Health Assessment Basics Notes

7/24/2019 Health Assessment Basics Notes

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Weeks 1 3 notes

Chapter 1:

Assessmentis the collection of data about a persons state of health by collecting and

analyzing subjective data and objective data, which will form a database !linicaljudgment and diagnoses can be made based off of the database

Diagnostic reasoningis the process of analyzing health data and drawing conclusions to

identify diagnoses "t involves hypothesis forming and deductive reasoning #his has four

major components$

o %ttending to initially

available cues &a sign or

symptom or a piece of

laboratory data'

o

(ormulating diagnostichypotheses

o )athering data relative to the

tentative hypotheses

o *valuating each hypothesis

with the new data collected,

thus arriving at a finaldiagnosis

+ake sure you gather data fully and eliminate any gaps you may have "f you are not sure

of something, ask an epert of the particular subject to validate the data

-ursing process$ assessment, diagnosis, outcome identification, planning,

implementation, evaluation #o function at the epert level of clinical judgment involves

using intuition and critical thinking

#here are various critical thinking skills that nurses can use$

o "dentifying assumptions

o "dentifying an organized and

comprehensive approach

o .alidation

o /istinguishing normal from

abnormal

o +aking inferences

o !lustering related cues

o /istinguishing relevant from

irrelevant

o 0ecognizing inconsistencies

o "dentifying patterns

o "dentifying missing

information

o romoting health

o /iagnosing actual and

potential &risk' problems

o 2etting priorities

o "dentifying patientcentered

epected outcomes

o /etermining specific

interventions

o *valuating and correcting

thinking

o /etermining a

comprehensive plan

First-level priorityproblems are those that are emergent, life threatening, and immediate

Second-level priorityproblems are those that are net in urgency &those that re4uire

prompt intervention to forestall further deterioration' Third-level priorityproblems are


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those that are important to the patients health but can be addressed after the urgent health

problems are addressed Collaborative problemsare those in which the approach to

treatment involves multiple disciplines

*videncebased practice &*5' is considered to be one of the bestpractice techni4ues for

treating patients *5 is 6a systematic approach to practice that emphasizes the use of

best evidence in combination with the clinicians eperience as well as the patient

preferences and values, to make decisions about care and treatment7 #here are 8 factors

of *5 clinical decision making$

o *vidence from research and

evidencebased theories

o hysical eamination and

assessment of patient

o !linical epertise

o atient preferences and

values

#here are four different types of data to collect$

o !omplete &total health' database$ includes a complete health history and a fullphysical eamination, and describes the current and past health state and forms a

baseline against which all future changes can be measured

o (ocused &problemcentered' database$ is for a limited or shortterm problem, and

usually only focuses on one problem, one cue comple, or one body system

o (ollowup database$ used to evaluate the status of any identified problems at

regular and appropriate intervals

o *mergency database$ is often collected rapidly alongside lifesaving measures

/iagnosis must be swift and sure

9olistic health involves the whole person &the mind, body, and spirit' -urses work hard

with health promotion and disease prevention !ulture must be included in the holistic

model of health care

Chapter 2:

9ispanics are the largest and fastest growing population in the :nited 2tates, followed by

%sians, 5lacks, %merican "ndians, %laskan natives, -ative 9awaiians, and other acific

"slanders

#he amount of immigrants to the :nited 2tates has tripled from 1;;


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o *ffective !are$ results in positive outcomes and satisfaction for the patient

o 0espectful !are$ takes into consideration the values, preferences, and epressed

needs of the patient

o !ultural and =inguistic !ompetence$ is a set of congruent behaviors, attitudes,

and policies that come together in a system among professionals that enables

work in crosscultural situations

Health disparitiesare the unusual and disproportionate fre4uency of a given health

problem within a population when compared with other populations

Culturally sensitiveimplies that caregivers possess some basic knowledge of and

constructive attitudes toward the diverse cultural populations found in the setting in

which they are participating

Culturally appropriateimplies that the caregivers apply the underlying background

