluster information together 3. Critically think- Ask why? and how come? 4. Validate the data Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 15  Frequency of Assessment Varies with the person’s illness and wellness needs and setting. Comply with hospital policy/ physician’s order Assessment = Documentation Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 16  The Interview Process of communication Sending- verbal and non verbal communication. Receiving- interpret the information to make meaning (consider past experience, culture and self concept). Internal factors- liking others, empathy and ability to listen. External factors- ensure privacy, refuse interruptions, note taking, electronic medical record, physical environment (comfortable, remove distractors) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 17  The Interview Techniques of communication Introducing the interview: Introduce yourself and what you are going to do, explain why this is important. Open-ended, closed or direct questions: Start with open narrative: “tell me how can I help you” etc.. Its unbiased and encourages person to talk. Eye contact, lean foreword, and ask “tell me more”. Direct questions are useful for specific information, they short with one or two word answer (i.e. Have you ever had double vision? ) ( Do you exercise and follow diet?). Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 18  The Interview Responses- Assisting the narrative: Facilitate by using “mm” “yes” nodding. Silence: after open ended questions, to allow time. Reflection: use patients words to focus on things. Empathy: feel ”with” the patient. Clarifications: ask if information are ambiguous or confusing. Interpretation, explanation and summary. Traps of Interviewing: providing false reassurance, giving unwanted advice, using authority, using avoidance language, using professional jargon, talking too much, using misleading questions, interrupting. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 19  The Complete Health History Provides full picture of a person’s past and present health: 1. Biographical data 2. Source of history 3. Reason for seeking care 4. History of present illness 5. Past illness 6. Family history 7. Review of systems (head to toe approach or system approach) 8. Functional Assessment including activities of daily living (ADL’s) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 20  The Complete Health History 1. Biographic data Name, address, phone number, age, place and date of birth etc. 2. Source of information Who is providing the information, how reliable are they- well or unwell? 3. Reason for seeking care (chief complain) Patient’s own description of the reason for his/ her visit (“..”) 4. History of present illness Collect all data separately and in chronological order, use “PQRSTU” to better describe a symptom Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 21  The Complete Health History To organize critical characteristics of a symptom, use the mnemonic “PQRSTU” P: Provocative (what brings it on?) or Palliative (what makes it better or worse?) Q: Quality(How does it look, feel, sound?) or Quantity (How intense/severe is it?) R: Region or Radiation. Where is it? Does it spread anywhere? S: Severity Scale. How bad is it? T: Timing. Ask about onset , duration and frequency U: Understanding patient’s perception of the problem Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 22  The Complete Health History 5. Past illness Past medical or past surgical history (Might affect current health status) 6. Family history Might highlight diseases the patient could be at risk of 7. Review of systems Head to toe or system approach. Evaluation of past and present health state of each system, to double check and to evaluate health promotion practices 8. Functional Assessment including activities of daily living (ADL’s) Measures a person’s self care ability to formulate nursing diagnosis Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 23  The Complete Health History 7. Review of Systems 1. Integumentary assessment 2. Sensory assessment 3. Neurological assessment 4. Respiratory assessment 5. Cardiovascular assessment 6. Gastrointestinal assessment 7. Musculoskeletal assessment 8. Women’s and Men’s health Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 24  The Complete Health History 8. Functional Assessment- Activity of daily living (ADL’s) 1. Health perception-management 2. Nutritional-elimination 3. Activity-exercise 4. Sleep-rest 5. Cognitive –perceptual 6. Self-concept (how you think about self) Self-esteem (how you feel about self). 7. Interpersonal-relationship 8. Coping & stress management 9. Personal habits 10. Environment/Hazards 11. Occupational health Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 25  Cultural Competence A health profession role encompasses a relationship with people from different cultures. A key to understand culture diversity is self-awareness and knowledge. Culture definition: Is a pattern of shared attitude, beliefs, norms and values among those who speak same language or live in a defined geographical region. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 26  Cultural Competence Cultural competency includes attitude, knowledge (i.e. sociology, psychology, demography, immigration history) and skills necessary for providing quality care to diverse population. It is complex and multifaceted. Religious and cultural values have a significant impact on health care that patient receive. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 27  Cultural Competence Health care providers must be culturally sensitive, appropriate and competent: 1. Culturally sensitive: Caregivers have basic knowledge of diverse cultural populations. 2. Culturally appropriate: Caregivers should apply this knowledge to provide a person with the best care. 3. Culturally competent: Caregivers should understand the total context of individual’s situation and cultural similarities and differences. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 28  Cultural Competence Heritage: includes person’s culture, ethnicity, religion and socialization experience Ethnicity: group of people that share the same traits- geographic origin, religion, language and values. Heritage Assessment Tool: listed all of the questions that may be asked. The response arises the image to whether the person identifies with his/her traditional heritage or not. