Health Assessment Review

What is health assessment? Concerned with health promotion and disease prevention Used to make a judgment or diagnosis about the health of an individual A guide for data collection and health evaluation

Medical diagnosis vs. Nursing diagnosis Medical diagnosis concerned with the etiology of disease Nursing diagnosis concerned with the impact of the health problem on the whole person and with the individual’s response to the problem Nurses constantly observe and collect data: all part of assessment

Interviewing An assessment tool is used to collect data to assist in formulating a diagnosis Assess culture: a set of values, beliefs and traditions that are passed down Language barriers can sometimes create communication problems, nurses need to be aware of this and be creative in interviewing

Interview Essential to ensure privacy Make the environment conducive to an interview Listen to the client and/or family and allow adequate time for answering questions Always introduce yourself, including status and why you are there Take special care with the patient with visual & hearing impairments or who does not speak english

Collecting information Use open ended and closed ended questions to obtain data Open ended asks the client for narrative or a chance to provide their story Closed questions solicit yes or no answers and can be useful for clarification There are many responses the nurse can make that will encourage or discourage conversation Always remember to conclude the interview

Nonverbal skills Messages that are productive and enhance the relationship Defeating and non-productive: inattentiveness, authority, superiority, rolling eyes, behaviors that demonstrate a lack of respect

History: Adult Chief complaint/ characteristics Biographical data Source of history Reason for seeking care History of present illness Past history: can include surgeries, childhood illnesses Family history Review of systems

Integumentary Skin is an indicator of health status Assessed by inspection and palpation structures assessed are: the skin, hair, nails and scalp Always assess the subjective data first, usually a series of questions aimed at getting the client’s perspective

Inspection Inspect for colour, vascularity, lesions and body odours Inspect for obvious deviations from normal Abnormals: blue, red, yellow Document colour, type, location of lesions

Palpation Temperature and moisture Turgor Edema Texture

Nails Inspect shape, colour, angle and texture Shape should be convex and follow the curve of the finger Angle between the nail and its base should be about 160 degrees Clubbing is an abnormal sign Capillary refill

Pressure ulcers Important aspect to assess in client’s with restricted mobility Stages 1-4 Also a stage x which refers to those ulcers which are not able to be staged Preventable with nursing attention

Musculoskeletal Begin with subjective data related to the client’s musculoskeletal health Assess for any risk factors Techniques used are inspection and palpation The client’s range of motion is also assessed

ROM Test the range for each joint and move the client through Compare both sides Do not force the joint beyond its normal range If the client expresses pain or discomfort stop

Stance and gait Stance should be evenly distributed, able to stand on heels, toes, and to have erect posture Gait: toes point straight ahead, erect posture, stride equal on both sides Assess client walking into room

Inspection Inspect for symmetry Redness and swelling over joints Muscle tone and strength Ability to perform ROM

Palpation Palpate for warmth over joints Crepitus in a joint Normal range of motion without any stiffness, or grinding of joints Decrease in total bone mass as we age

Abdominal and Nutritional Abdomen contains several vital organs Assess the client’s subjective data Assess any risk factors that the client may have Make sure the client is lying down and that you have a warm stethoscope Patient should also have an empty bladder

Assessment Abdomen divided into 4 quadrants Each quadrant is assessed The sequence is always inspection, auscultation and palpation Palpation may stimulate bowel sounds and is done after auscultation of the abdomen

Inspection Look at skin colour and surface characteristics, including the umbilicus, contour, symmetry, peristalsis, pulsations and masses

Auscultation Used to assess bowel sounds and vascular sounds Performed systematically, using the 4 quadrants Listen for bowel sounds and note frequency and characteristics Bowel sounds are clicks and gurgles that should be heard every 5-30 seconds Listen for 1-5 minutes

Palpation Palpate: light and deep Watch patient’s face for signs of discomfort Abdomen should be soft, relaxed and free of tenderness Palpate liver, spleen, kidneys: liver, spleen not palpable, only right kidney may be palpable

