Transcript UNIT V Assessment - University of Kentucky

Introduction to Assessment
Nur 869
Lab 1
Assessment
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Systematic & continuous collection,
validation, and communication of
client data
 Nursing process
 Initial and ongoing
 Medical vs Nursing
 Essential components
Purposes of Assessment
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Obtain Baseline Date regarding functional abilities
Supplement, confirm, or refute date obtained in
nursing history
Obtain data that helps establish nursing diagnoses
and plan care
Evaluate physiologic outcomes of health care and
thus client progress
Screen for presence of risk factors
Types of Assessment
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Initial
Focused
Emergency
Ongoing
Types of Data
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Objective Data
• “signs”
• info perceived by
the senses
• Ex: T 101, moist
skin
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Subjective Data
• “symptoms”
• info perceived
only by affected
person
• Ex: feeling
nervous, tired
Characteristics of Data
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Complete
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Factual &
Accurate
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Relevant
Problems r/t Data Collection
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Organization
 Omission
 Irrelevant or
Duplicate Data
 Misinterpretation
 Too little data
 Documentation
Why is a health history taken?
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Patterns of
wellness/illness
Physical &
Behavioral risk
factors
Deviations from
norm
Nurse as a resource
Functional Health Patterns
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Health Perception/
Management
Nutritional-Metabolic
Elimination
Activity-Exercise
SexualityReproduction
Sleep-Rest
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Sensory-Perceptual
Cognitive
Role-Relationship
Coping-Stress
Tolerance
Value-Belief
Nursing Health History
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Chief Complaint
 Present Problem
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Usual health status
Chronological story
Impact on functioning
Medications
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Past Medical History
 Family History
 Personal & Social
History
 Review of Systems or
Functional Patterns
Client Profile – UK Clinical Setting
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Biographical Data
 Chief Complaint
 History of Present
Illness
 Current Medications
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Current Treatments
 Past Illnesses or Past
Hospitalizations
 Allergies
General Survey – Clinical Setting
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Age/Sex/Race
Mental Status
Behavior
Mood
Appearance
Body Type
Posture
Body Mechanics
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Speech
• Use of language
• Thought Process
• Reliability as historian
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Height/Weight
 Vital Signs
Explanation- Affect/Mood
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Affect – observable behaviors which
indicate the feelings or emotional status of
the client.
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Mood – term which refers to the client’s
emotional state as described by the client.
Documentation Terms
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Affect
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Broad
Restricted
Blunted
Flat
Labile
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Mood
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Appropriate
Inappropriate
Depressed
Anxiety
Agitated
Elated
Manic
Euphoric
Euthymic (normal)
irritable
General Principles - History
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Explain purpose
 Communication techniques
 Utilization of data sources
 Document
 Avoid interruptions or tiring the client
 Consider client’s developmental level
Developmental Principles
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Pediatric
• Parent/child
interactions
• Integrate child
• Respect
adolescent, give
choices
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Geriatric
• Do not
stereotype
• Assess and
accommodate:
• sensory &
physical
functioning
Psychosocial Considerations History
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Avoid stereotypes
 Healthcare beliefs
 Language differences
 Eye contact
 Non-judgmental
 Stressors/Coping Mechanisms
Cultural Awareness Considerations
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Time Orientation
Activity Orientation
Human Nature Orientation
Human-Nature Orientation
Relational Orientation
• Seidel, 2003, pp. 43.
History - Biographical Data
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Name
Race
Age
Gender
Marital status
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Birthplace, date
Address
Source of medical
care
Insurance coverage
Past Health History
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Previous hosp. &
surgeries
Allergies
Illnesses &
Accidents
Immunizations
Medications
Habits/Lifestyle
ADLs
Client’s Family History
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Blood relatives
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Significant others
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Health history
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Family as resource
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Stressors in family
Present Illness/Health Concerns
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Onset
Duration
Location, quality, and intensity
Precipitating factors
Relief factors
Client’s expectations
Subjective and Objective data
PQRST – Characterize Symptoms
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Precipitating factors
Quality
Radiation
Severity
Temporal Factors
OLD CARTS –
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Onset
Location
Duration
Character
Aggravating factors
Relieving factors
Temporal factors
Severity
Reasons for Seeking Healthcare
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Chief complaint
 Why?
