Download Intro to Assessment

Intro to Health Assessment
Health Assessment
Health Assessment includes:
What is it?
Why are we learning it?
Nursing Process
1) Assessment
1) Health History
2) Physical examination
3) Diagnostic data
2) Nursing Diagnosis
• Interpret data
3) Outcome Identification
4) Planning
5) Implementation
6) Evaluation
1. Theoretical and Experiential
Knowledge
2. Critical Thinking
3. Assessment Skills
4. Communication Skills
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
Developmental Considerations
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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?
Developmental Considerations in
Assessment
Theorists
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Erikson – Psychodynamic
theory
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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
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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
Erikson’s Stages
1. Trust vs mistrust (infants)
2. Autonomy vs shame and doubt (toddlers)
3. Initiative vs guilt (preschool)
4. Industry vs inferiority (school age)
5. Identity vs role confusion (adolescents)
6. Intimacy vs isolation (young adults)
7. Generativity vs stagnation (middle adults)
8. Integrity vs despair (late adults)
Piaget’s Stages
1. Sensorimotor - physical manipulation
of objects and events (0-2 yr)
1. Preoperational – language (2-7 yr)
2. Concrete Operational – logic in mental
reasoning (7-11 yr)
3. Formal Operational – abstract concepts
Infants
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Physical development
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Average term weight is 3.4
kg (7.5 lb). Triple birth
weight by 1 year.
Primitive reflexes that
begin to disappear
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Behavioral and Cognitive
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Trust vs. Mistrust
Language – crying, imitate
sounds (9-10 months), first
word!
Grasp reflex disappears
~2 months
Vision improves
Posture, holding head up,
sitting, crawling, and
walking
Whom are you
assessing?
Complications at birth?
Immunization up to date?
Injuries?
Nutrition?
Hearing or vision impairments?
Lead poisoning?
Contributes to
development of
systems
SIDS –
Causes?
Recommendations?
Decreased airflow,
decreased blood
flow to brain
Toddlers
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Physical
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Rate of growth decreasing
Upright posture
Improvements in fine
motor skills
Behavioral and Cognitive
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Stacking blocks!
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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
Growth Charts
Birth to 36 months
Boys, 1-17 yrs
Preschoolers
Physical
 Growth of long bones
 Begin to lost baby fat
 Permanent teeth appear
Allow to play with
instruments prior to use
Behavioral and Cognitive
 Initiative vs. guilt
 More autonomous
 Communicate more
effectively
 Awareness of others’
needs and interests
 Develop gender roles
 Delayed imitation
 Egocentrism
School Age
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
Adolescents
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
Early Adulthood
Physical
 Maximum potential for
growth and development
 Reduction in activity
↓ caloric intake
Behavioral and Cognitive
 Intimacy vs. role isolation
 Achievements important,
career
 Mate selection
Middle Adulthood
Physical
 Wrinkling of skin
 Graying or loss of hair
 Decrease in muscle mass
and tone
 Vision and hearing
decrease
 At risk populations
develop
Secondary Prevention
Behavioral and Cognitive
 Generativity vs.
stagnation
 Many decisions about
career, lifestyle, family –
“midlife crisis”
 Empty nest syndrome
 Intelligence remains
constant, more
experience
Older Adulthood
Physical
Behavioral and Cognitive
 Many variations
 Ego identity vs despair
 Chronic illnesses
 Ego identity – acceptance
of choices made in their
 Changes in sensation
lives
 Loss of lean body mass,
increase in fat deposition.  Despair - Loss of spouse
can be devastating
 Posture deteriorates,
 Stereotyping by society –
wider gait
ageism
 Poor skin turgor, xerosis
(drying)
 More prone to injury due
to loss of bone mass.
Further classification
1. Young-old (65-74 yrs)
2. Middle-old (75-84 yrs)
3. Old-old (85 or older)
Lueckenotte (2000)
Developmental Considerations
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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.
Approach to Identifying Priorities
1.
Immediate priorities (ABCs)
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2.
Second-level priorities
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3.
