Introduction To The Nursing Health Assessment PDF

Introduction to the Nursing Health Assessment NURS 1090  Unit Outcomes  Discuss the components of a health history.  Identify Geriatric Syndromes.  Practice history-taking skills.  Relate physical assessment to the nursing process.  Discuss use of physical asses...

Introduction to the Nursing Health Assessment NURS 1090  Unit Outcomes  Discuss the components of a health history.  Identify Geriatric Syndromes.  Practice history-taking skills.  Relate physical assessment to the nursing process.  Discuss use of physical assessment techniques of inspection, palpation, percussion, and auscultation Definitions Health Assessment: systematic collection of information concerning the patient’s health – Health History: an interview to gather subjective data from the patient or patient’s representative – Physical Assessment: process of gathering objective data about the patient Types of Health Assessment Initial (baseline, admission) – Establish a baseline – Problem identification – Reference/future comparison Focused – Concentrates on specific manifestation or body system – Evaluate effects of previous interventions  Types of Health Assessment Emergency – Identify life-threatening problems Ongoing Assessment/Reassessment – Shift assessments – Compare to baseline data Health assessment formats vary in organization and scope of information gathered Health Assessment Nursing Responsibilities Using nursing judgment to decide which parts of the health assessment apply to patients. Understanding assessments written by other healthcare professionals. Communicating findings to the HCP to aid in formulation of a medical diagnosis.  Getting Started: Health History Meeting the patient – Introduce yourself, explain your role-you will be conducting an interview – Discuss purpose of the questions: To identify patient needs and concerns To provide for continuity of nursing care To help plan for a safe and successful discharge  Environment – Be aware of noise, lighting, temperature Provide privacy and confidentiality – Explain that the information will only be seen by you and others assigned to your care. Types of Interview Questions Closed Questions – Require short answers: yes/no – More fully describes and identifies specific problem areas – Helps identify symptoms, precipitating factors, or relief measures Example: “Are you having pain now?” – Can be restrictive but can also be therapeutic Types of Interview Questions Open-ended questions – Allows patient to tell the ‘story’ – “Tell me about the problems you have been having” – “What brought you to the hospital?” – Combination of closed and open questions frequently used – Assess the source and reliability of information – Note name and relationship of the historian, if not the patient  Interview Questions You may need to modify your techniques for patients with special needs: Hearing/vision/speech – – Non-English speaking or English as a second language Medical Translators – – Intellectual disability; confused – – Ill or in pain, medicated/sedated, emotional – Older adult  Older Adult Information obtained may depend on cognitive level – May be poor historian – Obtain information from family member Allow patient to complete sentences Try not to end interview abruptly May have sensory impairments Allow adequate time to answer questions and report information  Getting Started: Patient Profile (Demographics, Biographical Data) You may have some of this information before meeting the patient Age Gender Race and ethnic origin Occupation Marital status or significant other Religious preference Reason for seeking health care Chief Complaint or Reason for Visit – Use exact words of patient History of Present Illness (HPI) – This is the patient’s perception “What brings you here today?” “What are you concerned about at this time?” – Use exact words of patient How do the Chief Complaint and HPI differ?  Health History  Provides data about past health care experiences/current health habits  Medical:  Past/current medical problems  “Have you ever been hospitalized?”  Surgical:  Past surgical procedures  Trauma  “Have you every had surgery?”  Health History Medications : – Prescription, over-the-counter, herbals – Does the patient take the medication as prescribed Allergies: – Allergic reactions to food, latex, drugs, contact agents, environmental – Note specific reaction and treatment  Family History Provides data about immediate family/blood relatives – Hereditary/genetic diseases – Death from hereditary diseases  Social Data Occupation Level of education Economic status Support system Home and neighborhood conditions Psychologic Data  Major stressors  Usual coping patterns  Culture and Diversity Culture: Patterns of behavior/thinking people living in social groups learn, develop, share. – These beliefs, values, customs and social differences help guide a person’s decision making and world view Diversity: Array of differences among individuals, groups, communities. Be aware and sensitive to differences Cultural Assessment Family Structure Ethnic Heritage/Country of origin Social Organization Communication Patterns Foods Spiritual/Religious  Spiritual/Religious Practices: Spirituality : An individual’s process of finding meaning and purpose in life; a belief system Religion: a specific system of beliefs and practices – Assess spiritual and religious beliefs and their effect on health during