Comprehensive Health Assessment: Foundations for Evidence-Based Practice, Summaries of Nursing

Download Comprehensive Health Assessment: Foundations for Evidence-Based Practice and more Summaries Nursing in PDF only on Docsity! Comprehensive Health Assessment: Foundations for Evidence-Based Practice Health Assessment: Exam 1 Chapter 1: Evidence-Based Assessment Assessment is the collection of data about an individual's state of health. It is a systematic approach to practice that uses research evidence, clinical expertise, clinical knowledge, and the client's values and preferences. Decisions should not be made without good reason, and that is why we need data to make appropriate clinical decisions. What Data do we Turn to? Research: Research leads to positive patient outcomes. The nurse should search the literature on the subject matter for positive outcomes that occurred as a result of the implementation. For example, the spread of infection can be stopped by using personal protective equipment (PPE), hand washing, gloves, and masks. Clinical Experience: Clinical experience is another important source of data. Clinical Knowledge: Clinical knowledge is also crucial in the assessment process. Client's Preferences and Values: The client's preferences and values must be considered when making clinical decisions. ADPIE ADPIE is a five-step systematic approach to nursing practice: Assessment: This step always comes first because you cannot proceed to the other steps until you have the assessment information. The nurse collects both subjective and objective data, reviews the clinical record, health history, physical exam, functional assessment, and documents relevant data. Diagnosis: In this step, the nurse determines what is going on. The nurse compares clinical findings, interprets data, makes hypotheses, and derives a diagnosis. 1. 2. Planning: This is where the nurse plans what to do about the identified problem. The nurse establishes priorities, develops patient goals, and establishes realistic, measurable outcomes. Implementation: This is where the nurse puts the plan into action. The nurse uses evidence-based interventions, coordinates care, uses community resources, and provides health teaching and health promotion. Evaluation: This is where the nurse determines if the interventions worked. The nurse evaluates the progress toward outcomes and includes the patient in the evaluation process. Example of ADPIE in Action Assessment: The nurse observes that the client is shaky and sweating. The nurse takes the glucose level and determines that the glucose is low. Diagnosis: As a result of the assessment findings, the nurse determines that hypoglycemia is occurring. Planning: The nurse establishes her priority of increasing the glucose level first and then educating the client about glucose maintenance. Implementation: The nurse gives the client some juice and crackers. When the client is stable, the nurse will provide education and resources to assist the client with glucose maintenance. Evaluation: The nurse determines that after 15 minutes, the glucose level increased as a result of the implementation. The client was also able to verbalize that they must drink some juice and crackers if this occurs to them while they are at home. Appropriate Database for the Situation Complete Database: This includes a complete health history, full physical exam, current and past medical history. This is a baseline, and the perception of health and illness can be measured against it. This will give the first diagnosis. In a primary care setting, the nurse builds relationships with the client, while in the hospital setting, data is gathered on admission. Problem-Centered Focus Database: This is a mini-database that focuses on one main problem, such as a sore throat. This can occur in all settings. Follow-up Database: This involves examining what has occurred since the last visit, whether the condition has gotten worse or better. For example, a follow-up from surgery. 3. 4. 5. 1. 2. 3. Cultural Awareness and Competence Minorities and immigrants may be at risk for healthcare disparities. Becoming culturally aware and competent is important for nurses to provide equitable, high-quality care. Cultural awareness involves exploring one's own personal history and values, using thoughtful reasoning, responsiveness, and discrete interactions. Cultural Assessment When assessing a client's cultural background, the nurse should avoid applying stereotypes and instead listen and learn. Relevant domains to assess include heritage, health practices, communication, family roles, nutrition, beliefs, religion, and primary language. The Health Interview The health interview is a structured interaction between the nurse and the patient, with the mutual goal of promoting the patient's optimal health. Successful interviews involve building trust and rapport, using