NUR 362 - Exam One (1).pdf

Module 1 - Introduction to Health Assessment and Beginning Your Assessment Nursing vs Medical Assessment - Medical: - Focus is on the diagnoses and treatments of the disease - Nursing: - Focus on diagnoses & treatment of the actual or potential human responses...

Module 1 - Introduction to Health Assessment and Beginning Your Assessment Nursing vs Medical Assessment - Medical: - Focus is on the diagnoses and treatments of the disease - Nursing: - Focus on diagnoses & treatment of the actual or potential human responses - Identifies many contributing factors to the individual’s health and wellness Importance of Nursing Health Assessment - Systemic way of gathering data (Head-to-Toe) - Establishing trust & rapport with client - Opportunity to interact with client - Organizes thinking to identity concerns - Helps communicate with healthcare team Components of Comprehensive Health History - Identifying data & source of history - Reliability of the history - Chief complaint - History of present illness (HPI) - 8 dimensions - Past medical history - Family history - Review of systems (ROS) - Health patterns Types of Assessment - Admission/Comprehensive - When patient enters the healthcare system (e.g. hospital) - Focused - Usually system-specific and targeted (e.g. knee pain) - Time-Lapse - Follow-up on a previous health problem (e.g. hypertension) - Emergency - Rapid identification of life-threatening problem (e.g. chest pain) - Focus is on Airway, Breathing, Circulation Nursing Health Assessment Steps - Identifying client - Identify source and reliability of information - Chief complaints – OLDCARTM - History of Present Illness (HPI) - Current health status - Past medical history - Family history  - Review of symptoms (ROS) - Consider social determinants of health Social Determinants of Health (SDOH) - Conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks - Non-medical circumstances - 5 Key Domains - Health care and quality - Neighborhood and built environment - Social and community context - Economic stability - Education access and quality - * account for 75% of all health outcomes according to the CDC General Survey/Inspection - Begins the moment you lay eyes on the patient - You are an observer gathering data - Apparent state of health/illness - Do they look well? Do they look their stated age? - Level of consciousness (LOC) - Alert and awake? Oriented to person place and time? - Facial expression & speech - Frowning? Grimacing? Do they look happy or sad? Clear or slurred speech? - Eye contact? Consider that decreased eye contact may be cultural - Posture, gait, motor activity, and speech - Sitting up straight, walking - is posture erect? Bent over? Stride? - Changing positions frequently - Do they use assistive devices (walker, cane, wheelchair, etc) - Skin color and obvious lesions - Color consistent with ethnicity? - Odors of body and breath - Any prominent odors - Dress, grooming, and personal hygiene - Are they appropriately dressed for the season? Condition of clothing and shoes? - Signs of distress - Are they guarding or protecting areas of the body? Labored breathing? Data Collection - Subjective - Symptoms - What the patient tells you  - Patient states their history, chief complaint and review of systems - PMH/PSH, Family History, Social/Personal History, Review of Systems - Objective - Signs - Nurse’s observation - Physical exam findings - Vital Signs, Physical Assessment, General Survey, Lab/Test Results Subjective Data by System - PMH – past medical history - Acute and chronic issues relating to system - FH – family history - Issues in family origin - Personal/Social History - Lifestyle and habits that affect the system - Review of Systems - List of questions organized by body systems to determine normal or abnormal function Review of Systems (ROS) - The ROS also helps gather information about the patient’s reason for seeking health care - List of questions organized by body systems to determine if there is normal or abnormal function - Identifies specific symptoms or complaints - You will “work up” positive symptoms using eight dimensions - OLDCART-M Eight Dimensions (Attributes) of a Symptom/Problem (OLDCART-M) 1. Onset – when the symptoms began - When did it start? What were you doing when it happened? 2. Location – where the symptom began - Where is it? (Have the patient point to location) Does it spread or radiate? 3. Duration – how long the symptom has been going on - How long does it last? How often does it occur? Does it change over time? 4. Characteristic Symptoms – what the symptoms feels like, how it is described, and its severity - What does it feel like? What is the pain of the symptom on a scale of 0-10? Characteristic? Intensity? 