knowledge that must be possessed to provide a given person with the best possible health

care

Culturally competentimplies that the caregivers understand and attend to the total

contet of the individuals situation, including awareness of immigration status, stress

factors, other social factors, and cultural similarities and differences

Cultural careis the provision of health care across cultural boundaries and takes into

account the contet in which the patient lives as well as the situations in which the

patients health problems arise

Heritage consistencyis a concept that describes 6the degree to which ones lifestyle

reflects his or her respective %merican "ndian tribal culture7

Traditional$ living within the norms of the traditional cultureModern$ acculturated to the

norms of the dominant society

Cultureis learned from birth through the processes of language ac4uisition and

socialization, shared by all members of the same cultural group, adapted to specific

conditions related to environmental and technical factors and to the availability of natural

resources, and dynamic and ever changing

Ethnicitypertains to a social group within the social system that claims to possess

variable traits such as a common geographic origin, migratory status, religion, race,

language, shared values, traditions, symbols, and food preferences

Religionis the belief in a divine or superhuman power or powers to be obeyed and

worshipped as the creator&s' and ruler&s' of the universe 0eligion may be a seen as a

shared eperience of spirituality or as the values, beliefs, and practices that people are

either born into or may adopt to meet their personal spiritual needs through communal

actions such as religious affiliation, attendance and participation in a religious institution,

prayer or meditation, and religious practices

Spiritualityis borne out of each persons uni4ue life eperience and his or her personal

effort to find purpose and meaning in lifeReligionrefers to an organized system of

beliefs concerning the cause, nature, and purpose of the universe, especially belief in or

the worship of )od or gods


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Socializationis the process of being raised within a culture and ac4uiring the

characteristics of that group &*ducation is a form of socialization'

o Acculturation$ the process of adapting to and ac4uiring another culture

o Assimilation$ the process by which a person develops a new cultural identity and

becomes like the members of the dominant culture

o Biculturalism$ dual pattern of identification and often of divided loyalty

2ome 4uestions for heritage assessment can include$

o Where were you born>

Where did you grow up>

o /id your parents encourage

you to participate in religious

or ethnic activities> What

kind of school did you go to>

/id you go to a special

religious school after regular

school hours>

o 9ave you visited the

nation&s' or the

neighborhoods where your

family originated>

o Who are the people living in

the neighborhood where you

now live>

o /o you participate in ethnic

celebrations from your

heritage>

o Who lived in your home>

Were they related to you>

o /o you maintain ties to

family>

o Was your family name

changed when the family

came to the :nited 2tates>

Was the name changed to

facilitate assimilation>

o What school did you go to>

Was it public or private>

o Who are your friends, and

how often do you spend time

with them>o /o you speak or read the

language of your parents or

grandparents>

o /o you identify as an ethnic

%merican or as an %merican>

o /o you mostly participate in

social activities with

members of your family>

o /o you mostly have friends

from a similar cultural

background as you>

o /o you mostly eat the foods

of your familys tradition>

o /o you mostly participate in

the religious traditions of

your family>

Healthis the balance of the person, both within ones being &physical, mental, or

spiritual' and in the outside world &natural, communal, or metaphysical' as a comple,

interrelated phenomenon

o

/isease can be viewed in three different ways$

o 5iomedical &scientific' theory$ is based on the assumption that all events in life

have a cause and effect, that the human body functions more or less mechanically,

that all life can be reduced or divided into smaller parts


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o -aturalistic &holistic' theory$ a belief that the forces of nature must be kept in

natural balance or harmony #he yinyang theory believes that health eists when

all aspects of the person are in perfect balance

o +agicoreligious perspective$ the basic premise is that the world is seen as an

arena in which supernatural forces dominate #he fate of the world and those in it

depends upon the action of supernatural forces for good or evil

ain is a universally recognized phenomenon, and it is an important aspect of assessment

for people of various ages ain is a very private, subjective eperience that is greatly

influenced by cultural heritage *pectations, manifestations, and management of pain

are all embedded in a cultural contet 2ilent suffering has been identified as the most

valued response to pain by health care professionals

o Chapter 3:

%n interview is the first and the most important part of data collection "t collects

subjective data &what the person says about himself or herself' #he patient is in charge

during the interview % successful interview includes$

o )athering complete and accurate data about the persons health state, including

the description and chronology of any symptoms of illness

o *stablishes rapport and trust so the person feels accepted and thus free to share all

relevant data

o #each the person about the health state so that the person can participate in

identifying problems

o 5uild rapport for a continuing therapeutic relationship? this rapport facilitates

future diagnoses, planning, and treatmento 5egin teaching for health promotion and disease prevention

% contract consists of spoken or unspoken rules for behavior #he interview contract

terms include$

o #ime and place of the interview and succeeding physical eamination

o "ntroduction of yourself and a brief eplanation of your role

o #he purpose of the interview

o 9ow long it will take

o *pectation of participation for each person

o resence of any other people &family, other health professionals, students'

o !onfidentiality and to what etent it may be limited

o %ny costs that the patient must pay

All behavior has meaning.

#he process of communication involves$

o 2ending information


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o 0eceiving information

o "nternal factors

=iking others *mpathy #he ability to listen

o *ternal factors *nsure privacy 0efuse interruptions hysical environment

2et room temperature at a comfortable level rovide sufficient lighting 0educe noise 0emove distracting objects or e4uipment lace the distance between you and the patient at 8 @ feet %rrange e4ualstatus seating, avoid standing

%rrange a facetoface position /ress #he patient should remain in street clothes ecept in the case of an

emergency

Aour appearance and clothing should be appropriate to the setting

and should meet conventional professional standards &a uniform or

lab coat over conservative clothing, a name tag, neat hair'

-otetaking &but keep to a minimum' #ape and video recording *lectronic 9eath 0ecording &*90'

#here are various techni4ues of communication during an interview$

o "ntroduction

o #he Working hase

Bpenended 4uestions !losed or direct 4uestions 0esponses &assisting the narrative'

(acilitation 2ilence 0eflection *mpathy !larification

!onfrontation "nterpretation *planation 2ummary

#here are various traps with interviews$


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o roviding false assurance or

reassurance

o )iving unwanted advice

o :sing authority

o :sing avoidance language

o *ngaging in distancing

o :sing professional jargon

o :sing leading or biased

4uestions

o #alking too much

o "nterrupting

o :sing 6why7 4uestions

-onverbal skills can include$

o hysical appearance

o osture

o )estures

o (acial epression

o *ye contact

o .oice

o #ouch

While closing the interview, it gives a chance to summarize the information you have

learned during the interview

When you have a patient that is a child, you must build rapport with the child and their

parent&s'

When working with an infant, nonverbal communication is important "f their needs are

met, they will be calm Blder infants have an aniety to strangers, and work best if their

parent is in view % preschooler is egocentric but may view things with an animistic

sense % schoolage child can understand more and are more objective and realistic

%dolescents can have some maturity but in times of stress, they may fall back upon

childish traits With older adults, avoid using 6elderspeak7 (or people who are hearing

impaired, a sign language interpreter is needed for a complete health history "n

emergencies, try to interview as much as possible while working to save the person Aou do not have to answer all personal 4uestions

!rying is actually a form of relief to the person, or get angry #his usually does not have

to do with the interviewer

*ti4uette refers to the conventional code of good manners that governs behavior and

varies crossculturally

Chapter 4:

9ealth history se4uence$

o 5iographic data$ name, address, phone number, age, date of birth, birthplace,

gender, marital status, race, ethnic origin, occupation &hospitals must record

language and communication needs'

o 0eason for seeking care$ record signs and symptoms and talk about what

prompted the visit

o resent health or history of present illness$ the final summary should include$


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1 =ocation

C !haracter or 4uality

3 Duality or severity8 #iming

@ 2etting

E %ggravating or

relieving factors

F %ssociated factors

G atients perception

o ast history$

!hildhood illnesses %ccidents or injuries 2erious or chronic

illnesses

9ospitalizations

Bperations Bbstetric history "mmunizations =ast eamination date %llergies !urrent medications

o (amily history$ a pedigree or genogram is sometimes sent home to gain a more

accurate understanding of family conditionso 0eview of systems$

)eneral overall health

state

2kin 9air 9ead *yes *ars

-ose and sinuses +outh and throat -eck 5reast %illa 0espiratory system

!ardiovascular eripheral vascular )astrointestinal :rinary system +ale genital system (emale genital system 2eual health +usculoskeletal

system

-eurologic system 9ematologic system *ndocrine system

o (unctional assessment or activities of daily living &%/=s'$

2elfesteem, self

concept

%ctivityH*ercise 2leepH0est -utritionH*limination "nterpersonal

relationships

0esources 2piritual resources

!oping and stress

management

ersonal habits %lcohol "llicit or street drugs *nvironmental

hazards

"ntimate partner

violence


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Bccupational health

(or children, the health history is altered slightly$o 5iographic data$ name, nickname, address, phone number, parents name and

work numbers, age, date of birth, birthplace, gender, race, ethnic origin,

information on other family members at home

o 0eason for seeking care$ can happen spontaneously, and can be initiated by the

child, parent, social worker, or classroom teacher

o resent health or history of present illness$ note factors such as severity of pain,

associated factors such as relation to activity, eating, body position, and the

parents intuitive sense of a problem, and the parents coping ability and reaction

of other family members to childs symptoms or illness

o ast health$

renatal status =abor and delivery ostnatal status !hildhood illness 2erious accidents or

injuries

2erious chronic

illnesses

Bperations or

hospitalizations

"mmunizations %llergies +edications

o

/evelopmental history$

)rowth +ilestone !urrent development &!hildren 1 month through preschool' 2choolage child

o -utritional history

o (amily history

o 0eview of systems &same systems as adult'

o (unctional assessment &including %/=s'$

"nterpersonalrelationships

%ctivity and rest *conomic status

&parents jobs' 9ome environment

*nvironmentalhazards

!opingHstress

management

9abits 9ealth promotion


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%dolescents tend to follow the 9**%/222 method of interview

o 9ome

o *ducation and employment

o *ating

o %ctivities

o /rugs

o 2euality

o 2uicide and /epression

o 2afety &2avagery'

#he health history is also adjusted for the older adult as well$

o 0eason for seeking care

o ast health$

)eneral health %ccidents or injuries, serious or chronic illnesses, hospitalizations,

operations =ast eamination Bbstetric status !urrent medications

o (amily history

o 0eview of systems$

*yes *ars +outh 0espiratory system !ardiovascular

system

eripheral vascular

system :rinary system 2eual health +usculoskeletal

system -eurologic system

o (unctional assessment &including %/=s'$

2elfconcept, self

esteem

Bccupation %ctivity and eercise 2leep and rest -utritionH*limination

"nterpersonal

0elationships

0esources !oping and stress

management

*nvironmental 9azards

Chapter 8:

2ome skills re4uired for a physical eamination include$ inspection, palpation, percussion

and auscultation


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"nspection is concentrated watching, focusing first on the patient as a whole, but then on

each individual body system "t begins when you first meet the person and develop a