hospitalization. – Rituals and religious practices – Prayer/meditation Older adult – May have been raised in organized religion – May observe traditional religious practices Violence Communication or behavior which threatens or harms self or others Interpersonal violence/Patient abuse – Fear of spouse, partner, caregiver, parent, adult child Observe – Behavior – Explanations that do not correlate with physical injuries – Signs of injury Mandatory Reporting in Ohio Health and Wellness Patterns : Activities of Daily Living Diet and Elimination Exercise, Activity, Sleep Leisure activities Home environment Recent travel Exposure to sun, pollutants Use of safety equipment Health and Wellness Patterns: Substance Use Tobacco: pack/years – Number of packs per day X the number of years smoked 2 ppd x 5 yrs = 10 pack years – Attempts at smoking cessation method Success/failure – When did they quit Health and Wellness Patterns: Substance Use Alcohol (ETOH) – Type and amount per day Social drug use – Marijuana, cocaine, heroin, prescription drugs Review of Systems (ROS) Questions to gather information about the various body systems This is the Patient’s perception- subjective data Some information may have already been gathered with the Health or Medical History Pay special attention to the system related to the chief complaint (the System of Focus)  Review of Systems General: client’s perception of general health (ie: mood, weight loss/gain) Nervous and musculo-skeletal systems: mobility, sensation, memory (ie: decreased mobility, forgetfulness) Cardiovascular: heart and peripheral vascular systems (ie: chest pain, palpitations, perfusion to extremities)  Respiratory: chronic disorders or acute infections. (ie: shortness of breath, wheezing) Integument and head: skin, hair, nails , eyes, ears, nose, sinuses, mouth, teeth, throat/neck. (ie: vision/hearing changes, rashes) Gastrointestinal: including abdomen (ie: appetite, bowel movement patterns, abdominal pain) Genitourinary: urinary tract; kidneys (ie: incontinence, color of urine, urgency) Older Adult Assessment: Common Geriatric Syndromes Clinical conditions that do not fit into discrete disease categories – Sleep disorders – Problems with eating/feeding – Incontinence – Confusion – Evidence of falls – Skin breakdown “SPICES”  Katz Assessment Tool Various categories to measure functional status Health History: Conclusion Conclusion: End the health history by giving the patient the opportunity to add information or express concerns. – “Is there anything else you would like to tell me?”  General Physical Assessment Considerations Organized head-to-toe or by body system Order: Inspection, Palpation, Percussion and Auscultation Vital signs: often the first physical contact Patient comfort: temperature, privacy, draping, position Room to move; adjustable lighting  General Physical Assessment Considerations Patient Safety – Assist patient with positioning – Assistance may be needed if patient is weak or has an alteration in mental status – Be alert in case the patient becomes light-headed when sitting up or standing (orthostatic hypotension) – Keep your hands on the patient if loss of balance is possible Inspection -Observational skills – Visual moisture, color, shape, position, size – Olfactory (smell) and auditory (hearing) note abnormal odors, sounds – Symmetry/Asymmetry: always look side-to-side with paired organs or appendages; are they equal or unequal? – **If patient is ill, inspect body system of chief complaint first Palpation – Examination of the body using touch: determines texture, temperature, position, size, consistency, location, tenderness – Often done with inspection skin turgor and temperature pulses moisture vibration surface abnormalities/tenderness  Percussion  A method of assessment performed by tapping body parts to elicit a sound. Determines size, consistency and borders of organs  Tympanic  Musical; drum-like  Heard during percussion of abdomen- air filled stomach  Resonance  Hollow sound  Heard over thorax – lungs filled with air  Dullness  Thud-like sound  Can be heard over abdomen and/or thorax  Produced by dense tissue such as liver, spleen, heart  **Performed by advanced provider Percussion  Auscultation  Technique to listen to sounds produced within the body  Some are “normal”, some are “abnormal”  Normally a stethoscope is used  May need to use Doppler device  What can be auscultated – Heartbeat, extra or abnormal sounds – Breath sounds – Bowel sounds – Vascular sounds  Documentation Let patient know you will be recording notes during health history Electronic documentation – Electronic Medical Record (EMR) – Usually “prompts” the nurse for specific information—flowsheets, drop down boxes may also allow comments or narrative notes for additional information Practice thinking in objective terms and seeing specific details If using handwritten notes, they must be neat and legible Only use acceptable abbreviations Documentation, cont Traditional paper chart Narrative documentation – Subjective: include with quotation marks ie: patient states “I feel like I can’t take a deep breath” – Objective: use accurate terminology ie: Resp. rate 30,shallow. Wheezing to bilateral anterior and posterior upper lobes  Documentation, cont Avoid vague, nonspecific terms: – OK, adequate – Normal/abnormal – Good/bad/worse – Average Use objective terms, specific details Use only acceptable abbreviations – JCAHO