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 29  Heritage Assessment Four Short questions can be asked: 1- Do you participate in social activities with members of your family? 2- Do you have friends from a similar cultural background as you? 3- Do you eat the foods of your family’s tradition? 4- Do you participate in the religious traditional of your family? If a person answers 2-4 positively, the probability of health practices relevance to their culture is high. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 30  Cultural Competence: Cultural Care “Crescent of care nursing model” Guide the care of Muslim patients in Arab and Islam societies Holistic approach by meeting spiritual, cultural, psychosocial, interpersonal and clinical care needs. The patient and family is the center (primary social unit) (Lovering, 2012). Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 31  Assessment Techniques 4 basic techniques for physical health assessment: Use mnemonic (IPPA) 1. Inspection 2. Palpation 3. Percussion 4. Auscultation They are performed one at a time and usually in this order Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 32  Assessment Techniques 1. INSPECTION- sense of sight It is the first assessment used in the performance of a physical assessment Critical observation of a subject Starts as a general survey and then become focused and systematic Adequate exposure- cultural competence Compare the right and left sides Requires good lighting Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 33  Assessment Techniques 1. INSPECTION- sense of sight Use mnemonic ABCT Appearance- posture, body movements, dress, grooming & hygiene Behavior Cognition Thought processes Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 34  Assessment Techniques 2. PALPATION- touch Follows and confirms points you noted during inspection Light palpation- for surface characteristics Deep palpation- for abdomen Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 35  Assessment Techniques 2. PALPATION- touch The dorsa (backs) of hands and fingers: temperature, moisture Fingertips: pain, texture, swelling, pulsation and lumps Finger pads and palms: vibration Fingers and thumb: to detect the position, size, shape, and consistency of an organ or mass Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 36  Assessment Techniques 2. PALPATION- touch (IMPORTANT TIPS) Always warm your hands and ensure person is in comfortable position. Slow and systematic Start with light palpation then deep (if needed) Identify any tender areas and palpate them last Cultural consideration Privacy- expose minimum needed Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 37  Assessment Techniques 3. PERCUSSION- touch and tapping Technique requires tapping of body with fingers. Used to evaluate: location, position, size and density of underlying structures Signalling the density (air, fluid or solid) of structure by a characteristic notes 1. Direct (immediate): striking hand directly contacts the body wall 2. Indirect: stationary hand placed on body wall and tapped by fingers of other hand Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 38 Assessment Techniques Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 39  Assessment Techniques PERCUSSION SOUNDS (Chapter 8: Table 8.1) Resonance: heard over the lung fields – air filled spaces – very hollow sound. Hyper-resonance: Normal over child’s lung. Abnormal in the adults. Emphysema. Tympany: heard over the gut area – duller sound – like tapping on a watermelon. Dullness: dense organ, as liver or spleen. Flat: no air. bone Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 40  Assessment Techniques 4. AUSCULTATION- listening Can be unassisted or performed with the use of special instruments (stethoscope). Notice the character and quality of the sound heard (Rhythm- regular, irregular, pitch- high, low, duration, quality- harsh, soft, intensity- soft to loud. Listen to: Speech, percussion tones, breathing sounds, cough, loud abdominal sounds. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 41  Assessment Techniques 4. AUSCULTATION- listening 2 heads – diaphragm and bell Diaphragm transmits high-frequency sounds (breath, heart and bowel sounds) Bell is used for low-pitched vascular sounds (bruits and extra heart sounds/ murmurs) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 42  Assessment Techniques 4. AUSCULTATION- listening When using the diaphragm – press it firmly onto the patient’s skin. When using the bell –rest it lightly on the skin. Warm stethoscope by rubbing it your palms. Man’s hairy chest causes a crackling sound: wet the hair. Never listen through a gown, pay attention to room noise. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 43  Safety and Infection Control SAFTY Patient Informed consent (verbal/ written) Nurse Competent nurse- knows her/ his limits Respect and courtesy Validation of data Manual handling (back straight etc) Environment Side rails / height of bed Privacy and confidentiality Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 44  Safety and Infection Control INFECTION CONTROL Patient Past and present history Standard, contact, droplet and airborne precaution Nurse Hand washing/rubbing (technique and 5 moments of hand washing) Personal protective equipment (PPE) Comply with hospital policy Environment Clean used equipment (disinfection/ sterilization) Waste disposal Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 45  References Jarvis, C (2016). Physical Examination and Health Assessment (7th ed.). Philadelphia: W.B. Saunders, USA. Lovering, S. (2012). "The Crescent of Care: a nursing model to guide the care of Arab Muslim patients." Diversity & Equality in Health & Care 9(3): 171-178. Mebrouk, J. (2008). "Perception of nursing care: Views of Saudi Arabian female nurses." Contemporary Nurse : a Journal for the Australian Nursing Profession 28(1/2): 149-161. Rassool, G. H. (2000). "The crescent and Islam: healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring." Journal of Advanced Nursing 32(6): 1476-1484. http://www.indexmundi.com/united_arab_emirates/demographics_profile.html http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/V olume82003/No3Sept2003/PatientSafety.html Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 46