N305 Health Assessment

8/11/2019 N305 Health Assessment

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N305 Health Assessment 9/5/2014 7:31:00 PM

Introduction to health assessment:

What is health?

• “a state of complete physical, mental, and social well-being and not

merely the absence of disease or infirmity.” –WHO (1946)• 1986-Ottawa Charter affirms social, economic and environmental

aspects of “health”

• A relative state where a person lives to their potential and includes 6

facets: physical, emotional, social, cultural, spiritual, developmental.

Health is the summation of these 6 facets and is simply not the

absence of disease.

• Our health is also determined by how well we can adapt to changes in

our environment

◦ How well we adapt

-immune system, stress relief techniques, support systems

ADL (activities of daily living)

Health is not a constant. A healthy person feels good on all levels.

What contributes to health:

Lifestyle, family history, genetics, environment, socioeconomic, occupation,

education, culture, spirituality, age, access to health care, nutrition, RNs!!!!!!

Determinants of Health:

1. income and social status

2. social support networks

3. education and literacy

4. employment/working conditions

5. social environments

6. physical environments

7. personal health practices and coping skills

8.

healthy child development

9. biology and genetic endowment

10. health services

11. gender

12. culture



Diet is embedded in many of the 12 determinants of health.

Age isn’t part of it.

Florence Nightingale

1860/1969 (individual/environment)

“what you want are facts, not opinions…the most important practical lesson

that can be given to nurses is to teach them what to observe and how to

observe…” (p.105)

“And nothing but observation and experience will teach us the way…”

Why Health Assessment?-information about patient, knowledge that leads to best course of action for

patient care

-health promotion makes RNs different

How are you?

-illness, injury, disease, alterations in health, health, wellness, wellbeing

- interested in both ends of the spectrum of health and illness

Professional LensProfessional and Practice Considerations

- situational awareness’

- context dependent

- general survey



-

clinet assessment

- priority setting

- nursing knowledge and judgment

- nursing process

-

clinical reasoning- interprofessional collaboration

The Nursing Process

The information obtained throughout the health assessment should be doc-

umented in a clear, concise manner. This information is collated in the

patient’s medical records. The ability of the nurse to extrapolate the

findings, prioritize them, and finally formulate and implement the plan of

care is the overall goal. This is called “the Nursing Process.”



Client Assessment strategies and scopes vary significantly.

Individual Depends on the client, purpose, context, setting etc.

Family Determines nursing care plan and interventionsAggregate Contributes to interprofessional plan and strategies.

Population

Community

Also need to consider:

- professional approach

o with clients and team members

- communication

o empathy, caring, effective

o therapeutic

- Professional relationship

o Boundaries

o Touch, space, dignity, respect, comfort, safety, privacy

Three effective verbal communication skills

- Active listening

o

The ability to focus on patients and their perspectives- Restatement

o The content of communication

- Reflection

o Identify the themes of communication and what the patient may

be feeling.

Individual Assessment: assessing social, env, econ, health, physical,

mental, social, family, community

60-sec assessment

- purpose, directions

ABC without touching the patient

Tubes and lines

Respiratory equipment

Patient safety survey



Environmental survey

Sensory

Additional…

Lab and Diagnostic Examples: blood work (CBC), x-rays, angiogram

Role and responsibility of RN

o Understand or clarify purpose of test

o

Inform client or others

o Prepare client or others

o Understand or report pertinent findings

o Discuss or relay information with client.

Health Hx: Components

Interview: Phases and Process

Preparation/Preinteraction phase

o Collect data (if possible)

o Create setting: private, comfortable, safe

Initial/ Introductory phase

o Introduce: name, role and purpose

Working phase

Summarizing phase

Client Considerations

- Age

- growth and development

- sensory

- language

- culture

- gender

- emotional state

Perceptions and Concerns

- subjective

- “self -report”

- what does client perceive?



-

What is of concern?

- Attend to statements, inferences, possibilities, lead, cues

- Consider potentially sensitive topics and vulnerability

o What might they be?

o

What might they depend on… gender, age, culture

Assessnebt types, Depth, Scope

- emergent/urgent

-

unstable, life threatening, at risk

comprehensive

- health history, phys exam, lab/diag

-head to toe regions and sustems

-systems: CNS, CVS, Resp, GI/GU, MSK/Integ

- focused. Issue-oriented

-narrow scope

-in depth relationto concets of client, rn

- functional

health patterns/aspects

Organizing Frameworks

functional head-to-toe

body systems

Individual Assessment

Findings

o Normal

o Abnormal

o Expected

o

Unexpected

Ongoing



Communication of Findings

-among and between team members

SBAR

S: situation (name, role, overview of issues)

B: background (pertinent history)

A: assessment (summary of facts and assessment)

R: recommendation (actions asking for, what do you need or

want to happen next)

Health Care Team (interactions with certain professionals)

What is health assessment?



The purpose of the nursing health assessment is to determine a

patient’s health status, risk factors, and need for health education

as a basis for developing a nursing plan of care.

Three types: emergency, comprehensive (physical), patient history

The extent of health assessment depends on the acuity of the

patient’s condition.

Nursing and medicine both perform health assessments but they

differ! Medicine focuses on diagnoses and treatment of the disease.

Nursing focuses on diagnoses and treatment of the actual or

potential human responses. The nursing assessment identifies many

contributing factors to the individual’s health and wellness. These

include the 6 facets. Deviation or changes in response is noted.

