Assessing Health Status Chapter 22 Assessing Health Status Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 22 Lesson 22.1 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory Discuss the types of assessment used in various situations. Demonstrate the techniques used during physical examination. Clinical Practice Assess the patient’s psychosocial and physical functioning by gathering information in an organized way. Perform a basic physical examination on a patient. Perform a visual acuity test on a patient. Carry out focused physical assessments of the cardiovascular, respiratory, gastrointestinal, and neurologic systems. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment: Data Collection Performed on an almost continual basis Initial detailed assessment on admission Includes: Physical examination History and demographic data Information pertinent to daily care Current health problems Focused assessment on every successive shift Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment: Data Collection (cont’d) Nurses must be aware of how the illness is affecting the patient’s life Not only health, all other areas Assess for cultural preferences and health beliefs Phrase questions in a positive, nonthreatening way Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment: Data Collection (cont’d) The initial or admission assessment should include an interview to determine: Social data Marital status, occupation, visual or hearing deficits Dentures, prostheses ALLERGIES—food, drug, or other Medications being taken (including OTC and herbal supplements) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment: Data Collection (cont’d) Diet Any limitations or special foods Smoking Use of alcohol Activities of daily living Previous surgeries Health problems, current and past Reason for admission Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment: Data Collection (cont’d) Physical data Head and neck Chest, heart, and lungs Abdomen Genitourinary system Extremities and musculoskeletal system Endocrine system Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Physical Assessment Provides a complete picture of physiologic functioning Comprehensive, in-depth Includes all systems of the body Brief, scanning type of examination Confined to a specific body part or system Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Physical Examination Techniques: Inspection and Observation Inspect visually the various parts of the body and the behavioral responses of patients Visual observation of: General appearance Contours of the body Skin tone and color, rashes, scars, lesions Deformities or extremity weakness Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Physical Examination Techniques: Palpation Performed using the hands and fingertips to touch and feel various parts of the body Used to ascertain: Size, shape, and position of body parts Texture, temperature, and moisture of skin Presence of muscle spasm or rigidity Pain, tenderness, or swelling Presence of a growth Restriction in body part movement Skin temperature and turgor Presence of edema Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Physical Examination Techniques: Percussion Another method of obtaining information about body structures Light, quick tapping on the body surface to produce sounds Variations in the sounds reflect characteristics of organs or structures below the surface Percussion helps in determining: Size of organs Location of organs Density of organs Presence of air or fluids in tissue or in a body cavity Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Physical Examination Techniques: Auscultation Listening to presence or absence of body sounds using a stethoscope Particularly useful for: Lung sounds: use the diaphragm for all lobes Heart sounds Use the diaphragm for normal S1-S2 and to count heart rate Use the bell for some abnormal heart sounds Abdomen (bowel sounds) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 22-7: Auscultate the heart in each area Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Physical Examination Techniques: Olfaction (Smelling) Using the nose to identify odors characteristic of certain problems, such as: Breath odor for sweetness, acetone, or alcohol Wound odors Odors from discharges such as vaginal infections Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Basic Physical Examination Height and weight (without shoes) Infant without diaper (never leave unattended) Vital sign measurement Review of body systems Head and neck, chest, heart, and lungs Skin and extremities Abdomen Genitalia, anus, and rectum Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Review of Body Systems: Head and Neck General appearance Appearance of the eyes Condition of the hair Difficulty in hearing or seeing Pupils equal in size and accommodated to light Corneas clear (or is there opacity?) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Review of Body Systems: Chest, Heart, and Lungs Is the chest symmetric? Are shoulders at equal height? Is there any lordosis, kyphosis, or scoliosis? Any signs of dyspnea? Is there a noticeable point of maximal impulse PMI ? Heart sounds normal? (S1-S2) Apical pulse rate normal? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Review of Body Systems: Lung Sounds Using the diaphragm of the stethoscope, listen: Over the trachea Over the upper area of the chest Over the central chest and back Sounds Vesicular Bronchovesicular Adventitious Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 22-9: Sites for auscultation of lung fields (anterior) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 22-9: Sites for auscultation of lung fields (posterior) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Review of Body Systems: Skin and Extremities Inspect skin for: Rashes or lesions Flaking or dryness Signs of dehydration or edema (shoe or ring tightness) Turgor Capillary refill (less than 3 seconds) Assess peripheral pulses Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Review of Body Systems: Abdomen Bowel sounds should be assessed in all four quadrants on admission Normal (5 to 30 sounds/min) Hypoactive Hyperactive Silent Distention or tenderness Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 22-11: Auscultation of bowel sounds Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Review of Body Systems: Genitalia, Anus, and Rectum Unless patient has a specific complaint in these areas, the nurse does not visually assess them They may be assessed, however, when bathing the patient, performing perineal care, or assisting with toileting Ask the patient if there are any problems with these areas Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Systematic Way to Perform an Assessment A systematic way to perform such an assessment Rest and activity Nutrition, fluids, and electrolytes Safety and security Hygiene Oxygenation Psychosocial and learning Elimination Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Focused Assessment Brief examinations Occurs when a complete head-to-toe assessment is not needed Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 A systematic way to perform an assessment is to use the acronym RNS HOPE. Which letter is correctly defined? H—health O—oxygenation P—physical E—evaluation Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Maggie’s patient has been receiving dialysis for several months. She has a dialysis shunt in her left arm. When taking vital signs on her patient, it is important for Maggie to remember: blood pressure should be measured on both arms after the patient has been resting for 5 minutes. blood pressure should be obtained in the left arm only. blood pressure should be obtained in the right arm only. if blood pressure is elevated it should be taken in the other arm. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 On auscultation, Maggie notices her patient has rhonchi in her lungs bilaterally. Rhonchi can best be described as: whistling, musical, high-pitched sounds produced by air being forced through a narrowed airway. coarse, low-pitched, rattling sounds caused by secretions in the larger air passages. croaking sounds heard when there is partial obstruction. fine or coarse sounds that are high-pitched. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 During the physical examination of your patient, he states, “I have a ringing in my ears.” This is known as: vertigo. tinnitus. cerumen. petechiae. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 22 Lesson 22.2 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory Describe how to gather information for a comprehensive database for a patient. Clinical Practice Teach patients the assessment techniques for the early detection of cancer. Educate patients about the recommendations for periodic diagnostic testing. Assist with a medical examination by positioning and draping the patient, and organizing the equipment. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment of the Areas of Basic Needs “RNS HOPE” Rest and activity Nutrition, fluids, and electrolytes Safety and security Hygiene Oxygenation Psychosocial and learning Elimination Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Positioning and Draping Most examinations begin with patient seated on the end of the examination table with a drape over the lap and legs Patient assumes supine position and drape is pulled up over the upper body so chest and/or abdomen can be exposed Lithotomy position Knee-chest position Lateral or Sims’ position Prone position Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Elements of the Physical Examination Bladder should be emptied Ask patient to disrobe and put on an examination gown Prepare exam table Necessary equipment for the physical examination is made ready Examinations Pelvic exam and Pap smear Rectal examination of the prostate Body systems Interior of the eye Ears are examined Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Special Focused Examinations Neurologic check Performed at regular intervals on patients who have had a head injury or brain surgery Pupil size is measured Patient is asked to track the nurse’s finger or an object as it is moved to six different positions Glasgow Coma Scale is used in most hospitals to score the neurologic exam Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Evaluation Topics can include the following: The need for regular physical examinations Recommended periodic diagnostic tests The need for immunizations The necessity of regular dental examinations The warning signs of cancer The way to perform self-breast examination The method of performing self-testicular examination Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient and Family Teaching Topics can include the following: The need for regular physical examinations Recommended periodic diagnostic tests The need for immunizations The necessity of regular dental examinations The warning signs of cancer The way to perform self-breast examination The method of performing self-testicular examination Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.