1. Intro to Health Assessment

2. Health Assessment What is it? Why are we learning it? Health Assessment includes: 1.Theoretical and Experiential Knowledge 2.Critical Thinking 3.Assessment Skills 4.Communication Skills 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 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

3. Developmental Considerations Infancy – birth to 1 year Infancy – birth to 1 year Toddler – 1 to 3 years Toddler – 1 to 3 years Preschooler – 3 to 6 years Preschooler – 3 to 6 years School age – 6 to 12 years School age – 6 to 12 years Adolescent – 12 to 20 years Adolescent – 12 to 20 years Early adult – 20 to 40 years Early adult – 20 to 40 years Middle adult – 40 to 64 years Middle adult – 40 to 64 years Late adult – 65+ years Late adult – 65+ years Why consider development while assessing?

4. Developmental Considerations in Assessment Theorists Erikson – Psychodynamic theory Erikson – Psychodynamic theory Social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved Social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved 8 stages based on age 8 stages based on age Each stage must be accomplished before moving into next stage Each stage must be accomplished before moving into next stage Piaget – Cognitive theory Piaget – Cognitive theory How a person perceives and processes information How a person perceives and processes information 4 stages not based on age but in order 4 stages not based on age but in order Each stage represents a change in how children understand their environment 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

5. Infants Physical development Physical development Average term weight is 3.4 kg (7.5 lb). Triple birth weight by 1 year. Average term weight is 3.4 kg (7.5 lb). Triple birth weight by 1 year. Primitive reflexes that begin to disappear Primitive reflexes that begin to disappear Grasp reflex disappears ~2 months Grasp reflex disappears ~2 months Vision improves Vision improves Posture, holding head up, sitting, crawling, and walking Posture, holding head up, sitting, crawling, and walking Behavioral and Cognitive Behavioral and Cognitive Trust vs. Mistrust Language – crying, imitate sounds (9-10 months), first word! Contributes to development of systems SIDS – Causes? Recommendations? Complications at birth? Immunization up to date? Injuries? Nutrition? Hearing or vision impairments? Lead poisoning? Whom are you assessing? Decreased airflow, decreased blood flow to brain

6. Toddlers Physical Physical Rate of growth decreasing Rate of growth decreasing Upright posture Upright posture Improvements in fine motor skills Improvements in fine motor skills Behavioral and Cognitive Behavioral and Cognitive 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 Stacking blocks!

7. Growth Charts Birth to 36 months Boys, 1-17 yrs

8. Preschoolers Physical Growth of long bones Growth of long bones Begin to lost baby fat Begin to lost baby fat Permanent teeth appear Permanent teeth appear Behavioral and Cognitive Initiative vs. guilt Initiative vs. guilt More autonomous More autonomous Communicate more effectively Communicate more effectively Awareness of others’ needs and interests Awareness of others’ needs and interests Develop gender roles Develop gender roles Delayed imitation Delayed imitation Egocentrism Egocentrism Allow to play with instruments prior to use

9. School Age Physical Muscles stronger and more coordinated Muscles stronger and more coordinated Bones replace cartilage Bones replace cartilage Behavioral and Cognitive Industry vs. inferiority – a desire to achieve Industry vs. inferiority – a desire to achieve Reading and writing improve Reading and writing improve Manage feelings and impulses better Manage feelings and impulses better Identify sex and gender roles Identify sex and gender roles Identify self as worthy individual Identify self as worthy individual

10. Adolescents Physical Growth spurts in height and weight Growth spurts in height and weight Menarche and thelarche in girls Menarche and thelarche in girls Behavioral and Cognitive Ego identity vs. role confusion Ego identity vs. role confusion Formal operational thought Formal operational thought Identity confusion Identity confusion May be embarrassed of own body May be embarrassed of own body Emotional independence Emotional independence More knowledgeable More knowledgeable

11. Early Adulthood Physical Maximum potential for growth and development Maximum potential for growth and development Reduction in activity Reduction in activity Behavioral and Cognitive Intimacy vs. role isolation Intimacy vs. role isolation Achievements important, career Achievements important, career Mate selection Mate selection ↓ caloric intake