Vital Signs Provide data to reflect the status of the client’s health Measure the temperature first, then pulse, respirations and blood pressure Important to know the client’s normal readings prior to beginning

Temperature Assess by oral, rectal, tympanic, axilla Several factors may impact on normal temperature Rectal is most accurate Tympanic is quickest but may not be as accurate Axilla used for children

Pulse Measures contraction of the heart Assess rate, rhythm, amplitude, contour and elasticity Rate: normal is 60-100 beats per minute Tachycardia: greater than 100 Bradycardia: less than 60

Amplitude and contour describe the strength of the pulse Never use your thumb to measure pulse Count for one full minute Various areas for assessing pulse

Respirations Monitor by observing the client’s chest rise and fall with each breath Count respirations for 30 seconds and multiply by 2 Don’t let the client know that you are counting respirations as this may change breathing pattern Normal rate: 12-20 breaths per minute with a regular rhythm and equal bilateral chest expansion

Blood Pressure Reflects the pressure that is exerted on the walls of the arteries Expressed as the ratio of the systolic pressure over the diastolic pressure BP will normally vary over the day Normal: systolic 100-140 mm Hg; diastolic 60-90 mm Hg A difference of about 10 mm Hg between arms is normal If concerned always check the other arm , try different equipment or get another nurse to verify

Cardiac Assessment Subjective data: look at past history, risk factors Teach risk reduction measures Tie BP, skin, nails, head, neck and thorax and lungs, and peripheral pulses into this assessment Techniques inspection, palpation and auscultation

Inspection Observe the neck and precordium ( front of the thorax or chest) for any visible pulsations Inspect the epigastric area for pulsation of the abdominal aorta Client should be supine with the head of bed elevated 30-45 degrees

Palpation Systematic Assess specific cardiac landmarks: aortic, pulmonic, tricuspid, and mitral areas Each area is palpated for pulsations or thrills Assess the apical pulse in the mitral area (4th or 5th intercostal space). Use one finger pad for accurate palpation…can auscultate apical as well

Auscultation Used to determine the heart sounds caused by closure of the heart valves Use same landmarks as previously Listening for rate and rhythm Listen for the heart sounds (S1 and S2), these are the “lub” Dup” sounds Listen for the full lub-dup for apical pulse

Peripheral Vascular Assess subjective data. Assess risk factors Teach risk reduction measures Includes measuring the BP and assessing peripheral pulses Techniques used are inspection and palpation

Inspection Inspect for size, symmettry, presence of edema and venous patterning Look at skin colour Look at nail colour (hands and feet): clubbing Inspect for varicosities Look at distribution of hair

Palpation Palpate for temperature Palpate the pulses: peripheral, brachial, radial, carotid Use the pads of the fingers Palpate for symmetry and amplitude Palpate for edema If an occlusion is suspected you can try to auscultate

Capillary refill Quick and easy way to get a picture of the client’s peripheral vascular status Compress the nail bed until it blanches Release it and note the time it takes for colour to return

Genitourinary Assess subjective data Normal urine should be straw coloured with no offensive odour or sediment Usually about 200-300 mls of urine in bladder will stimulate the need to void but bladder can distend to hold 3000-4000 mls Techniques inspection and palpation

Inspection Inspect organs associated with urination. Looking for obvious signs of discharge or infection Any noticeable deviations from normal

Palpation Palpate for urethral discharge in men Physicians can palpate the prostate gland The urinary bladder can be palpated if it is full The kidneys can be palpated but it can be difficult to feel anything

Kidneys Integral part of body functioning Role is to filtrate waste from the body

Fluid balance Essential part of assessment Intake includes fluid from IVs, oral, liquid meals Output includes urine, diarrhea, emesis, wound drainage Important to ensure an adequate fluid balance: positive balance when intake is greater than output, negative balance when intake is less than output

Labs Review your readings Review your notes The areas covered from labs will be the “common sense” types of questions Take your time!!