Health Assessment Exam 1

• Nursing Process

  ADPIE: Assessment, Diagnosis, Planning (Outcomes), Implementation, Evaluation
• subjective data


  what a patient tells you; not measurable (their feelings, perceptions, pain status)
• objective data

  - what the nurse observes; measurable (what the nurse sees, hears, feels & smells during assessment & physical exam)

  - vital signs
• primary data


  info provided directly from patient
• secondary data


  information from the patient's chart, family members, or other health care team members
• Emergency Assessment


  rapid focused assessment conducted to determine potentially fatal situations (only find out info that is necessary)

  A- Airway

  B- Breathing

  C- Circulation

  D- Disability

  E- Exposure
• Comprehensive Assessment


  - includes a complete health history & physical assessment

  - Can be done upon admission to a hospital, Rehab, Healthcare facility, or Annual Exam (Outpatient, PCP), every 8 hrs in ICU setting
• focused assessment


  - based on patient's health issues

  - can occur in all settings

  - usually involves specific systems (smaller in scope than Comprehensive Assessment but more in depth on other specific issue/s)
• Nursing Diagnosis

  - collect, analyze, and cluster data

  - make a diagnosis & prioritize plan of care

  P = Problem w/ NANDA diagnosis (dx)

  E = Etiology (R/T/related to statement or cause of problem)

  S = Signs & Symptoms (AMB)
• Nursing Planning


  involves setting goals & determining measurable outcomes:

  - Action Verb

  - Realistic specific behavior to measure success

  - A time frame to accomplish the outcome
• Nursing Implementation/Intervention


  - carrying out the plan to achieve the goals & outcomes ("doing phase"); you can continue to assess your client's response & modify as needed
• Nursing Evaluation


  - involves determining the effectiveness of the plan

  - Did client meet the goals and outcomes?

  - Assess the client's response based on criteria set for the outcome
• Inspection

  - Physical Exam technique

  - Always begin w/ inspection

  - "Look before you touch"

  - Use senses of sight, hearing and smell

  - Be systematic working from head to toe
• Palpation


  - physical exam technique

  -use the sense of touch to collect data

  - usually follows inspection

  - light & deep palpation

  - always wash and warm hands b4 palpating
• Percussion

  -physical exam technique

  -entails striking a body surface w/ a quick, light blows & eliciting vibrations and sounds

  -Typically performed by MD, an Advanced Practice RN, or an experienced RN
• Auscultation

  -physical exam technique

  -involves using your sense of hearing to collect data

  -listen to sounds produced by the body (heart, lung, bowel, vascular sounds)
• Components of Health History


  -past health history

  -current medications

  -family history

  -functional health assessment

  -growth and development
• vital signs


  - measurement of the bodys most basic functions

  includes:

  -temperature

  -pulse

  -respiration

  -blood pressure

  - pain & oxygen saturation
• normal range for oral temp.

  97.7-99.5 F/ 36.5-37.5 C
• oral temperature


  - convenient, accurate

  - wait 15 minutes to take after any hot/cold drinks, smoking, chewing gum

  -normal oral temp. 98.6 F/37C
• factors that influence normal temperature

  - diurnal temp. fluctuates 1-1.5 degrees F

  -menstruation cycle

  -exercise --> increases core body temp.

  - age --> older adults have a lower mean body temp. (96.8F/36 C) due to loss of subcutaneous fat
• blue probed thermometer


  used w/ oral & axillary
• red probed thermometer


  used w/ rectum
• axillary (armpit) temperature

  -least reliable (sweating & heavy clothing can affect temp.)

  -easy to obtain

  -wait 30 mins after washing axilla (arm has to be kept down to get an accurate reading)

  -tends to be 1 degree lower than oral

  - avg. 96.7-98.5F/35.9-36.9C
• rectal temperature

  -invasive, uncomfortable, disruptive

  -tends to be 1 degree higher than oral

  -avg 98.7-100.5F/37.1-38.1C

  -most accurate temperature (get to the true core body temp.)