effective communication techniques, and tailoring the approach to the patient's needs (e.g., for older adults). Communication Techniques Effective communication techniques in the health interview include using open-ended questions, facilitation, reflection, empathy, and clarification. Nurses should avoid negative techniques like unwanted advice, avoidance language, professional jargon, biased language, and interrupting the patient. Closing the Interview When closing the interview, the nurse should ease into the conclusion, summarize key points learned, identify health problems and plans for action, and highlight any positive health aspects. Considerations for Older Adults Older adult patients may have a great deal of background data, require more time to respond to questions, and have decreased cognitive and physical abilities. Nurses should adapt their approach accordingly, such as using therapeutic touch and professional interpreters when needed. Health Literacy and Education Health literacy refers to a patient's ability to understand instructions, navigate the healthcare system, and communicate concerns. Nurses should be aware that a patient may have average literacy but lack healthcare literacy, which can impact medication compliance and readmission rates. The Complete Health History The complete health history includes collecting subjective data across various domains, such as biographical information, reason for seeking care, present health history, past history, medication reconciliation, family history, and a review of systems. The PQRST framework is a useful tool for gathering details about the patient's presenting concerns. Mental Status Assessment Mental status assessment involves evaluating an individual's consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process and content, and perceptions. This is typically done through observation and interaction during the health history interview. Appearance and Behavior Appearance Observe the patient's appearance to assess if they look disheveled. Behavior Observe the patient's behavior, such as whether they are nervously pacing or exhibiting other unusual behaviors. Cognition and Thought Processes Cognition Assess the patient's ability to recall their name and personal information. Thought Processes Evaluate whether the patient's thought processes make sense and if they can logically think through processes. For example, determine if the patient is aware of the current year and the ongoing pandemic, or if they believe they are in an alternative universe where a pandemic did not occur. When a Full Mental Exam is Needed Patients may require a full mental exam in the following situations: Patients whose initial screening suggests an anxiety disorder or depression. • • • • • • Patients exhibiting behavioral changes, such as memory loss or inappropriate social interaction. Patients with brain lesions, such as those caused by trauma, tumor, or cerebrovascular accident (stroke). Aphasia Impairment of language ability secondary to brain damage. Psychiatric Mental Illness Patients exhibiting symptoms of psychiatric mental illness, especially with acute onset. Mini-Mental State Exam The Mini-Mental State Exam is a useful tool for assessing cognitive function, particularly in clients with pre-existing cognitive concerns or conditions, such as dementia and Alzheimer's disease. Assessing Cognitive Function Memory Assess both short-term and long-term (remote) memory. Examples: "What did you eat for breakfast?" and "Tell me about your wedding day." Orientation to Time and Place Assess the patient's awareness of where they are and the current date. Naming Assess the patient's ability to name objects. Reading and Copying Assess the patient's ability to read written words and copy a simple shape, such as a circle. Visual Spatial Orientation Assess the patient's awareness of their own body position and space, particularly in cases of brain injury or stroke. Example: A patient with a right-side brain injury may exhibit left-side neglect, being unaware of the left side of their body and only attending to the right side. • • • • • • • • • • • Vital Signs Vital signs provide objective measurements that help monitor a patient's health and indicate deterioration, especially in acute care settings. These include: Temperature Normal range: 35.8°C to 37.3°C (96.4°F to 99.4°F) Abnormal findings: Hyperthermia (greater than 38°C or 100.4°F) and hypothermia (less than 36°C or 96.8°F) Measurement methods: Rectal, oral, axillary, tympanic, and temporal Pulse Palpate the pulse to assess rate, rhythm, and force. Normal range: 60-100 beats per minute (bpm) Respiratory Rate Observe the patient's breathing pattern and count the number of breaths per minute. Blood Pressure Measure the patient's systolic and diastolic blood pressure. Oxygen Saturation (SpO2) Measure the oxygen saturation of the patient's