 Quotes
 Specify
 Clarify
Resources
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Home and outside environment
 Community resources
 Financial
 Family & significant others
 Consider Basic Human Needs
Medical Diagnostic Data
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Medical vs
Nursing
Diagnosis
 Nursing
Implications r/t
Medical
Diagnosis
Contributions of Lab Data
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Verifies data
Provides baseline
information
Evaluates outcomes
Identifies problems
missed in history
and assessment
Test: Complete Blood Count
(CBC)
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Analysis of peripheral venous blood
specimen
 Main components:
• RBC = red blood cell count
(erythrocytes)
• WBC = white blood cell count
(leukocytes)
• Hgb = hemoglobin
• Hct = hematocrit
Test: Urinalysis (UA)
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Analysis of a urine
specimen
Screens for:
• urinary infection
• renal disease
• diabetes mellitus
Urinalysis
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Main components
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pHProteinSpecific gravityGlucoseKetonesBlood-
4.6 - 8.0
up to 10mg/100ml
1.003 - 1.030
negative
negative
up to 2 RBCs
Test: Electrolytes (lytes, e-)
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Inorganic
substances in the
body that conduct
electrical current
Usage:
• Assess fluid
balance
Electrolytes
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Main Components:
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Na+
K+
ClCa
P
Mg
sodium
potassium
chloride
calcium
phosphate
magnesium
Test: Chest X-Ray (CXR,
PA Chest, PA & LAT Chest)
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Radiographic exam
of the thorax
Visualizes
respiratory &
cardiac function
Identifies & follows
progression/
remission of dx
process
Test: Arterial Blood Gas (ABG)
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Assesses the adequacy
of ventilation and
oxygenation via
arterial blood
 Use: measures
respiratory and
metabolic (renal)
disturbances
Arterial Blood Gases
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Main
Components:
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pH
PaCO2
PaO2
HCO3
SaO2
General Nursing Implications
Assess client’s readiness to learn
 Explain procedure to client
 Assist client in dealing with the test
 Provide privacy
 Prepare client for test
 Universal precautions
 Send specimens promptly
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Specific Nursing Implications
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Electrolytes:
• Note diet, food and fluid intake
• Note s/s that could affect fluid balance
(N/V/D)
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Chest X-Ray:
• Transport
• Remove metal objects
• Stand clear
Specific Nursing Implications
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Arterial Blood
Gases
• Anticoagulants?
• Time drawn
• Check site for
bleeding
• Pressure
• Sample on ICE
• STAT to lab
Physical Assessment:
Pediatric Principles
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Assess:
• coping ability
• previous knowledge
• readiness
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Encourage
questions
Explain at
developmental
level
Physical Assessment:
Pediatric Principles
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Use concrete terms
Small amounts of
info at a time
Simple & clear
explanations
Only offer choices
that are available
Honest
praise/rewards
Physical Assessment Methods
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Inspection
 Palpation
 Auscultation
 Percussion
Equipment
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Stethoscope
Pen light
Blood Pressure Cuff
Thermometer
Watch with second hand
Inspection
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Assessment
process during
which the nurse
observes the
client
Inspection
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Initial contact and ongoing
Use olfaction, touch
General appearance, body language
Systematic unhurried approach
Expose part, respect privacy
Examine: color, size, shape, position,
symmetry (compare like areas)
Know “normals”
Observe “normals/abnormals”
Palpation
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The use of the hands and the sense
of touch to gather data
Palpation
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Detects texture, shape, temp, movement,
pain, moisture
Short fingernails, warm hands
Gentle approach
Light palpation first, if pain - STOP!
Palpate tender areas last
Three types:
• Light palpation (1/2 inch)
• Deep palpation (1 inch)
• Bimanual deep palpation (2 hands)
Auscultation
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The act of
listening to
sounds within the
body to evaluate
the condition of
body organs
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Auscultation
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Stethoscope:
• bell for low pitch sounds (cardiac sounds)
• Diaphragm for high pitch sounds (bowel,
breath, normal cardiac)
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4 characteristics of sounds
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Frequency/pitch: # vibrations per second
Loudness: soft, medium, loud
Quality: types; gurgling, blowing
Duration: short, medium, long (specify)
Auscultation
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Quiet environment
 Know landmarks
 Know “normals”
 PRACTICE! PRACTICE!
PRACTICE!
 Requires concentration, practice, and
application of knowledge
Percussion
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Tapping of
various body
organs and
structures to
produce vibration
and sound.
Documentation - Purpose
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Communication
Quality Assurance
Legal
Reimbursement
Research
Planning Client Care
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Education
 Statistics
 Accrediting/Licensure
 Historical Document
Principles of Documentation
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Timing
Confidentiality
Permanence
Signature
Accuracy
Sequence
Appropriateness
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Completeness
Standard Terminology
Brevity
Legibility
Legal Awareness
Study Guide
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5.
State the purposes of the physical exam.
Name the necessary equipment need to perform
a physical exam.
Describe the four basic techniques used in
physical examination.
Describe guidelines for preparing a client and
the environment for a physical examination.
What are the components of a general survey?