12. Middle Adulthood Physical Wrinkling of skin Wrinkling of skin Graying or loss of hair Graying or loss of hair Decrease in muscle mass and tone Decrease in muscle mass and tone Vision and hearing decrease Vision and hearing decrease At risk populations develop At risk populations develop Behavioral and Cognitive Generativity vs. stagnation Generativity vs. stagnation Many decisions about career, lifestyle, family – “midlife crisis” Many decisions about career, lifestyle, family – “midlife crisis” Empty nest syndrome Empty nest syndrome Intelligence remains constant, more experience Intelligence remains constant, more experience Secondary Prevention

13. Older Adulthood Physical Many variations Many variations Chronic illnesses Chronic illnesses Changes in sensation Changes in sensation Loss of lean body mass, increase in fat deposition. Loss of lean body mass, increase in fat deposition. Posture deteriorates, wider gait Posture deteriorates, wider gait Poor skin turgor, xerosis (drying) Poor skin turgor, xerosis (drying) More prone to injury due to loss of bone mass. More prone to injury due to loss of bone mass. Behavioral and Cognitive Ego identity vs despair Ego identity vs despair Ego identity – acceptance of choices made in their lives Ego identity – acceptance of choices made in their lives Despair - Loss of spouse can be devastating Despair - Loss of spouse can be devastating Stereotyping by society – ageism Stereotyping by society – ageism Further classification 1.Young-old (65-74 yrs) 2.Middle-old (75-84 yrs) 3.Old-old (85 or older) Lueckenotte (2000)

14. Developmental Considerations Infant – gentle, calm. Primary interaction with parents Infant – gentle, calm. Primary interaction with parents Preschooler – be direct. Let play with equipment. Only concrete explanation, don’t go into detail. 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. School age – they are curious. Explain how and why. Talk to child first than parent. Adolescent – be respectful. Explain everything. Avoid silence. Adolescent – be respectful. Explain everything. Avoid silence. Older adults – slow down. Be respectful, patient. Like to tell stories. Older adults – slow down. Be respectful, patient. Like to tell stories.

15. Approach to Identifying Priorities 1. Immediate priorities (ABCs) Airway Airway Breathing Breathing Circulation Circulation Vital Signs Vital Signs 2. Second-level priorities Mental status change Mental status change Acute pain Acute pain Urinary elimination problems Urinary elimination problems Untreated medical problem (diabetic without insulin) Untreated medical problem (diabetic without insulin) Abnormal lab values Abnormal lab values Risks of infection, safety, security Risks of infection, safety, security 3. Third-level priorities Lack of knowledge Lack of knowledge Activity, rest, sleep Activity, rest, sleep

16. Health History 1. Establishes a rapport – relationship, understanding, trust 2. Helps to focus on the patient’s chief concern and sets the stage for the Physical Examination (PE) 3. Less invasive than the PE 4. Types of data Subjective data – what person says about himself or herself Subjective data – what person says about himself or herself Objective – what you observe during a PE Objective – what you observe during a PE

17. Health History Open-Ended Questions Broadly stated and encourage an open response Broadly stated and encourage an open response Aim is to describe problem or symptoms Aim is to describe problem or symptoms “How are you feeling?” “How are you feeling?” Closed or Direct Questions Direct and specific questions to get details Direct and specific questions to get details Aim is to focus on the problem. More specific. Aim is to focus on the problem. More specific. “When did the pain begin? Is the pain sharp, dull, or achy?” “When did the pain begin? Is the pain sharp, dull, or achy?” Open-EndedClosed Purpose – to obtain subjective data from pt.

18. Phases of an Interview Introduction phase Introduction phase Nurse introduces self to client Nurse introduces self to client Nurse describes purpose of interview 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 describes the process of the interview so that client knows how long interview will take and what to expect Discussion phase Discussion phase Nurse helps discussion Nurse helps discussion Discussion is client centered Discussion is client centered Nurse uses various communication techniques to collect data Nurse uses various communication techniques to collect data Summary phase Summary phase Summarization of data Summarization of data Allows for clarification of data Allows for clarification of data Provides validation to the client that nurse understands problem Provides validation to the client that nurse understands problem