6general survey7

alpation applies the sense of touch to assess teture, temperature, moisture, organ

location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation

&cracking or rattling sound', presence of lumps or masses, and tenderness or pain

o (ingertips$ good for fine tactile discrimination, as of skin teture, swelling,

pulsation, determining presence of lumps

o % grasping action of the fingers and thumb$ to detect the position, shape, and

consistency of an organ or mass

o #he dorsa &backs' of hands and fingers$ best for determining temperature because

the skin is thinner than on the palms

o 5ase of fingers &metacarpophalangeal joints' or ulnar surface of the hand$ best for

vibration

ercussion is tapping the persons skin with short, sharp strokes to assess the underlying

structures "t is used for$

o +apping out the location and size of an organ by eploring where the percussion

note changes between the borders of an organ and its neighbors

o 2ignaling the density &air, fluid, or solid' of a structure by a characteristic note

o /etecting an abnormal mass if it is fairly superficial? the percussion vibrations

penetrate about @ cm deep &a deeper mass would give no change in percussion'

o *liciting a deep tendon refle using the percussion hammer

#he sounds that can be heard by percussion include various 4ualities$

o %mplitude &intensity'$ a loud or soft sound =oudness depends on the force of the

blow and the structures ability to vibrate

o itch &fre4uency'$ the number of vibrations per second +ore rapid vibrations

produce a highpitched tone 2low vibrations yield a lowpitched tone

o Duality &timbre'$ a subjective difference due to a sounds distinctive overtones

.ariations within a sound wave produce overtones Bvertones allow you to

distinguish a ! on a piano from a ! on a violin

o /uration$ the length of time the note lingers

#he types of sounds can include$

o 0esonant

o 9yperresonant

o #ympany

o /ull

o (lat

%uscultation is listening to sounds produced by the body, such as the heart and blood

vessels and the lungs and abdomen

#he eamination room should be warm, comfortable, 4uiet, private, and well lit

2ome e4uipment used include$


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o latform scale with height

attachment

o 2phygmomanometer

o #hermometer

o ulse oimeter &in hospital

setting'o aper and pencil or pen

o (lashlight or penlight

o BtoscopeHophthalmoscope

o #uning fork

o -asal speculum

o #ongue depressor

o ocket vision screener

o 2kinmarking pen

o (leible tap measure and

ruler marked in centimeters

o 0efle hammer

o 2harp object &split tongue

blade'o !otton balls

o 5ivalve vaginal speculum

o !lean gloves

o +aterials for cytologic study

o =ubricant

o (ecal occult blood test

materials


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%ll e4uipment should be cleaned to create a clean environment

#he best way to prevent nosocomial infections is to wash your hands before and after

every physical patient encounter, after contact with blood, body fluids, secretions and

ecretions, after contact with e4uipment contaminated with body fluids, and after

removing gloves

5egin the assessment by measuring the persons height, weight, 5, temperature, pulse

and respirations "f needed, measure visual acuity using the 2nellen eye chart #hen ask

the patient to change into a gown, leaving underpants on &leave the room', and when you

reenter, wash your hands in front of the patient, and as you perform your assessment,

eplain everything to the patient !heck hands &skin color, nail beds, and

metacarpophalangeal joints'

When checking infants, the parent should be present lace the infant on a padded

eamination table &or held against the parents chest for some steps' #he checkup

should be 1 C hours after feeding #he environment should be warm #alk softly, make

eye contact, and smile +ovements should be smooth and deliberate Bffer toys as adistraction "f asleep, use the time to check heart, lung and abdominal sounds first

Btherwise, perform least distressing steps first 2ave the eamination of the eye, ear, nose

and throat until last

(or a toddler, the parent can help position the child and comfort them during invasive

procedures /o not offer the toddler a choice when there is no choice

#he preschool child is similar to the toddler but the child is more cooperative

#he schoolage children are more interested in learning about the body and are more

cooperative #he se4uence follows that of an adult

#he adolescent is similar to that of an adult, but should be done without anyone else in

the room #he aging adult work with the headtotoe approach best

(or an ill person, the assessment is altered accordingly

Chapter 10:

#here are two processes we use to understand pain$ nociceptive andHor neuropathic ain

is highly comple and subjective that originates from the !-2 or the -2 &or both' #he

specialized nerve endings are called nociceptors

-ociceptive pain develops when nerve fibers in the periphery and in the central nervous

system are functioning and intact -ociception can be divided into four phases$transduction, transmission, perception, and modulation

