2Signs and Symptoms Signs Objective data as perceived by the examiner Can be seen, heard, and measured and can be verified by more than one personExamples: rashes, altered vital signs, visible drainage or exudateLab results, diagnostic imaging, and other studiesWhat is objective data?Give examples of signs.
3Signs and Symptoms Symptoms Subjective data Perceived by the patient Examples: pain, nausea, vertigo, and anxietyNurse unaware of symptoms unless the patient describes the sensationEncourage a full description by the patient of the onset, the course, the character of the problem, and any factors that aggravate or alleviateWhat is subjective data?Give examples of symptoms.
4Signs and Symptoms Disease and Diagnosis Disease It is any disturbance of a structure or function of the body; a pathologic condition of the bodyIt is recognized by a set of signs and symptomsSigns and symptoms are clustered in groups to help the physician to make a medical diagnosisThe nurse also relies on assessment of signs and symptoms to formulate a nursing diagnosisWhat does the term “disease” mean to you?What are some signs and symptoms of a typical disease?
5Signs and Symptoms Origins of Disease Disease or illness originates from many causes: hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, and environmentalUnknown etiologyDiseases that have no apparent causeHave students give examples of diseases that fall into the categories of:hereditarycongenitalinflammatorydegenerativeinfectiousdeficiencymetabolicneoplastictraumaticenvironmentalunknown etiology
6Signs and Symptoms Risk Factors for Development of Disease A risk factor is any situation, habit, environmental condition, genetic predisposition, physiologic condition, and other that increases the vulnerability of an individual or a group to illness or accidentRisk factors do not necessarily mean that a person will develop a disease condition, only that the chances of disease are increasedCategories of risk factorsGenetic and physiologic, age, environment, and lifestyleWhat does the term “risk factor” mean?What are the four categories of risk factors?If a patient has a risk factor, what does that indicate?
7Signs and Symptoms Terms Used to Describe Disease Chronic Remission Develops slowly and persists over a long period, often for a person’s lifetimeRemissionPartial or complete disappearance of clinical and subjective characteristics of a diseaseAcuteBegins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatmentDescribe a chronic disease.What is an acute disease?What does the term “remission” mean?
8Signs and Symptoms Terms Used to Describe Disease Organic disease Results in structural change in an organ that interferes with its functioningFunctional diseaseMay be manifested as organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalitiesWhat is the difference between organic and functional disease?
9Signs and Symptoms Frequently Noted Signs and Symptoms Infection Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites that produce tissue damageInflammationProtective response of the body tissues to irritation, injury, or invasion by disease-producing organismsWhat are the signs and symptoms of infection?What are the signs and symptoms of inflammation?What are the differences and similarities of infection and inflammation?
10Signs and Symptoms Frequently Noted Signs and Symptoms Cardinal signs of infection and inflammationErythemaEdemaHeatPainPurulent drainageLoss of functionWhat are the cardinal signs of infection and inflammation?Describe each sign and symptom.
11AssessmentProcess of making an evaluation or appraisal of the patient’s conditionMedical AssessmentPhysical examination is conducted by the physicianThe nurse is often expected to carry out certain functionsWhat does the term “assessment” mean?What is involved in a medical assessment?Ask students to volunteer information of their experiences of a medical assessment.
12Assessment Medical Assessment Functions that may be expected of the nurseEquipment and suppliesPreparing the exam roomAssisting with equipmentPreparing the patientCollecting specimensWhat functions might be required of a nurse during a medical assessment?What equipment and/or supplies are necessary for a physical assessment?
13Assessment Nursing Assessment Initiating the nurse-patient relationshipThe first interview is the most challenging to conduct.Introduce yourself and state name, position, and purpose of the interview.Give an estimate of time.Ask if the patient has any questions and answer them appropriately.Communicate trust and confidentiality.Convey competence and professionalism.How should a nurse approach a patient for the first time?What does the term “professionalism” mean?How does the first nurse-patient interaction affect trust in the relationship?
14Assessment Nursing Assessment The interview Provide relaxed, unhurried manner.Conduct in a quiet, private, well-lighted setting.Convey feelings of compassion and concern.Determine by what name the patient wishes to be addressed.Nurse should have an accepting posture, relaxed, eye level, and pleasant facial expression.What elements are conducive to provide a therapeutic interview?