19. Internal and External Factors of Communication Sending Messages Appearance – clothing, hair, jewelry Appearance – clothing, hair, jewelry Nonverbal communication – body language (gestures, facial expressions, eye contact, touch) Nonverbal communication – body language (gestures, facial expressions, eye contact, touch) Verbal communication – empathy. Speech – is it clear? Can the patient understand you? Verbal communication – empathy. Speech – is it clear? Can the patient understand you? Receiving Messages Overall appearance of patient – neat? wet? orderly or rowdy? Overall appearance of patient – neat? wet? orderly or rowdy? Nonverbal and verbal communication Nonverbal and verbal communication Listening actively – requires complete attention. What is the pt. not saying? Difficulty with language, pronunciation, or memory? Listening actively – requires complete attention. What is the pt. not saying? Difficulty with language, pronunciation, or memory? External factors Privacy Comfort Room temperature Noise Seated at eye level Internal factors Whom are you interviewing?

20. Enhancing Data Collection Facilitation – encouraging pt. to continue talking “uh-huh, go on, tell me more” 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. 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. 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.” 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. Confrontation and Clarification – clarify inconsistencies of data. A story can change, especially with embarrassing issues. Interpretation – sharing with pt. the conclusions you have drawn. Interpretation – sharing with pt. the conclusions you have drawn. Explanation – inform. Could be about diet, medication use, etc. Explanation – inform. Could be about diet, medication use, etc. Summary – review of data gathered. Summary – review of data gathered.

21. Traps to Avoid False assurances – everything’s not always ok False assurances – everything’s not always ok Unwanted advice – sometimes must let pt. decide. Be objective. Give pt. all the facts. Unwanted advice – sometimes must let pt. decide. Be objective. Give pt. all the facts. Avoiding the issues – be direct and honest Avoiding the issues – be direct and honest Professional jargon Professional jargon Biased questions – “You don’t smoke, do you?” Biased questions – “You don’t smoke, do you?” Talking too much and interrupting 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? 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. Answering personal questions – not necessary and might be uncomfortable. Use common sense and experience

22. Interviewing Special Populations Hearing Impaired Hearing Impaired Recognize clues such as staring at your mouth or face, speaking loudly 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 Determine if there’s a better way to communicate such as writing or signing Acutely Ill Acutely Ill If pt. is in an emergency situation, ask priority questions first. Use closed (direct questions). If pt. is in an emergency situation, ask priority questions first. Use closed (direct questions). Drugs or Alcohol Influenced Drugs or Alcohol Influenced Ask simple and direct questions. Ask simple and direct questions. Try not to appear threatening Try not to appear threatening Sexually Aggressive People Sexually Aggressive People Very important to set professional boundaries 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 Must make it clear you are a health professional and can best care for that person by maintaining a professional relationship Crying Crying It’s ok if a pt. cries. It usually is a big relief to let out emotions. 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. Do not move onto another topic. Talk about what’s bothering him or her. Anger and Threat of Violence Anger and Threat of Violence Ask the pt. why they are angry and try to deal with the feelings Ask the pt. why they are angry and try to deal with the feelings If pt. becomes threatening, remember your safety comes first If pt. becomes threatening, remember your safety comes first Leave the examining room and try to position yourself between the pt and the door Leave the examining room and try to position yourself between the pt and the door

23. Domestic Violence Considerations Most common people to become victims of abuse are the intimate partner and the elderly. 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 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. Don’t be afraid to ask the pt. if you suspect abuse. You are an advocate for the patient. Abuse Assessment Screen (AAS) Abuse Assessment Screen (AAS) “Because domestic violence is so common in our society, we are asking all women the following questions” “Because domestic violence is so common in our society, we are asking all women the following questions” Document, Document, Document Document, Document, Document Write down direct quotes from pt. even if it includes swearing Write down direct quotes from pt. even if it includes swearing