5. Associated manifestations – what else is going on when the patient experiences the symptom? - Are you feeling any other symptoms? Does anything else happen when you get the described symptom? After the patient has answered the question, offer three related symptoms to confirm that there isn’t anything else related to the problem  - Pertinent negatives (what the patient denies) 6. Relieving and exacerbating factors – anything the patient has tried to alleviate the symptom. Anything that makes this symptom worse - What makes it better (non-pharmacological)? Positioning? Heat/ice? Resting? What makes this worse? 7. Treatment – any interventions the patient has previously tried. Be sure to clarify if the treatment was effective - Medications (prescribed, OTC, herbal)? How much medication and how often? Seen a provider? Holistic approach (chiropractic, acupuncture)? 8. Meaning – what they think is going on and how the symptom has affected their life - What do you think might be going on? How has it affected your daily life? Does it impact work, school, sleep, eating, or exercise? 5 Hand Hygiene Moments & Why 1. Before touching a patient - To protect the patient of pathogens carried on your hands 2. Before clean/aseptic procedure - To protect the patient from infection due to pathogens carried on your hands and from their own (endogenous) flora 3. After bodily fluid exposure risk - To protect yourself and the environment from pathogens carried on your hands 4. After touching a patient - To protect yourself, the environment, and subsequent patients from pathogens carried on your hands 5. After touching a patient's surroundings - To protect yourself, the environment, and subsequent patients from pathogens carried on your hands Vital Signs - TEMPERATURE - Normal Range: 36.5 -37.5 C (97.6 - 99.6 F) - 37 C = 98.6 F - Body temperature fluctuates throughout the day - Abnormal - Hypothermia (Low) < 36 C - Febrile (High) > 38 C - Hyperthermia > 39 C - Factors that affect temperature - Hot or cold drinks (oral temp) - Bundled up? Wearing a hat? (temporal temp) - Outside in cold or heat - Sweaty forehead  - Cultural sensitivity - Always label as C or F and type of thermometer - HEART RATE - Normal: 60 - 100 beats per minute (bpm) - Abnormal - Bradycardia < 60 bpm - Tachycardia > 100 bpm - Remember to check apical pulses at apex of the heart - Apex: located at the 5th ICS MCL (intercostal space midclavicular line) - Auscultate on the chest for 60 seconds - Note rate and rhythm - If irregular, listen at the apex of the heart for another 60 seconds - Factors affecting heart rate - Activity prior to assessment - Are they in pain? - How are they feeling? - Always label rate with beats per minute, rhythm, and where the pulse was taken - RESPIRATORY RATE - Normal: 12 - 20 breaths per minute - Abnormal: - Bradypnea < 12 breaths per min - Tachypnea > 20 breaths per min - Auscultate the breath for 60 seconds - Note rate, rhythm, depth and effort - Inspect/observe for 30 seconds and multiply by 2 - 15 seconds is not long enough - Try not to be awkward - BLOOD PRESSURE - Systolic - TOP # - Pressure in the arteries when the heart pumps - Diastolic - BOTTOM # - Pressure in the arteries when the heart rests between beats - This is the time when the heart fills with blood and gets oxygen Category Systolic Diastolic Normal < 120 and < 80 Elevated 120-129 and < 80 Hypertension Stage 1 130-139 or 80-89 Stage 2 >/= 140 or >/= 90 - Factors affecting BP - Activity prior to assessment - Are they in pain? - Position - Medications - “White Coat Hypertension” - Always label with arm, position, type of cuff - Correct Size Cuff/Procedure Important! - Errors that result in false high readings - Cuff too small (narrow) - Cuff too loose or uneven - Arm below heart level - Arm not supported - Inflating or deflating cuff too slowly (high diastolic) - Deflating cuff too quickly (low systolic and high diastolic) - Errors that result in false low readings - Cuff too large (wide) - Arm above heart level - Inaccurate level of inflation - Pressing stethoscope too tightly against pulse - PULSE OXIMETRY - O2 levels - Normal: 92-100% - Abnormal: less than 90% - Measures the arterial oxygenation saturation, SpO2 - Compares the amount of light emitted to the amount absorbed and calculates the percentage of oxygen saturation - Locations: Finger pads, toe pads, ear lobes - Factors affecting O2 - Nail polish - Cold fingers - Poor perfusion - Hypotension - Always label as percent, where the measurement was taken, and O2 source Pain - What is pain?  - An unpleasant sensory and emotional experience associated with actual or potential tissue damage - Is whatever the experiencing person says it is, existing whenever they say it does - Pain is a subjective finding - 0 - 10 scale - Face scale – for little kids - Manifestations - The absence of both physiological or behavior signs does not mean the patient is without pain - People who experience chronic pain may exhibit a flat affect; stress, depression, or anxiety can heighten pain perception - People who experience chronic pain adapt to their pain level - Abdominal pain can indicate benign or life-threatening conditions - conduct careful history - Physiologic: - Increased BP - Increased HR - Increased RR - Behavioral - Verbal - Non-verbal - Impact on ADLs - Acute Pain - Cause: - Result of potential or actual tissue injury that activates local nerve fibers; usually known source - Treatment: - Usually has a cure - Example: - Touching a hot stove resulting in a burned hand, pain from the burn - Chronic Pain - Cause: - Abnormal pain-signaling process occurring either peripherally or centrally - Nerve signals (from inflammation/nerve injury) bombarding the CNS/periphery, resulting in persistent pain - Treatment: - Irreversible, cyclical, persists longer than 3-6 months - Example: - Rheumatoid arthritis - persistent pain signal from prolonged autoimmune inflammation  - Fibromyalgia - a disorder that amplifies painful sensations by affecting the way your brain processes pain signals - How does pain influence us? - Affective Domain - our emotions - Unrelieved pain can lead to: anger, fear, anxiety, sadness, depression - All increase pain perception - Behavior Domain - how we act - Behaviors are related to pain - Avoiding behaviors (avoid people, avoid painful behaviors) - Engaging in certain behaviors to avoid pain (distraction) - Cognitive Domain - what we think about - Meanings associated with pain (beliefs, attitudes, expectations can influence patient response) - Inspection of Pain - what will you see - Acute pain: vital signs - Increased HR, BP, RR, diaphoresis, facial grimace - Chronic pain: vital signs - Changes may be modified or absent (patient has adapted to constant pain) - Observe non-verbal adaptations to pain - Grimacing when getting up/down or with movement - Movement is altered - For the non-verbal, unconscious, cognitively impaired - Rubbing painful areas - Frowns or grimaces - Increased muscle tension - Guarding - Avoids painful movements - Restlessness - Specialized types of pain - Nociceptive: occurs in tissues other than the nervous system - Somatic: originates in bone, skin, and soft tissue; easy to pinpoint - Often described as aching or throbbing - Visceral: originates internally from stretching, distention, inflammation, or damage to organs - Often diffused and hard to pinpoint; multiple descriptors - Cancer: often first symptom of cancer or related to diagnostic procedures, surgery, or treatments - Neuropathic: arises from damage to the peripheral nerves or the CNS - Result of abnormal sensory input  - Referred: pain perceived at a location other than the site of the painful stimulus/origin - If they are in pain and can’t tell us? * Tips for Physical Assessment - Assure client privacy - Check with client for comfort level - Courteous, clear instructions - Hand hygiene - Use appropriate body mechanics - Get familiar with your equipment Module 2 - Cultural and Spiritual Assessment Nursing Process (ANA Standards) - ADPIE - Assessment - Diagnosis - Planning - Implementation - Evaluation ACEs & Trauma-Informed Care - Adverse childhood experiences (ACEs) affect 64% of the US population - Research shows that those with a history of ACEs are at higher risk for chronic physical and mental health illnesses - ACEs can cause toxic stress that can negatively affect brain development, stress response systems, and immune responses - ACEs can include traumatic events and other aspects of child’s upbringing that threaten feelings of stability, safety, and bonding Trauma-Informed Care 1. Understanding the prevalence of trauma and adversity and their impacts on health and behavior 2. Recognizing the effects of trauma and adversity on health and behavior 3. Training leadership, providers, and staff on responding to patients with best practices in trauma-informed care 4. Integrating Knowledge about trauma and adversity into policies, procedures, practices and treatment planning 5. Avoiding retraumatization by approaching patients who have experienced ACEs and/or other adversities with non-judgemental support Healthy People 2030 - This is a framework that identifies risk factors, health issues, and diseases of concern in the US  - Goals and objectives serve to improve the health of individuals and communities - Overall goal is to increase laity of life