15Assessment Nursing Health History The initial step in assessment processInformation on patient’s wellness, changes in life patterns, sociocultural role, and mental and emotional reaction to illnessBiographical dataDate of birth, sex, address, family members’, marital status, religious preference, occupations, source of health care, and insuranceWhat is the initial step in taking a health history?What is the rationale for obtaining a health history?
16Assessment Nursing Health History Reasons for seeking health care Chief complaintDocument information in patient’s own words.The nurse can use the PQRST method:P provocative/palliativeQ quality/quantityR region/radiationS severityT timingDefine the “chief complaint.”What is the “PQRST” method?
17Assessment Nursing Health History Present illness or health concerns The data collected relate to the progression of the present illness from the onset of the current signs and symptomsPast health historyPrevious hospitalizationsAllergiesHabits and lifestyle patternsAbility to perform ADLsPatterns of sleep, exercise, and nutritionWhat data is obtained when inquiring about the present illness?What data is obtained from the past health history?
18Assessment Nursing Health History Family history Immediate and blood relativesIncludes health or cause of death, as well as history of illnessObjective is to determine patient’s risk for illnesses of a genetic or familial natureProvides information about family structure, interaction, and functionWhy is it important to obtain a family health history?
19Assessment Nursing Health History Environmental history Provides data about patient’s home environmentPsychosocial and cultural historyData about primary language, cultural groups, educational background, attention span, and developmental stageCoping skills and family supportIdentify major beliefs, values, and behaviors when treating themWhat typical information is obtained while performing an environmental assessment?Why is it important to obtain a psychosocial history?
20Assessment Nursing Health History Review of systems Systematic method for collecting data on all body systemsRecord in clear and concise manner with appropriate terminologyAsk specific questions relating to functioning of each systemWhat does the term “review of systems” mean?How is it applicable to a nursing assessment?
21Assessment Nursing Physical Assessment The purpose is to determine the patient’s state of health or illnessInitial step of the nursing process and in forming the nursing care planWhen to perform a physical assessmentPerform assessment as soon after admission as possible.Initial assessment is done by an RN.Ongoing assessment is the responsibility of LPN and RN.What is the purpose of the nurse’s physical assessment?Why does an RN perform the initial assessment?Why is it both the RN and LPN/LVN’s responsibility to perform ongoing nursing assessments?
22Assessment Nursing Physical Assessment Where to perform a nursing assessmentComfortable, private settingIn most cases, the patient’s own room works very well and is convenientMethods of nursing physical assessmentHead-to-toeSystem-by-systemFocusedAsk students to describe an environment in which they would prefer a physical assessment be conducted.What is the difference among head-to-toe assessment, system-by-system assessment, and focused assessment?
23Assessment Nursing Physical Assessment Performing the nursing physical assessmentItems needed: penlight, stethoscope, blood pressure cuff, thermometer, gloves, and a tongue bladeNurse also makes use of the senses of touch, smell, sight, and hearingAlways wash your hands before beginning assessment.Documentation of the interview and assessment is necessary utilizing facility formsTelephone consultationWhat typical items are needed to perform a nursing physical assessment?Why is it important for the nurse to wash his/her hands before assessing the patient?What senses does the nurse utilize when assessing the patient?In what instances does the nurse perform a telephone consultation?
24Equipment used during a physical examination. Figure 5-1(From Elkin, M.K., Perry, A.G., Potter, P.A. . Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)Equipment used during a physical examination.
25Assessment Performing the Nursing Physical Assessment Head-to-toe assessmentNeurologicLevel of consciousnessLevel of orientationHand gripsWhy is the neurologic system the first system to assess when performing a head-to-toe assessment?
26Assessment Head-to-Toe Assessment (continued) Skin and hair Observe skin for color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions.Note color of sclera, mucous membranes, tongue, lips, nail beds, palms, and soles.Determine the quantity, quality, and distribution of hair.Hair should be smooth, not oily or dry.Scalp should be free of dandruff, lesions, or parasites.In what situations have you witnessed skin or hair abnormalities?When does the nurse begin the assessment of the patient?
27Figure 5-3(From Elkin, M.K., Perry, A.G., Potter, P.A. . Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)Assess skin turgor by grasping fold of skin on back of patient’s hand, sternum, forearm, or abdomen.