24. AMA Definitions for Elder Abuse and Neglect Physical abuse Physical abuse Violent acts that result or could result in injury, pain, impairment, and/or disease Violent acts that result or could result in injury, pain, impairment, and/or disease Physical neglect Physical neglect Failure of family member or caregiver to provide basic goods and/or services such as food, shelter, health care, and medications Failure of family member or caregiver to provide basic goods and/or services such as food, shelter, health care, and medications Psychological abuse Psychological abuse Behaviors that result in mental anguish. (Threats) Behaviors that result in mental anguish. (Threats) Psychological neglect Psychological neglect Failing to provide basic social stimulation Failing to provide basic social stimulation Financial abuse Financial abuse Intentional misuse of elderly person’s financial resources without consent Intentional misuse of elderly person’s financial resources without consent Financial neglect Financial neglect Failure to use the assets of the elderly person to provide necessary services Failure to use the assets of the elderly person to provide necessary services

25. Abuse Terminology Abrasion Abrasion A wound caused by rubbing the skin or mucous membrane A wound caused by rubbing the skin or mucous membrane Bruise (Contusion) Bruise (Contusion) Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface Ecchymosis Ecchymosis A hemorrhagic spot, larger than petechia, in the skin or mucous membrane, forming a nonelevated, round, or regular, blue or purplish patch A hemorrhagic spot, larger than petechia, in the skin or mucous membrane, forming a nonelevated, round, or regular, blue or purplish patch Hematoma Hematoma A localized collection of extravasated blood, usually clotted in an organ, space, or tissue A localized collection of extravasated blood, usually clotted in an organ, space, or tissue Hemorrhage Hemorrhage An escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ An escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ Contusion Abrasion Ecchymosis

26. Abuse Pictures Incision (Cut) Incision (Cut) A cut or wound made by a sharp instrument A cut or wound made by a sharp instrument Laceration Laceration A wound produced by tearing and/or splitting of body tissue, usually from blunt impact over a bony surface. A wound produced by tearing and/or splitting of body tissue, usually from blunt impact over a bony surface. Lesion Lesion Any pathologic or traumatic discoloration of tissue or loss of function Any pathologic or traumatic discoloration of tissue or loss of function Patterned injury Patterned injury An injury caused by an object that leaves a distinct pattern on the skin and/or organ An injury caused by an object that leaves a distinct pattern on the skin and/or organ Petechiae Petechiae Small red or purple spot on the body Small red or purple spot on the body Disorders of coagulation. Strangulation. Disorders of coagulation. Strangulation. With bruising, should suspect abuse With bruising, should suspect abuse Puncture Puncture The act of piercing or penetrating with a pointed oubject The act of piercing or penetrating with a pointed oubject laceration petechiae

27. Components of Health History The general survey The general survey Fourteen cues to be observed Fourteen cues to be observed Age Age Sex Sex Race Race Vital Signs Vital Signs Apparent state of health Apparent state of health Signs of distress Signs of distress Facial expressions Facial expressions Mood Mood State of awareness State of awareness Speech Speech Dress, grooming, personal hygiene Dress, grooming, personal hygiene Nutrition Nutrition Stature Stature Posture and gait Posture and gait

28. Components of Health History Reasons for seeking health care Reasons for seeking health care Health perception/Health management Health perception/Health management Present health or history of present illness Present health or history of present illness Location Location Quality Quality Quantity Quantity Timing Timing Setting Setting Aggravating/alleviating factors Aggravating/alleviating factors Associated factors Associated factors Client’s perception Client’s perception Childhood illnesses Childhood illnesses Adult illnesses Adult illnesses 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

29. Components of Health History Nutritional-metabolic pattern Nutritional-metabolic pattern Elimination pattern Elimination pattern Activity-exercise pattern Activity-exercise pattern Sleep-rest pattern Sleep-rest pattern Cognitive-Perceptual pattern Cognitive-Perceptual pattern Role-relationship pattern Role-relationship pattern Sexuality-reproductive pattern Sexuality-reproductive pattern Coping-stress-tolerance pattern Coping-stress-tolerance pattern Value-belief pattern Value-belief pattern

30. Functional Assessment (ADLs) Self esteem Self esteem Activity and exercise Activity and exercise Sleep patterns Sleep patterns Nutritional assessment Nutritional assessment Spiritual and social supports Spiritual and social supports Coping mechanisms Coping mechanisms Alcohol, smoking, and drug use Alcohol, smoking, and drug use Environmental hazards such as working conditions Environmental hazards such as working conditions Domestic violence assessment Domestic violence assessment