Intro to Health Assessment

1. Intro to Health Assessment

2. Health Assessment What is it? Why are we learning it? • Health Assessment includes: • Theoretical and Experiential • Knowledge • Critical Thinking • Assessment Skills • Communication Skills • Nursing Process • Assessment • Health History • Physical examination • Diagnostic data • Nursing Diagnosis • Interpret data • Outcome Identification • Planning • Implementation • Evaluation Assessment is the collection of data about the individual’s health state. COPD Nursing Diagnosis: Impaired gas exchange related to alveolar membrane changes, diminished airway size, airflow limitation, respiratory muscle fatigue, and excessivemucus production

3. Developmental Considerations • Infancy – birth to 1 year • Toddler – 1 to 3 years • Preschooler – 3 to 6 years • School age – 6 to 12 years • Adolescent – 12 to 20 years • Early adult – 20 to 40 years • Middle adult – 40 to 64 years • Late adult – 65+ years Why consider development while assessing?

4. Theorists Erikson – Psychodynamic theory Social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved 8 stages based on age Each stage must be accomplished before moving into next stage Piaget – Cognitive theory How a person perceives and processes information 4 stages not based on age but in order Each stage represents a change in how children understand their environment Developmental Considerations in Assessment • Erikson’s Stages • Trust vs mistrust (infants) • Autonomy vs shame and doubt (toddlers) • Initiative vs guilt (preschool) • Industry vs inferiority (school age) • Identity vs role confusion (adolescents) • Intimacy vs isolation (young adults) • Generativity vs stagnation (middle adults) • Integrity vs despair (late adults) • Piaget’s Stages • Sensorimotor - physical manipulation • of objects and events (0-2 yr) • Preoperational – language (2-7 yr) • Concrete Operational – logic in mental • reasoning (7-11 yr) • Formal Operational – abstract concepts

5. Physical development Average term weight is 3.4 kg (7.5 lb). Triple birth weight by 1 year. Primitive reflexes that begin to disappear Grasp reflex disappears ~2 months Vision improves Posture, holding head up, sitting, crawling, and walking Behavioral and Cognitive Trust vs. Mistrust Language – crying, imitate sounds (9-10 months), first word! Infants Contributes to development of systems SIDS – Causes? Recommendations? Complications at birth? Immunization up to date? Injuries? Nutrition? Hearing or vision impairments? Lead poisoning? Whom are you assessing? Decreased airflow, decreased blood flow to brain

6. Physical Rate of growth decreasing Upright posture Improvements in fine motor skills Behavioral and Cognitive Autonomy vs. shame and doubt More autonomous Object permanence, mental representation Negativism – constant protests Ritualism – same order Parallel play – mimic other children Telegraphic speech – few words at a time, basic commands Toddlers Stacking blocks!

7. Growth Charts Boys, 1-17 yrs Birth to 36 months

8. Physical Growth of long bones Begin to lost baby fat Permanent teeth appear Behavioral and Cognitive Initiative vs. guilt More autonomous Communicate more effectively Awareness of others’ needs and interests Develop gender roles Delayed imitation Egocentrism Preschoolers Allow to play with instruments prior to use

9. Physical Muscles stronger and more coordinated Bones replace cartilage Behavioral and Cognitive Industry vs. inferiority – a desire to achieve Reading and writing improve Manage feelings and impulses better Identify sex and gender roles Identify self as worthy individual School Age

10. Physical Growth spurts in height and weight Menarche and thelarche in girls Behavioral and Cognitive Ego identity vs. role confusion Formal operational thought Identity confusion May be embarrassed of own body Emotional independence More knowledgeable Adolescents

11. Physical Maximum potential for growth and development Reduction in activity Behavioral and Cognitive Intimacy vs. role isolation Achievements important, career Mate selection Early Adulthood ↓ caloric intake

12. Physical Wrinkling of skin Graying or loss of hair Decrease in muscle mass and tone Vision and hearing decrease At risk populations develop Behavioral and Cognitive Generativity vs. stagnation Many decisions about career, lifestyle, family – “midlife crisis” Empty nest syndrome Intelligence remains constant, more experience Middle Adulthood Secondary Prevention

13. Physical Many variations Chronic illnesses Changes in sensation Loss of lean body mass, increase in fat deposition. Posture deteriorates, wider gait Poor skin turgor, xerosis (drying) More prone to injury due to loss of bone mass. Behavioral and Cognitive Ego identity vs despair Ego identity – acceptance of choices made in their lives Despair - Loss of spouse can be devastating Stereotyping by society – ageism Older Adulthood • Further classification • Young-old (65-74 yrs) • Middle-old (75-84 yrs) • Old-old (85 or older) • Lueckenotte (2000)

14. Developmental Considerations • Infant – gentle, calm. Primary interaction with parents • Preschooler – be direct. Let play with equipment. Only concrete explanation, don’t go into detail. • School age – they are curious. Explain how and why. Talk to child first than parent. • Adolescent – be respectful. Explain everything. Avoid silence. • Older adults – slow down. Be respectful, patient. Like to tell stories.