  -common in children (infants)
• tympanic temperature (ear)

  -accurate if done right

  -tympanic membrane shares same vascular supply as hypothalamus

  -senses infrared emissions of the tympanic membrane

  -inaccurate reading if earache, infection, scarring
• temporal temperature


  -newer & noninvasive

  -uses infrared emissions from the temporal artery

  -temp. readings are closer to core readings (can be 1 degree F higher than oral/ 2 degrees F higher than axillary

  -accuracy can be affected by diaphoresis (sweating) in patients
• no touch- infrared forehead temperature

  -non-invasive (not as accurate)

  -minimizes spread of infection

  -measures infrared energy coming off the human body

  -approx.. 1 degree less than oral
• hyperthermia

  -high body temperature, febrile (>100.4F/37.8C)

  -possibly from infection, trauma, surgery

  -disruption in cellular metabolism can change body temp.

  -Sx/sy: skin warm to touch, tachycardia (high HR), flushed skin, shivering, malaise (lethargic, tired), fatigue, loss of appetite
• nursing interventions for hyperthermia

  -obtain blood cultures/white blood cell count/sedimentation rate (measures the distance red blood cells fall in a test tube in one hour)/electrolytes as ordered-administer antibiotics after obtaining labs. provide fluids & rest, minimize activity. Ice, cooling blanket, fans as necessary. Antipyretics (aspirin, acetaminophen/tylenol, ibuprofen/advil; causes temp. to go down). oral hygiene (bacteria can grow in mouth), dry clothing, dry bed linens (skin breakdown can occur if sheets are as wet as body)
• hypothermia

  -abnormally low body temperature (<95F/35C)

  -usually d/t accidental prolonged exposure to cold

  -Sx/sy: severe shivering (initially), feelings of cold & chills, pale cold waxy skin, hypotension, decreased urine output, lack of muscle coordination (muscle contracts to warm up), disorientation, drowsiness
• nursing interventions for hypothermia

  -provide warm environmental temperature

  -warming blanket (bear hug)

  -warmed IV fluids/warm oral fluids

  -Keep head covered (lot of heat is loss at the top of head)
• afebrile

  without fever
• pulse

  -Beat of the heart as felt through the walls of the arteries.

  -palpating a peripheral pulse gives a rate & rhythm of the heartbeat & condition of the artery

  -monitor pulse for rate, rhythm, strength, elasticity

  -pulse points: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis
• heart rate


  -number of times per minute you feel or hear the pulse (heart beat)

  -normal = 60-100 bpm
• bradycardia

  -slow heart rate (<60 bpm)

  - caused by: medications (digoxin, beta blockers), hypothyroidism, changing position from lying to sitting to standing, hypothermia, long term physical fitness
• tachycardia

  - fast heart rate (>100 bpm)

  - caused by: exercise, fever, stress, anxiety, fear, hyperthyroidism, acute pain, medications (epinephrine, levothyroxine, beta2 adrenergic agonists;albuterol, shock, cardiac disease
• heart rate technique

  - use pads of 1st 3 fingers & place on radial artery pulse

  -if rhythm is regular count the number of beats in 30 secs and multiply by 2

  -if rhythm is irregular count the number of beats over a minute

  -start count w/ "zero" then the 2nd beat felt is "one"
• apical heart rate

  The rate obtained by placing the stethoscope over the apex of the chest wall and counting (5th intercostal space at the left midclavicular line)

  -use to assess prior to administration of cardiac medications

  -irregular rhythms

  -rapid rates > 100 bpm

  -heart rate of infants

  -ALWAYS COUNT AN APICAL PULSE FOR ONE FULL MINUTE
• rhythm

  -normally even tempo

  -irregularities are called arrythmias

  -you would document the pulse as either regular or irregular