#ransduction occurs when there is stimulus in the form of traumatic or chemical injury,

burn, incision, or tumor #he tissue releases chemicals, including substance , histamine,

prostaglandins, serotonin, and bradykinin, which are neurotransmitters

#ransmission has the pain impulse move from the spinal cord to the brain

erception indicates the conscious awareness of a painful sensation


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/uring modulation is how the pain message is inhibited by a builtin system that will

eventually slow down and stop the processing of a painful stimulus

-europathic pain is considered to be an abnormal processing of the pain message from an

injury to the nerve fibers

#here are various sources of pain$

o .isceral pain$ originates from the larger interior organs #he pain can stem from

direct injury to the organ or from stretching of the organ from tumor, ischemia,

distention, or severe contraction

o /eep somatic pain$ comes from sources such as the blood vessels, joints, tendons,

muscles, and bone

o !utaneous pain$ is derived from skin surface and subcutaneous tissue

o 0eferred pain$ pain felt at a particular site but originates from another location

#here are various types of pain$

o %cute pain$ shortterm and selflimiting, often follows a predictable trajectory,

and dissipates after an injury heals

"ncident pain happens predictably when certain movements take placeo ersistent &chronic' pain$ is diagnosed when the pain lasts E months or longer

+alignant pain$ cancerrelated -onmalignant pain 5reakthrough pain

"nfants have the same capacity for pain as adults reverbal infants are at high risk for

undertreatment of pain because of persistent myths and beliefs that infants do not

remember pain

#here is no evidence to suggest that older adults feel less pain or that sensitivity is

diminished ain is more commonplace, however

#here are various pain assessment tools to help gather subjective data #here are overall

pain assessment tools, which are most useful for chronic pain #here are pain rating

scales and a descriptor scale

(or infants and children it is better to use the (aces ain 2cale 0evised &(2 0'

#here are variations such as the Bucher 2cale

% physical eamination can help gather objective data on pain "f pain is not treated,

there can be many acute pain responses and behaviors With acute pain behavior, the

patient may grimace, vocalize &moaning', agitation, restlessness, stillness, diaphoresis, or

have changes in vital signs (or patients with chronic pain, they may learn to adapt and

try to give little indication of pain 9owever, these behaviors can be seen as 6comfort7and be left untreated

We have a limited understanding of how to assess pain in infants &chronic pain' #he

!0"*2 score was developed to help find postoperative pain

With older adults, acute confusion is generally the best indicator of poorly controlled

pain (or patients with dementia, the %"-%/ is used to help identify pain


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Chapter 11:

-utritional status refers to the degree of balance between nutrient intake and nutrient

re4uirement Bptimal nutritional status is achieved when sufficient nutrients are

consumed to support daybyday body needs and any increased metabolic demands due

to growth, pregnancy, or illness :ndernutrition occurs when nutritional reserves are

depleted andHor when nutrient intake is inade4uate to meet daytoday needs or added

metabolic demands Bvernutrition is caused by the consumption of nutrients in ecess of

body needs

(or fullterm infants, there are many advantages of breastfeeding, including$

o (ewer food allergies and intolerances

o 0educed likelihood of overfeeding

o =ess cost than commercial infant formulas

o "ncreased motherinfant interaction time

%dolescents need more nutritional intake because of their body changes, but various

factors such as skipping meals and possible drug eperimentation must be considered

when trying to help them select healthier food choices

% woman may gain more weight during pregnancy because of the fetuss need for

nutrients

(or adults, the nutrition need stabilizes

Blder adults are at higher risk for overnutrition or undernutrition

#here are various nutritional assessment tools, such as the +-%, to help identify

individuals who are malnourished or are at risk for developing malnutrition, provide data

for designing a nutrition plan of care that will prevent or minimize the development of

malnutrition, and establish baseline data for evaluating the efficacy of nutritional care (ood diaries may be used to help come up with plans, or to monitor changes, such as with

children

ercent of ideal body weight Icurrentweight

idealweight 1

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Health Assessment Basics Notes