Components of a Health Assessment Health history Review of Systems Physical assessment head-to-toe sequence, system sequence

Transcription

1 Introduction to Health Assessment Taylor Chapter 25 Purposes of the Health Assessment Establish the nurse patient relationship Gather data about the patient s general health status Identify patient strengths Identify actual and potential health problems Establish a base for the nursing process Types of Health Assessments Comprehensive Conducted upon admission to healthcare facility Ongoing partial Conducted at regular intervals Focused Conducted to assess a specific problem Emergency Conducted to determine fatal conditions Components of a Health Assessment Health history Review of Systems Physical assessment head-to-toe sequence, system sequence Factors to Assess During a Health History Biographical data Reason for seeking healthcare History of present illness Past medical history Family history Lifestyle Review of Systems Collecting Subjective data on each body system Cardiovascular system: chest pain, palpitations Respiratory: shortness of breath, cough Usually collected with the Physical Assessment Preparing the Patient for Physical Assessment Consider the physiologic and psychological needs of the patient. Explain the process to the patient. Explain that physical assessments will not be painful (decrease patient fear and anxiety). 1

2 Explain each procedure in detail as it is conducted. Ask the patient to change into a gown and empty bladder. Answer patient questions directly and honestly Preparing the Environment for Physical Assessment Agree on a time for the assessment. The time should not interfere with meals, daily routines, or visiting hours. Make sure patient is as free of pain as possible. Prepare the examination table. Provide a gown and drape for the patient. Gather the supplies and instruments needed. Provide a curtain or screen if the area is open to others. Equipment Used During a Physical Examination Ophthalmoscope visualizes the interior structures of the eye Otoscope examines the external ear canal and tympanic membrane Snellen s chart screens for distant vision Nasal speculum visualizes the lower and middle turbinates of the nose Vaginal speculum examines the vaginal canal and cervix Tuning fork tests auditory function, air/bone conduction Percussion hammer tests deep tendon reflexes and determines tissue density Positions Used During a Physical Assessment Sitting used to take vital signs Supine allows relaxation of abdominal muscles Dorsal recumbent used for patients having difficulty maintaining supine position Sim s assessment of rectum or vagina Prone assessment of hip joint and posterior thorax Positions Used During a Physical Assessment (continued) Lithotomy assessment of female rectum and vagina; used for brief period only Knee chest assessment of the rectal area; used for brief period only Standing assessment of posture, gait, and balance Positions Techniques Used During a Physical Assessment Inspection assess size, color, shape, position, and symmetry Palpation assess temperature, turgor, texture, moisture, vibrations, and shape Percussion assess location, shape, size, and density of tissues Auscultation assess the four characteristics of sound, that is, pitch, loudness, quality, and 2

3 duration Characteristics of Masses Determined by Palpation Shape Size Consistency Surface Mobility Tenderness Pulsatile Pattern Used for Palpation, Percussion, and Auscultation of the Chest Types of Sounds Heard When Using Percussion Flat soft, for example, thigh area Dull medium, for example, liver Resonance loud, for example, normal lung Hyperresonance very loud, for example, emphysematous lung Tympany loud, for example, puffed-out cheek Using Hands to Produce Sound Waves During Percussion Physical Assessment Integument Head and neck Thorax and lungs Cardiovascular and peripheral vascular systems Breasts and axillae Abdomen Female and male genitalia Anus, rectum, prostate Musculoskeletal system Neurological system Purposes of Documentation Identify actual and potential health problems Make nursing diagnoses Plan appropriate care Evaluate patient s responses to treatment Nurse s Role in Diagnostic Procedures Assist before, during, and after diagnostic tests Be responsible for other activities associated with diagnostic tests Witness the patient s consent 3

4 Schedule the test Prepare the patient physically and emotionally for the test Provide care after the test Dispose of used equipment Transport specimens The Interview Jarvis Chapter 3 The Complete Health History Jarvis Chapter 4 Assessment Techniques Jarvis Chapter 8 General Survey, Measurement and Vital Signs Jarvis Chapter 9 Pain Assessment Jarvis Chapter 10 Pain What is pain? Nociceptors: Transduction: Transmission: Perception: Modulation: Nociception Figure 10-2 Types of Pain Nociceptive Pain: nerve fibers in the periphery and in the CNS are functioning and intact Trauma or injury Neuropathic Pain: abnormal processing of the pain message from an injury to the nerve fibers Diabetes Herpes Zoster (Shingles) HIV/AIDS Sciatica Chemotherapy Sources of Pain Sources of pain- Based upon their origin 4

5 Visceral pain: Deep somatic: Cutaneous: Referred pain: Common sites for referred pain Duration of Pain Types of pain (by duration) Pain can be classified by its duration Duration can provide information on possible underlying mechanisms and treatment decisions Pain is divided into acute or chronic categories Acute: Chronic: Structure and Function: Developmental Competence Infants Infants have same capacity for pain as adults What are some pain issues for infants? Structure and Function: Developmental Competence (cont.) Aging adult No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished What are some aging adult pain issues? Structure and Function: Developmental Competence (cont.) Gender differences Gender differences are influenced by societal expectations, hormones, and genetic makeup What are some pain issues with issues with gender? Subjective Data Pain How is it defined? Associated with actual or potential tissue damage or described in terms of such damage Pain is always subjective Pain is whatever the experiencing person says it is, existing whenever he or she says it does Subjective report is most reliable indicator of pain Because pain occurs on a neurochemical level, clinician cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend 5

6 support Subjective Data (cont.) Initial pain assessment Where is your pain? When did your pain start? What does your pain feel like? How much pain do you have now? Subjective Data (cont.) Initial pain assessment (cont.) What makes your pain better or worse? Include behavioral, pharmacologic, nonpharmacologic interventions How does pain limit your function or activities? How do you usually behave when you are in pain? How would others know you are in pain? What does this pain mean to you? Why do you think you are having pain? Pain Assessment Tools Various tools have been developed to capture one-dimensional aspects (i.e., intensity) or multidimensional components Select pain assessment tool based upon its purpose, time involved in administration, and patient s ability to comprehend and complete tool Educate the patient on how to use the tool Enlarge print when appropriate for individuals with impaired vision Printed language should be translated to native language of patient Pain Assessment Tools (cont.) Pain Assessment Tools (cont.) Infants and children Because infants are preverbal and incapable of self report, pain assessment is dependent upon behavioral and physiologic cues It is important to underscore understanding that infants do feel pain Children 2 years of age can report pain and point to its location They cannot rate pain intensity at this developmental level It is helpful to ask parent or caregiver what words their child uses to report pain Objective Data Physical examination process can help you understand the nature and location of the pain Even if there is no assessment finding to indicate the source or location of pain, the patient s report of pain is still valid Objective Data (cont.) Nonverbal behaviors of pain When individual cannot verbally communicate pain, you can (to a limited extent) identify 6

7 pain using behavioral cues Recall that individuals react to painful stimuli with a wide variety of behaviors 43 Objective Data (cont.) Nonverbal behaviors of pain (cont.) Acute pain behaviors: 7