by creating guidelines for a healthy lifestyle - Promotes health and disease prevention as it improves the quality and length of a person’s life - Nursing is vital for to reach the goals and objectives of Healthy People 2030 Disparities in Healthcare - Racial and ethnic minorities have higher rates of chronic disease and premature death compared to whites - transgender individuals are 10x more likely to attempt suicide in their lifetime than cisgender individuals - Black maternal mortality rate is 3x that of white women (consistently) - Instance of AIDS diagnosis and mortality for blacks compared to whites has increased overtime - American Indians and Alaska Natives (AI/AN) are 4x more likely to develop chronic liver disease and cirrhosis Diversity - Diversity Awareness is acknowledgement and appreciation of the existence of differences in attitudes, beliefs, thoughts, and priorities in the health seeking behaviors of different patient populations Generalization - A beginning point - Indicative of common trends, but further information needed to ascertain whether statements are appropriate to specific individuals Implicit Bias - Unconscious associations that may impact our judgment and behavior towards a certain class or group of people. - Not intentional, but may influence the way we interact with others Stereotype - An ending point - No attempt made to assess whether an individual even fits statements - Labeling an entire class or group Intersectionality - The complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups Factors that Influence Diversity - Race - Ethnicity - Sex - Gender  - Gender Identity - Age - Culture - Religion/Spirituality Race & Ethnicity - Race: categorical definitions of biologically distinctive physical traits - Usually related to physical characteristics like skin color, hair color or texture bone structure - Ethnicity: A self-identified belonging to a group that is differentiated by symbolic markers - It is not visible on the surface - usually related to culture, religion, language, dress, customs, geography, heritage Sex & Gender - Sex is the biological differences between males and females, such as genitalia, body shape, hormones, genetics, etc - Gender is one’s most innermost concepts of self as a man, woman, a blend of both, or neither - One’s gender identity can be the same or different than their sex assigned at birth - Sex and gender also differ from sexual orientation and gender expression - Sexual Orientation is the pattern of emotional, romantic, and sexual attraction to people of a particular gender - Gender Expression is how your gender presents through expression (cloths, behaviors, and their associated interpretations) - Pronouns - ask and be respectful - Offer your pronouns which invite the other person to offer theirs. - Pronouns are not a debate - * do not make assumption about any of these things Culture - Ethnocentrism - The view that one’s own culture’s way of doing things is the “right” way - All other ways are inferior - Ethnocentrism often leads to incorrect assumptions about others’ behavior based on your own norms, values, and beliefs - Culture & Cultural Domains - Socially acquired values, beliefs, customs, and practices of a particular group that are learned and shared - Culture guides thinking, perceptions, and decisions - Culture is not limited to ethnic or minority groups - Culture is not biologically determined - Diversity in cultures is an opportunity for learning and personal growth  - Cultural Competence - Acquiring knowledge and skills about a client’ background in order to provide culturally sensitive care - ”Competency” infers that you can master the information - Learning about generalizations, not specific individuals - Knowledge that can be learned in a classroom - Cultural Humility - Ongoing process - No end point of understanding - Realizing each person is an individual - Involves self awareness & reflection - Being okay with saying “I don’t know” - Nurse becomes “student” of the patient - Often experienced when directly interacting with individuals form diverse populations - ** Cultural Competence is not bad. It is great, but cultural humility requires an open mind with the understanding that we will never truly know it all, which takes the willingness to implement change to the next level Goals of Cultural Assessment 1. Establish Trust — Cultural and spiritual assessments require trust and rapport to be effective 2. Provide culturally appropriate nursing care to patients from other cultures — Build your patient relationships on respect and mutually acceptable plans that align with their beliefs and effective clinical care 3. Eliminate assumptions about what is “normal” — Learn