15. Approach to Identifying Priorities • Immediate priorities (ABCs) • Airway • Breathing • Circulation • Vital Signs • Second-level priorities • Mental status change • Acute pain • Urinary elimination problems • Untreated medical problem (diabetic without insulin) • Abnormal lab values • Risks of infection, safety, security • Third-level priorities • Lack of knowledge • Activity, rest, sleep

16. Health History • Establishes a rapport – relationship, understanding, trust • Helps to focus on the patient’s chief concern and sets the stage for the Physical Examination (PE) • Less invasive than the PE • Types of data • Subjective data – what person says about himself or herself • Objective – what you observe during a PE

17. Open-Ended Questions Broadly stated and encourage an open response Aim is to describe problem or symptoms “How are you feeling?” Closed or Direct Questions Direct and specific questions to get details Aim is to focus on the problem. More specific. “When did the pain begin? Is the pain sharp, dull, or achy?” Health History Purpose – to obtain subjective data from pt. Open-Ended Closed

18. Phases of an Interview • Introduction phase • Nurse introduces self to client • Nurse describes purpose of interview • Nurse describes the process of the interview so that client knows how long interview will take and what to expect • Discussion phase • Nurse helps discussion • Discussion is client centered • Nurse uses various communication techniques to collect data • Summary phase • Summarization of data • Allows for clarification of data • Provides validation to the client that nurse understands problem

19. Sending Messages Appearance – clothing, hair, jewelry Nonverbal communication – body language (gestures, facial expressions, eye contact, touch) Verbal communication – empathy. Speech – is it clear? Can the patient understand you? Receiving Messages Overall appearance of patient – neat? wet? orderly or rowdy? Nonverbal and verbal communication Listening actively – requires complete attention. What is the pt. not saying? Difficulty with language, pronunciation, or memory? Internal and External Factors of Communication • External factors • Privacy • Comfort • Room temperature • Noise • Seated at eye level Whom are you interviewing? Internal factors

20. Enhancing Data Collection • Facilitation – encouraging pt. to continue talking “uh-huh, go on, tell me more” • Silence – giving attention to the pt. to allow her to speak. Do not interrupt. • Reflection – repeating what the pt. has just told you. “So you’re saying you’ve been in pain for 5 days and it is worse when you walk?” Promotes trust from pt. Insures what you heard is accurate. • Empathy – emotions. If pt. just found out he has cancer. “It must be so hard on you and your family.” • Confrontation and Clarification – clarify inconsistencies of data. A story can change, especially with embarrassing issues. • Interpretation – sharing with pt. the conclusions you have drawn. • Explanation – inform. Could be about diet, medication use, etc. • Summary – review of data gathered.

21. Traps to Avoid • False assurances – everything’s not always ok • Unwanted advice – sometimes must let pt. decide. Be objective. Give pt. all the facts. • Avoiding the issues – be direct and honest • Professional jargon • Biased questions – “You don’t smoke, do you?” • Talking too much and interrupting • Don’t ask “why” when the pt. might not have answer – why didn’t you stop smoking when you knew it was bad for you? • Answering personal questions – not necessary and might be uncomfortable. Use common sense and experience

22. Interviewing Special Populations • Hearing Impaired • Recognize clues such as staring at your mouth or face, speaking loudly • Determine if there’s a better way to communicate such as writing or signing • Acutely Ill • If pt. is in an emergency situation, ask priority questions first. Use closed (direct questions). • Drugs or Alcohol Influenced • Ask simple and direct questions. • Try not to appear threatening • Sexually Aggressive People • Very important to set professional boundaries • Must make it clear you are a health professional and can best care for that person by maintaining a professional relationship • Crying • It’s ok if a pt. cries. It usually is a big relief to let out emotions. • Do not move onto another topic. Talk about what’s bothering him or her. • Anger and Threat of Violence • Ask the pt. why they are angry and try to deal with the feelings • If pt. becomes threatening, remember your safety comes first • Leave the examining room and try to position yourself between the pt and the door

23. Domestic Violence Considerations • Most common people to become victims of abuse are the intimate partner and the elderly. • You must remember that reporting of abuse is one of the most important ways of preventing future occurrences • Don’t be afraid to ask the pt. if you suspect abuse. You are an advocate for the patient. • Abuse Assessment Screen (AAS) • “Because domestic violence is so common in our society, we are asking all women the following questions” • Document, Document, Document • Write down direct quotes from pt. even if it includes swearing

24. AMA Definitions for Elder Abuse and Neglect • Physical abuse • Violent acts that result or could result in injury, pain, impairment, and/or disease • Physical neglect • Failure of family member or caregiver to provide basic goods and/or services such as food, shelter, health care, and medications • Psychological abuse • Behaviors that result in mental anguish. (Threats) • Psychological neglect • Failing to provide basic social stimulation • Financial abuse • Intentional misuse of elderly person’s financial resources without consent • Financial neglect • Failure to use the assets of the elderly person to provide necessary services