Airway
Breathing
Circulation
Vital Signs
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
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Lack of knowledge
Activity, rest, sleep
Health History
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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
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Subjective data – what person says about himself or
herself
Objective – what you observe during a PE
Health History
Purpose – to obtain subjective data from pt.
Open-Ended Questions
 Broadly stated and
encourage an open
response
 Aim is to describe
problem or symptoms
 “How are you feeling?”
Open-Ended
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?”
Closed
Phases of an Interview
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Introduction phase
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Discussion phase
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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
Nurse helps discussion
Discussion is client centered
Nurse uses various communication techniques to collect data
Summary phase
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Summarization of data
Allows for clarification of data
Provides validation to the client that nurse understands
problem
Internal and External Factors of
Communication
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?
External factors
•Privacy
•Comfort
•Room temperature
•Noise
•Seated at eye level
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?
Whom are you
interviewing?
Internal factors
Enhancing Data Collection
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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.
Traps to Avoid
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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
Interviewing Special Populations
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Hearing Impaired
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Acutely Ill
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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
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Ask simple and direct questions.
Try not to appear threatening
Sexually Aggressive People
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If pt. is in an emergency situation, ask priority questions first. Use closed (direct
questions).
Drugs or Alcohol Influenced
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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
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
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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
Domestic Violence Considerations
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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)
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“Because domestic violence is so common in our society, we are
asking all women the following questions”
Document, Document, Document
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Write down direct quotes from pt. even if it includes swearing
AMA Definitions for Elder Abuse
and Neglect
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Physical abuse
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Physical neglect
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Failing to provide basic social stimulation
Financial abuse
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Behaviors that result in mental anguish. (Threats)
Psychological neglect
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Failure of family member or caregiver to provide basic goods and/or
services such as food, shelter, health care, and medications
Psychological abuse
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Violent acts that result or could result in injury, pain, impairment,
and/or disease
Intentional misuse of elderly person’s financial resources without
consent
Financial neglect
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Failure to use the assets of the elderly person to provide necessary
services
Abuse Terminology
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Abrasion
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Bruise (Contusion)
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A hemorrhagic spot, larger than
petechia, in the skin or mucous
membrane, forming a nonelevated,
round, or regular, blue or purplish
patch
Hematoma
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Superficial discoloration due to
hemorrhage into the tissues from
ruptured blood vessels beneath the
skin surface
Ecchymosis
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A wound caused by rubbing the skin or
mucous membrane
A localized collection of extravasated
blood, usually clotted in an organ,
space, or tissue
Hemorrhage
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An escape of blood from a ruptured
vessel, which can be external, internal,
and/or into the skin or other organ
Abrasion
Contusion
Ecchymosis
Abuse Pictures
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Incision (Cut)
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An injury caused by an object that leaves
a distinct pattern on the skin and/or
organ
Petechiae
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Any pathologic or traumatic discoloration
of tissue or loss of function
Patterned injury
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A wound produced by tearing and/or
splitting of body tissue, usually from blunt
impact over a bony surface.
Lesion
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A cut or wound made by a sharp
instrument
Laceration
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laceration
Small red or purple spot on the body
Disorders of coagulation. Strangulation.
With bruising, should suspect abuse
Puncture
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The act of piercing or penetrating with a
pointed oubject
petechiae
Components of Health History
The general survey
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Fourteen cues to be observed
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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
Components of Health History
Reasons for seeking health
care
Health perception/Health
management
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Present health or history of
present illness
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Location
Quality
Quantity
Timing
Setting
Aggravating/alleviating
factors
Associated factors
Client’s perception
Childhood illnesses
Adult illnesses
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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
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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
Functional Assessment (ADLs)
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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
Multiple Choice #1
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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:
a)
b)
c)
d)
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.”
Multiple Choice #2
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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:
1.
2.
3.
4.
“The child
“The child
“The child
“The child
develops logical thought patterns.”
has the ability to think abstractly.”
has difficulty separating fantasy from reality.”
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.
Multiple Choice #3
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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?
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“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.
Multiple Choice #4
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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?
1.
2.
3.
4.
“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)