Health Assessment

• Skin color varies from person to person due to genetics, age, sun exposure, and other factors.
• Vital signs are the body’s indicators of health, also known as "Cardinal Signs," reflecting the status of several body systems like cardiovascular, neurologic, peripheral vascular, and respiratory systems

  
• Common, noninvasive physical assessment procedures that most clients are accustomed to
• Vital signs should be assessed upon admission, during a change in health status, pre and post-op/procedure, pre and post-medication administration, and before and after any nursing intervention that could affect them
• Factors affecting heat production include BMR, muscle activity, thyroxine output, epinephrine, norepinephrine, sympathetic stimulation, and fever
• Types of heat transfer include conduction, radiation, convection, and vaporization/evaporation
• Factors affecting body temperature include age, diurnal variations, exercise, hormones, stress, and environment
• Types of fevers include intermittent, remittent, relapsing, and constant
• Clinical onset of fever involves onset/chill, course/plateau, and defervescence
• Weber and Kelley's (2018) "Health Assessment in Nursing" discusses the importance of vital signs as indicators of health and the factors affecting body temperature
• Fever crisis occurs when the cause of fever is suddenly removed, leading to vasodilation and manifestations like flushed skin, sweating, decreased shivering, and possible dehydration
• Nursing interventions during fever include monitoring vital signs and skin color, lab values, providing adequate nutrition and fluids, oral hygiene, tepid sponge bath, dry clothing and linens, and administering antipyretics
• Pulse is a shock wave produced by the heart's contraction, with a normal rate for adults between 60 and 100 beats per minute
• Arterial or peripheral pulse sites include temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibialis, and dorsalis pedis
• Assessing the pulse rate involves palpating a peripheral pulse, counting the rate for a full minute, and noting the regularity (rhythm), with a pulse deficit indicating a condition where the apical pulse rate is greater than the radial pulse rate
• Pulse characteristics include quality, rate, rhythm, volume, and elasticity, with normal pulse amplitude quantified from 0 (absent) to 3+ (bounding)
• Respirations involve the act of breathing, with normal breathing assessed by observing chest wall expansion and bilateral symmetrical movement of the thorax
• Major physical pulmonary functions include ventilation, circulation, diffusion, and transport of oxygen and carbon dioxide in the blood and body fluids to and from the cells
• Blood pressure is the measure of pressure exerted as blood flows through the artery, with normal values below 120 (systolic) and below 80 (diastolic)
• Blood Pressure:

  • Systolic blood pressure (SBP) is the pressure in the arteries when the heart beats.
  • Diastolic blood pressure (DBP) is the pressure when the heart is at rest.
  • Measured in mm Hg and written in fraction form.
  • Normal values: below 120 (systolic) and below 80 (diastolic)
• Mental Status:

  • Refers to cognitive and emotional functioning.
  • Mental health is more than just the absence of mental disabilities or disorders.
  • Major areas of assessment: language, orientation, memory, attention span, and calculation
• Assessment Techniques:

  • Positioning: sitting on the examination table, wearing an examination gown.
  • Observations: hygiene, grooming, posture, body language, facial expressions, speech, and ability to follow directions.
  • Abnormal findings may indicate mental illnesses or neurological disorders
• Assessment of Speech and Language:

  • Note rate of speech, ability to pronounce words, tone of voice, loudness, and clarity.
  • Changes in speech could reflect anxiety, Parkinson’s disease, depression, or dysphasia
• Assessment of Sensorium:

  • Determine orientation to date, time, place, and grade level of alertness.
  • Abnormal findings may indicate neurologic or brain disorders
• Assessment of Memory:

  • Ask about personal details and history.
  • Loss of long-term memory may indicate cerebral cortex damage, as seen in Alzheimer’s disease
• Assessment of Calculation:

  • Start with simple problems like 4+3, 8÷2, and 15-4.
  • Inability to calculate may indicate organic brain disease or lack of exposure to mathematical concepts
• Assessment of Abstract Thinking:

  • Ask to identify similarities and differences between objects or explain proverbs.
  • Responses may reflect lack of education, mental retardation, or dementia
• Assessment of Mood and Emotional State:

  • Observe body language, facial expressions, and communication.
  • Lack of congruence in expression may indicate neurologic problems or emotional disturbances
• Assessment of Perceptions and Thought Processes:

  • Listen to logical and relevant statements.
  • Disturbed thought processes can indicate neurologic dysfunction or mental disorder
• Assessment of Judgment:

  • Determine the ability to evaluate situations and make realistic decisions.
  • Impaired judgment can occur in emotional disturbances, schizophrenia, or neurologic dysfunction
• Psychosocial, Cognitive, and Moral Development:

  • Freud's Theory of Psychosexual Development: stages from oral to genital.
  • Erikson's Theory of Psychosocial Development: stages from infant to older adult.
  • Piaget's Theory of Cognitive Development: stages from sensorimotor to formal operational.
  • Kohlberg's Theory of Moral Development: stages from preconventional to postconventional
• Pain:

  • Pain is subjective and individualized, associated with actual or potential tissue damage.
  • Types include acute and chronic pain, each with specific characteristics and implications
• Pain is directly related to tissue damage and may be somatic
• Sensitization is an increased sensitivity of a receptor after repeated activation by noxious stimuli or nociceptor
• Breakthrough Pain is a transitory increase in pain that occurs on a background of otherwise controlled persistent pain
• Bradykinin is a universal stimulus for pain
• Comfort implies renewal amplification of power
• Violence is the use of physical force to harm someone, to damage property, etc.
• Aggression is a forceful action or procedure, especially when intended to dominate or master
• Positive connotation of aggression is associated with the drive for success, as in aggressive men