directly from your patients - they are the experts on their culture and illness 4. Listen — to and validate feelings 5. Be self aware — Explore your own cultural density and how it influences your beliefs/behaviors to deliver care Nursing Assessment — Cultural Assessment Considerations - Culture and language question suggestions - How would you like to be addressed? - Do you consider yourself a part of a cultural group(s)? - Where were you born? (Might be diseases or treatments used in other countries compared to the US) Where have you lived since then? And when (during what years)? - What language do you speak at home? What other languages do you speak? What language is preferred for immunizations with health care providers? - How well do you understand, speak, and read English? - * don’t need to do this with every patient  - Reason for hospitalization - What do you think caused the illness? What do you call this illness? - The “M” of OLDCART-M - Family - Who belongs to the family? Who is the decision maker on health issues? - Nursing Care - What interventions would be used for this illness in your culture? - How do you feel about health care givers of a different sex or culture? - Nutrition - What foods are preferred? When and where are meals eaten? Are special foods preferred during lines, or religious seasons (ex: Lent or Ramadan)? Religion & Spirituality - Spiritually - Broader concept - Religious and non-religious - Helps to achieve balance in life, inner belief system - Personal effort to find meaning in life - Religion - Externals of our belief system: church, prayers, traditions, rites, rituals - Organized system - Not everyone is religious - Expressed through concepts and ideas about God/higher power, sacred beliefs - Spiritual Assessment/Distress - Discern spiritual distress and its effect on the patient and family health - Signs and symptoms of spiritual distress? (Ex. Fearful of death) - Interventions? - Religious Assessment - Do you practice a particular religion? What prayers, rituals, and/or diet would you like to continue in the hospital? Would you like the priest/rabbi/imam/minister/leader to be notified? - End of Life - How do you perceive end of life? What rituals? Nursing Support - Support and enhance client and family well-being and development spiritual practice - Determine ways to incorporate family spirituality and/or spiritual practice when providing care - Being present and listening during difficult times - Providing opportunities to practice religious rituals - Referring the patient to their religious leader of their choice PLATINUM RULE  - What may be considered as helpful, polite ,and friendly care in one culture, may show up as rude, thoughtless, and uninformed in another. - LEARN HOW OTHERS WHAT TO BE TREATED Summary: - As healthcare professionals, we have an obligation to provide culturally competent care - We all have biases - We tend to fear what we do not understand or haven’t been exposed to - Cultural and spiritual assessment is a lifelong learning process. Begin by asking not assuming - Substitute humility, curiosity and ultralight desire for fear, misunderstanding or judgment, and the outcomes will be “mutual empowerment, partnerships, respect, optimal care, and a lifelong learning” Module 3: Respiratory Subjective Assessment: - Dyspnea: - Air hunger, patient has uncomfortable awareness of shortness of breath especially at rest - Short of breath = SOB - Anxiety: - May describe as smothering feeling, not getting enough air in - Paresthesia (tingling) around lips, hands, and feet Starting your Respiratory Assessment - Evaluate LOC - Normal: alert & oriented x3, cooperative - Abnormal: irritable, somnolent, restless, confused, combative, disoriented - All can be signs of hypoxemia! What comes first? - Oxygen Saturation - Normal: 95-100% or the patient’s “normal range” - Abnormal: < 90% - General Survey: - Normal: sitting upright, relaxed, no signs of distress - Abnormal: pursed lip breathing, nasal flaring, tripod positioning, facial expression, skin color Physical Exam - INSPECTION - Shape & Configuration - Normal: - AP: Transverse/Lateral = 1:2 - Costal angle < 90 degrees  - Abnormal: - AP: Transverse/Lateral = 1:1 - Costal angle > 90 degrees - Obesity - Symmetry - Normal: - Clavicles should be at the same height - Sternum should be midline - Chest and chest movement equal during respiration - No deformities - Abnormal: - Flail chest (asymmetry) - Scoliosis - Misalignment of clavicles - Kyphosis - Presence of rib, sternum, or scapula deformities - Trachea - Normal: Midline - Abnormal: Deviated - Respiratory Rate - Normal: 12-20 breaths per min - Abnormal: - Bradypnea: < 12 breaths per min - Tachypnea: > 20 breaths per min - Respiratory Effort: - Normal: no use of accessory muscles and/or intercostal retractions - Abnormal: - Dyspnea - Use of accessory muscles (sternocleidomastoid, scalenes) and/or intercostal retractions - Inspiratory contraction - Respiratory Pattern - Normal: unlabored, regular - Abnormal: apnea, Cheyne Stokes - Skin - Normal: absence of color change - Abnormal: - Cyanosis: blueish discoloration; hypoxemia - Best inspected centrally or around the mouth - Pallor, ashen or gray (seen in black and brown colored people)  - Poor oxygenation, anemia - Rubor (reddish purple) or erythema - Chronic respiratory disease - Mucous Membranes - Normal: - Pink and moist - Abnormal: - Dry and discolored - Nails - Normal: - Absence of clubbing - Pink - Abnormal: - Clubbing - Discolored - PALPATION - Symmetry - Normal: Symmetrical expansion - Abnormal: asymmetrical expansion - Abnormalities - Normal: absence of tenderness, lesions, and/or masses - Abnormal: presence of tenderness, lesions, and/or masses - Crepitus - Normal: absent - Abnormal: present – indicative of subcutaneous air - Fremitus/Tactile Fremitus - Can palpate vibrations transmitted through the bronchopulmonary tree to the chest when patient is speaking - This is NORMAL – it represents air movement - Expected Findings: - Bilateral equal intensity intra-scapular - Decreased intensity as you move down and out to the side - Abnormal Findings: - Decreased intensity where it should be clear may indicate obstruction, COPD, pleural effusion, fibrosis, tumor - Increased intensity may indicate inflammation (fluid, blood, pus) - PERCUSSION - Tap on the tip of your finger (not finger pad) - Follow ladder technique, compare for symmetry - Will hear different notes depending on diagnosis  - **Nurses do not do this. This is for more advanced healthcare professionals - AUSCULTATION - Normal: - Lung sounds should always be clear and qual-anteriorly, posteriorly, and bilaterally - This represents air movement throughout the thorax - Bronchial (Tracheal) - Hard, loud, and high in pitch - Inspiration < Expiration - Bronchovesicular - Moderate in amplitude and pitch - Differences detected better on expiration but equal - Vesicular - Breezy, rustling, soft and low pitched - Inspiration > Expiration - Abnormal: - Crackles (Rales): small airways have tiny explosions with air as inspiration occurs - Fine to coarse bubbling, nonmusical - Wheeze: blocked/narrow airflow in bronchioles - High pitched, musical, continuous whistling - Rhonchi: fluid blocked airway - Coarse, loud, low-pitched, continuous (snoring, rumbling) - Stridor: obstructed upper airway - Loud, high-pitched - Diminished or Absent Problems and Assessment Findings Problem Process Typical Signs/Symptoms Typical Lung Sounds Asthma Bronchial hyper Cough can occur at end of expiratory wheezing responsiveness attack with sputum, can be crackles, involving release of episodic dyspnea silent chest inflammatory mediators, ↑ airway secretions, and bronchoconstriction Pneumonia Infection of lung Mucoid or purulent Biphasic crackles, parenchyma from the sputum, may be blood rhonchi respiratory bronchioles tinged, chills, high fever, to the alveoli dyspnea, chest pain throughout parietal pleura  Pneumothorax Leakage of air into the Sharp chest pain, Absent breath sounds pleural space through dyspnea, cyanosis on one side blebs on visceral pleura, with resulting partial or complete collapse of the lung Bronchitis Excessive mucous Dry or productive cough, Crackles, wheezing, production in bronchi chest pain around bronchi or rhonchi followed by and sternum obstruction of airways Health Promotion & Education - Influenza, pneumococcal, pertussis & other vaccinations - Encourage certain populations to receive - Self-management of asthma and allergy symptoms - Know about irritants (smoke, dust, fur) - Inhalers - OTC medications - Use to control allergy symptoms instead of ignoring - Beta-blockers and NSAIDs can make symptoms worse - Smoking cessation - Avoid smoking in the home or car/second hand smoke - 25 ft away from entrance of an enclosed area - SHS increases risk for emphysema, lung cancer, and causes airway lining irritation - PPE (aka respirator mask) Care of Aging Adults: Respiratory Considerations Change Results Decrease pulmonary elasticity - Decreased vital capacity - Less air exchange at the bases Limited chest expansion - Decreased vital capacity Decreased ciliary action - Less effective cough - Risk for pneumonia Decreased cough reflex - Less effective cough Social Determinants of Health (SDOH) - 6 Pillars: - Economic Stability - Neighborhood and Physical Environment - Education - Food - Community and Social Context - Health Care System