blood using a pulse oximeter. Vital Signs and Pain Assessment Vital Signs Breathing Most people are unaware of their breathing and do not mention when their respirations are being counted. Breathing is usually relaxed, regular, automatic, and silent. Avoid mentioning to the client that you are checking their respirations, as this may alter their breathing patterns. In aging adults, there may be a decreased vital capacity and increased reserves, leading to shallower breaths. Count respirations for 30 seconds and multiply by 2 to get the respiratory rate. Respirations should be even and regular, with a normal rate of 10-20 breaths per minute. • • • • • • • • • • • • Abnormal findings include labored breathing, use of accessory muscles, nasal flaring, and intercostal retractions. Rates less than 10 bpm or greater than 20 bpm are also considered abnormal. Blood Pressure Always document the client's position, the arm used, and the cuff size. Avoid using the arm with an AV fistula or the arm on the side where the client has had a mastectomy, as these are contraindications. A narrow or small cuff will yield a false high blood pressure reading, while a cuff that is too wide or large will yield a false low reading. Phase one (systolic) is the maximum pressure felt on an artery during left ventricular contraction, marked by a clear tapping sound. Phase five (diastolic) is the resting pressure that the blood exerts constantly between each contraction, marked by silence. Systolic pressure is the top number, representing the maximum pressure during the contraction phase (systole). Diastolic pressure is the bottom number, representing the resting pressure during the relaxation phase (diastole). Factors Affecting Blood Pressure Hypertension (>120/80 mmHg) and hypotension (<95/55 mmHg with other symptoms) are considered abnormal findings. Mean arterial pressure (MAP) is a measure of how well vital organs are being perfused during a cardiac cycle. A normal MAP is >60 mmHg. Factors that can impact blood pressure include hypertension, obesity, vasoconstriction (e.g., smoking, diabetes, atherosclerosis), stress, activity, age, gender, race, and circadian rhythm. Systolic blood pressure increases with age due to the loss of arterial elasticity, while diastolic pressure decreases with age, leading to an increased pulse pressure (>60 mmHg) in the aging client. Orthostatic Hypotension Orthostatic hypotension is a drop in systolic pressure of ≥20 mmHg or a drop in diastolic pressure of ≥10 mmHg when the client changes position from supine to standing. This is caused by abrupt vasodilation and puts the client at risk of syncope, falls, and injury. Older adults, those on bed rest, those with hypovolemia, and those taking high blood pressure medications are at a higher risk. Assess blood pressure in each position (supine, sitting, dangling, standing) and change positions slowly to prevent orthostatic hypotension. Oxygen Saturation Pulse oximetry is a non-invasive method to assess arterial oxygen saturation (SpO2). • • • • • • • • • • • • • • • • • It measures the amount of hemoglobin bound to oxygen by detecting the differences in the absorption of infrared light between oxygenated and deoxygenated red blood cells. Pulse oximetry may be less accurate in clients with low perfusion or anemia, as the hemoglobin may be well-saturated with oxygen, but the client may not have enough oxygen reaching the tissues. The sensor is placed on the finger, nose, or toes (more common for infants and children). Factors that can impact the results include hypoxia, dark or metallic nail polish, and peripheral arterial disease. Pain Assessment Pain is considered the 5th vital sign and is a subjective experience that is individualized to each person. Pain is not genetic but may be culturally learned. Neuropathic pain is caused by a lesion or disease that leads to abnormal processing of pain messages, often evolving into chronic pain. Visceral pain originates from larger interior organs and is often accompanied by autonomic responses like nausea, vomiting, and diaphoresis. Somatic pain results from musculoskeletal tissues or body surface and can be accompanied by autonomic responses. Referred pain is felt in one site but originates in another, which is useful for diagnostic purposes. Phantom pain is experienced in a body part that is no longer present. Pain assessment tools include numeric rating scales, verbal descriptor scales, and visual analog scales, with older adults often preferring descriptor scales. Objective data from the physical examination can provide information about the acute or chronic nature of the pain and any abnormal findings. Physiological changes associated with pain include tachycardia, increased blood pressure, increased oxygen demands, hypoventilation, hypoxia, and gastrointestinal symptoms like nausea and vomiting. • • • • • • • • • • • • • •