28Assessment Head-to-Toe Assessment (continued) Head and neck Note facial expression.Note symmetry of features.Assess arteries, veins, and lymph nodes.Palpate beneath the jaw and down each side of the neck to feel for enlarged lymph nodes.Palpate carotid arteries.Assess jugular vein distention.Auscultate the carotids for bruits.In what manner is the head and neck assessment conducted?
29Palpation of carotid artery. Figure 5-4(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. . Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)Palpation of carotid artery.
30Assessment Head-to-Toe Assessment (continued) Mouth and throat Eyes Inspect the lips and mucous membranes with tongue blade and penlight.Note condition of teeth and gums.Note breath odor.EyesNote symmetry.Assess for exudates.Assess sclera.Observe pupillary reflex.How do you assess the mouth and throat?What tools might be necessary to assess the mouth, throat, and eyes?How do you assess the eyes?
31Assessment Head-to-Toe Assessment (continued) Ears Nose Note symmetry. Assess ear canal.Note ability to hear and follow commands.Note use of hearing aids if applicable.NoseIt should be symmetrical.Assess patency.Observe for bleeding or drainage.Assess nares.How do you assess the ears?How do you assess the nose?
32Assessment Head-to-Toe Assessment (continued) Chest, lungs, and heart and vascular systemInspect for bilateral chest expansion.Note rate and rhythm of respirations.Breathing should be QUIET.Note posture.BreastsExamine and encourage monthly self-exams.How do you assess the chest, lungs, heart, and vascular system?How do you instruct the patient to perform monthly breast exams?
33Assessment Head-to-Toe Assessment (continued) Lung sounds Instruct patient to breath through mouth quietly and more deeply and slowly than a usual respiration.Place stethoscope firmly but not tightly on the skin and listen for one full inspiratory/expiratory cycle at each point.Systematically auscultate using a zigzag pattern.How do you properly auscultate the lungs?
34Assessment Head-to-Toe Assessment (continued) Spine Heart sounds Note the curvature while in a sitting and a standing position.Heart soundsAuscultate with stethoscope.Listen for intensity of the sound, faint to strong.Determine the regularity of the rhythm.How do you assess the spine?How do you assess heart sounds?Discuss spinal abnormalities.
35Sequence of patient positions for auscultation of heart sounds. Figure 5-8(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. . Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)Sequence of patient positions for auscultation of heart sounds.
36Assessment Head-to-Toe Assessment (continued) Peripheral vascular systemPalpate peripheral pulses.Rate the strength on a 0-to-4+ scale.Assess extremities for symmetry, color, and varicosities.Assess temperature of hands and feet.Perform capillary refill or blanch test.How do you assess peripheral pulses?How do you document the strength of peripheral pulses?Why would a nurse assess capillary refill?
37Palpation of arterial pulses. Figure 5-9(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. . Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)Palpation of arterial pulses.
38Assessment Head-to-Toe Assessment (continued) Abdomen Inspect for shape, contour, lesions, scars, lumps, or rashes.Auscultate for bowel sounds in all quadrants.Perform palpation and percussion.Genitourinary systemInspect labia/genitalia and pubic hair.Palpate the scrotum.Palpate suprapubic area.How do you perform an abdominal assessment?Why would you auscultate for bowel sounds prior to performing palpation on the abdomen?How do you assess the genitourinary system?How do you assess the male and female genitalia?Discuss how to provide privacy when assessing the perineum.
39Figure 5-11(From Thompson, J.M., Wilson, S.F. . Health assessment for nursing practice. St. Louis: Mosby.)Palpation of the abdomen to assess for distention, masses, or tenderness using light palpation.
40Palpation of the liver using moderate palpation. Figure 5-12(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. . Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)Palpation of the liver using moderate palpation.
41Assessment Head-to-Toe Assessment (continued) Rectum Legs and feet Spread buttocks and assess for hemorrhoids or lesions.Legs and feetPalpate femoral, dorsalis pedis, popliteal, and posterior tibial pulses.Observe and palpate for edema.Test for range of motion.Check color, motion, sensation, and temperature of both feet.What are hemorrhoids and rectal lesions?How do you assess the legs and feet?Reiterate assessment of peripheral pulses and assessment for edema.