N113 Health Assessment Status PDF

Nicholas Bachman, MSN, RN Nursing Instructor N113 Medical Surgical Nursing Los Angeles County College of Nursing & Allied Health 1 Objectives States the purpose of nursing health assessment. Explains the components of a nursing health history. Describes techniques for collecting assessment data Iden...

Nicholas Bachman, MSN, RN Nursing Instructor N113 Medical Surgical Nursing Los Angeles County College of Nursing & Allied Health 1 Objectives States the purpose of nursing health assessment. Explains the components of a nursing health history. Describes techniques for collecting assessment data Identifies the purpose of the physical health examination. Explains the techniques and/or methods of examination. Describes the equipment needed to perform a physical examination. Discusses the significance of selected physical findings. Explains expected outcomes of the health assessment. Summarizes the suggested sequencing to conduct a physical health assessment. Enumerates differences in assessment techniques appropriate for the young, middle and older adult. 2 Purpose of Assessment To make a judgment or a diagnosis Making reliable observations Distinguishing data Relevant vs. irrelevant Validating data Organizing data Categorizing data according to a framework Recognizing assumptions Identify gaps in data 3 1 Nursing Health History Biographical data – Name, address, sex, gender (pronouns), marital status, occupation, religious preference, where client gets medical care Chief complaint – Reason for the visit - What brought them to the hospital – Use the client’s words History of present illness (OLD CART format) Past health history Illnesses, allergies, immunizations, accidents, hospitalizations, surgeries, medications Family history Lifestyle Social data Psychological data Patterns of health care Spiritual needs 4 History of Present Illness: OLDCART format  OLDCART pertains to  Onset  Location  Duration  Characteristics  Aggravating factors  Relieving factors  Treatments treatment prior to arriving at the hospital  Can be written out in narrative form to tell the client’s story  Using specific client quotes makes for a stronger statement 5 Past Medical History  Illnesses  Allergies  Immunizations  Accidents/injuries  Hospitalizations  Surgeries  Medications 6 2 Family History of Illness  Include only direct blood relations  Parents  Grandparents  Siblings  First cousins  Include ages of individuals or cause of death with age at the time of death 7 Lifestyle  Personal/Social habits – Alcohol, Tobacco, Caffeine, illegal or recreational drugs w/ amount, frequency, and duration of use for each  Diet  Sleep patterns  Activities of Daily Living (ADL’s)  Basic activities of functional mobility and personal care  Eating, grooming, dressing, elimination, locomotion  Instrumental ADL’s (IADL’s)  Complex activities required for independent living  Transportation, food prep, finances, cleaning, meds 8 Social Data  Family relationships/friendships  Ethnic Affiliations  Educational History  Occupational History  Economic Status  Home and Neighborhood Conditions 9 3 Psychological Data  Major stressors  Coping patterns or strategies  Communication style  Should include both verbal and nonverbal expression 10 Patterns of Health Care  All health care resources the client is currently using and has used in the past.  Primary care provider (PCP)  Specialists  Dentist  Health clinic  Folk/Traditional health healers 11 Data Collection To collect data accurately, both the client and nurse must actively participate Sources of Data Primary= patient Secondary= family, labs, diagnostic tests, MD/nursing notes Types of Data – Subjective Symptoms or covert data – Apparent only to the patient and described only by patient – Objective Signs or overt data – Detected by nurse and/or can be measured or tested – Can be seen, heard, felt, or smelled 12 4 Data Collection Methods: Observing  Gather data by using your senses  Use vision, smell, hearing, & touch  Two aspects  Noticing data using cues  Selecting, organizing, & interpreting data 13 Data Collection Methods: Interviewing A planned communication/conversation with a purpose often to get information Two approaches to interviewing – Directive – nurse controls interview seeking specific info – Nondirective – often client led and helps to establish rapport Types of questions – Closed questions – Open-ended questions – Neutral questions – Leading questions 14 Data Collection Methods: Examining Physical assessment utilizing a systematic approach – Inspection – Auscultation – Palpation – Percussion Styles – Cephalocaudal (Head-to-toe approach) – Body systems approach 15 5 Validating Data Validation – Double-checking or Verifying – Data gathered during assessment must be complete, factual, & accurate because nursing diagnosis and interventions will be based on this information Cues – Subjective or objective data that can be directly observed by the nurse Inferences – Nurse’s interpretation or conclusion made based on the cues 16 Organizing Data  Written  Paper charting/Flowsheets  Computerized/Electronic  County currently using ORCHID for charting  Online Realtime Centralized Health Information Database 17 Conceptual Models/Frameworks School of Nursing – Betty Neuman Systems Model – Used in your Clinical Nursing Care Plan – intra-, inter-, and extra personal stressors Care Plans often include Erikson’s system of developmental stages – In Pediatrics, Piaget’s stages of cognitive development often used 18 6 Documenting Data Nursing documentation (charting) – To complete the assessment phase the nurse records client data – Accurate documentation is essential and should include all data collected about the client’s health status – All “charting” is a legal document. Any false entries make the nurse legally liable Record the physical findings – Data is collected in a factual manner and not interpreted by the nurse 19 Physical Assessment Purposes of the physical examination approach – To obtain baseline data – Supplement, confirm, refute data obtained in nursing history – Obtain data that will help establish nursing diagnosis and plan of care – Evaluate physiological outcomes – Make clinical judgments – Identify areas of health promotion & disease prevention Nurses use national guidelines and evidence-based practice to focus health assessment on specific conditions 20 Types of Physical Assessment Initial assessment – Done on admission to establish client’s baseline Problem-focused assessment – Determines status of a specific problem Emergency assessment – A crisis or change in status to identify a life-threatening problem Time-lapsed reassessment Follow-up assessment conducted at regular intervals 21 7 Preparation for Assessment Prepare the patient – Age specific approach Health Insurance Portability and Accountability Act (HIPAA) – Make client is are aware of your confidentiality Prepare the environment Position the client Draping – privacy Instruments 22 Method of Examination Inspection – Includes visual exam (moisture, texture, shape, size, color, symmetry), olfactory, and auditory Palpation – Use pads of fingers to determine texture, temperature, vibration, masses, distention, pulsation, and tenderness – Light palpation (superficial) precedes deep palpation Percussion – Indirect – place middle finger of nondominant hand on client’s skin and strike with the tip of middle finger from dominant hand – Direct – percusses an area of skin with 2-4 fingers typically only used for assessing sinuses – 5 types of sound – Flatness, Dullness, Resonance, Hyperresonance, Tympany Auscultation - Listening for sounds within the body – Direct (Using just your ear) & Indirect (Using stethoscope) – Pitch, Intensity, Duration, Quality 23 General Survey  Appearance & Behavior  Mental Status  Vital signs  Height and weight  The actual assessment - focus on the rest of your “Assessment” lectures in N113 24 8 Physical Assessment Technique Variations Adapt to your specific patient’s situation – Maybe they can’t move, so you will have to change how you perform your assessment Gerontological differences that maybe abnormal for younger clients will be normal for more elderly clients – i.e., S4 heart sound in someone young can be a problem in elderly – Take age into consideration when assessing 25 Record Physical Exam Findings  Document/record/chart your findings on patient’s record in ORCHID  The law says if you didn't chart it, you didn't do it 26 9