25. Abuse Terminology • Abrasion • A wound caused by rubbing the skin or mucous membrane • Bruise (Contusion) • Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface • Ecchymosis • A hemorrhagic spot, larger than petechia, in the skin or mucous membrane, forming a nonelevated, round, or regular, blue or purplish patch • Hematoma • A localized collection of extravasated blood, usually clotted in an organ, space, or tissue • Hemorrhage • An escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ Abrasion Contusion Ecchymosis

26. Abuse Pictures laceration • Incision (Cut) • A cut or wound made by a sharp instrument • Laceration • A wound produced by tearing and/or splitting of body tissue, usually from blunt impact over a bony surface. • Lesion • Any pathologic or traumatic discoloration of tissue or loss of function • Patterned injury • An injury caused by an object that leaves a distinct pattern on the skin and/or organ • Petechiae • Small red or purple spot on the body • Disorders of coagulation. Strangulation. • With bruising, should suspect abuse • Puncture • The act of piercing or penetrating with a pointed oubject petechiae

27. Components of Health History • The general survey • Fourteen cues to be observed • Age • Sex • Race • Vital Signs • Apparent state of health • Signs of distress • Facial expressions • Mood • State of awareness • Speech • Dress, grooming, personal hygiene • Nutrition • Stature • Posture and gait

28. Reasons for seeking health care Health perception/Health management Present health or history of present illness Location Quality Quantity Timing Setting Aggravating/alleviating factors Associated factors Client’s perception Childhood illnesses Adult illnesses Accidents/injuries Hospitalizations Surgeries Obstetric history Immunizations Physical examinations/dental visits Allergies/reactions Current medications Health maintenance Knowledge of current and past health and illness Communicable disease Social history Family history/genogram Components of Health History

29. Components of Health History • Nutritional-metabolic pattern • Elimination pattern • Activity-exercise pattern • Sleep-rest pattern • Cognitive-Perceptual pattern • Role-relationship pattern • Sexuality-reproductive pattern • Coping-stress-tolerance pattern • Value-belief pattern

30. Functional Assessment (ADLs) • Self esteem • Activity and exercise • Sleep patterns • Nutritional assessment • Spiritual and social supports • Coping mechanisms • Alcohol, smoking, and drug use • Environmental hazards such as working conditions • Domestic violence assessment

31. Multiple Choice #1 • A maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson’s psychosocial development theory, the nurse would instruct the mother to: • Allow the newborn infant to signal a need • Anticipate all of the needs of the newborn infant • Avoid the newborn infant during the first 10 minutes of crying • Attend to the newborn infant immediately when crying According to Erikson, the caregiver should not try to anticipate the newborn infant’s needs at all times, but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, he or she will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant’s signal would inhibit the development of trust and lead to mistrust of others. Test taking strategy: Eliminate option b, c, and d because the absolute terms “all,” “avoid,” and “immediately.”

32. Multiple Choice #2 • A nursing instructor asks a nursing student to describe the formal operations stage of Piaget’s cognitive developmental theory. The most appropriate response by the nursing student is: • “The child develops logical thought patterns.” • “The child has the ability to think abstractly.” • “The child has difficulty separating fantasy from reality.” • “The child begins to understand the environment.” In the formal operations stage, the child has the ability to think abstractly and logically. Option 1 identifies the concrete operations stage. Option 3 identifies the preoperational stage. Option 4 identifies the sensorimotor stage.

33. Multiple Choice #3 • A 59-year-old female patient arrives at the physician’s office complaining of severe back pain. Which of the following questions would be most important to ask when gathering information for the physician? • “Are you allergic to any drugs?” • “Can you point to where the pain is?” • “How have you treated the pain at home?” • “Are you experiencing any other symptoms?” #1 Establishes existence of drug allergies but does not address the diagnosis of pain. #3 May help determine treatment but will not aid in diagnosis. #4 This does not address the characteristics of the pain. #2 Assessing the exact location of the pain assists in determining cause and treatment.

34. Multiple Choice #4 • The nurse is interviewing a 52 year old patient who presents to a physician’s office complaining of feelings of hopelessness and depression. Which of the following statements made by the patient would reflect life changes common to this age group? • “I can’t imagine starting my life over again.” • “My lifestyle will change so much after my retirement.” • “My kids have all left home and I feel so depressed now.” • “The prospect of all this time on my hands is driving me crazy.” #1 Although this is a personal statement, it could be made by a variety of age groups #2 Most individuals retire in their 60s, and this patient would not typically have this concern yet. #4 This is an ambiguous statement that requires further investigation. #3 This statement reflects some of the developmental changes that occure in middle-age patients (empty nest syndrome)