For nurses it is a comprehensive health history and a physical

examination which aids in the health evaluation to determine the

health status of a person. This aids in how care should be executed

which is unique to each person.

i. Health History: A series of pertinent questions about the

patient and/or family. Use of past medical records. Knowledge

of physical, psychological, social issues, spiritual, culturalbeliefs. The identification of important data is a

systematic process.

ii. Physical Examination: A structured head-to-toe examination

to identify changes in the patient’s body systems. Findings may

support history data or trigger more questions.

General Survey

- height, weight, vital signs

- body frame

- body mass index (BMI)



Situational Awareness

- is the ability to identify, process, and comprehend the critical elements

of information about what is happening to the team with regards to the

mission. More simply, it's knowing what is going on around you

Health Assessment

o curiosity

o observation skills

o

knowledge and intellect

General survey

behaviour, physical appearance, mobility

Questions: Ask how he is, ask about why he is in today,

Notice from health assessment:nutrition, occupation, relaxed, good posture

Man on street: smoking, hygiene poor?, unkempt,

Questions: how long have you been smoking? When did you start smoking?

What are you reading today? Are you feeling comfortable? Do you live

closeby? Note grooming, nutrition, safety.

Health History

When is one anticipated? On admission to hospital, patient coming into

clinic for first time, long-term care, employment physical, before surgery,

admission to medical unit, clinic, surgery

What do we obtain?

Past and present illnesses, chief concern, drinking, drugs, smoking,

sexual health, occupation, family history,

Why do/ would RNs complete one? For plan of care. To inform and

work with other disciplines for plan of care.

Health Hx: Personal Data

Subjective: information

Objective

Primary from the client themselves



Secondary from the secondary source

Reliable

Inaccurate

Do own assessment

Get reports

Test-rest validity

EG redo vitals if not sure

Ask what they know –get 2nd opinion

Subjective pain- most important

Sometimes subjective is the most important.

Reliability is important- know what they are saying

- information getting, need to know is correct, hiding, making up

- clarify, see if misunderstanding

Primary data might not be reliable, e.g., patient with dementia

First language not English might need to clarify

If person insists they have tumor? How do we handle?

Syllabus pp 79-87

Health Hx: Components

E.g., phone number, contacts, address, male/fem, chief concern, sign

sensation symptoms, personal family, social, cultural, medical

Signs- can see

Symptoms- can’t

sensations



CLPD

Refer to pdf from email

Short form mcgill can be used anywhereEdmonton- more dimensional in terms of symptoms

Sim to ESR but includes distress

Vital Signs:

Bp, pulse, o2 sat

Temp

Expected findings: why do numbers vary?

Hypothermia

Hyperthermia

Comment Jensen, p.99

Interventions for fever are dependent on the patient and cause. Most often

rapid cooling is not beneficil or required.

Pulse

Sites- Adults

Radial, carotid, apical, brachial, femoral, popliteal, dorsalis pedis, posterior

tibial

Expected findings

Rate

60-100

Expected (60-100 sinus rhythm)

Tachycardia- rate over 100

Bradycardia- less than 60

Rhythm

Regular or irregular



Strength/ amplitude

Weak pulse due to blood loss

Respirations

Rate: expected

Tachypnea

Bradypnea/apnea

Rhythm

REGULAR

IRREGULAR

QUALITY/DEPTH

Blood Pressure: sys, diastolic, MAP

An increase in volume will

An increase in resistance (called vasoconstriction) will

Normotensive

-

sys, diastolic, MAPHypotensive

MAP should always be over 65

BP: influenced by age, gender, genetics, weight,

exercise, smoking, diet, emotions, medications, position

pulse oximeter

SpO2

Widely used

Arterial blood gases



SaO2

More accurate

But more invasive.



N301- Nursing Research 9/5/2014 7:31:00 PM

First paper due September 29th 8:00am

- APA format

3-4 pages

1. Who are the subjects (quantitative researchers)? OR who are the

participants (qualitative researchers)?

-The students

2. Was any theory building or theory development done (qualitative) OR was

a developed theory or existing model being tested (quantitative)?

Both. Some kids already know how to make their favourite food

3. Was data collected? (quantitative - data that can be summarized or

reported as one or more numbers) OR (qualitative - information gathered for

an improved understanding of the topic or phenomenon of interest)

Yes. Measurements, favourite foods/ recipes/ food types, sweet/salty,

preparation time, ingredient amounts

4. What were the variables (concepts that could have information

counted on each one - quantitative researchers) OR what may be thekey points of understanding gained from reading this booklet with these key

points actually called "codes" which would be grouped together to

form categories and with these categories then grouped into a theory that

would hopefully increase our understanding of the topic or phenomenon of

interest - qualitative researchers)?

Dessert, main meal, side, snack

Ingredient availability

5. What did you find? (qualitative researchers AND quantitative

researchers)

Measurements were not exact and exact amounts of ingredients and yield

was not provided. Children don’t have a good concept of time.



6. Was this a "good" study (quantitative - random selection of subjects,

objective researcher so no researcher bias, the findings from these children

can be generalized to all children OR qualitative - was this a trustworthy

research process that generated meaningful information that may be used

sometime and/or transferred into practice somewhere)random selection was not good, objective researcher (biased due to teacher)

bias due to age and preferences, not generalized to all children in the world

7. Which type of study was best at answering the question on page 1 of the

booklet - qualitative or quantitative?

Qualitative- theoretical thinking

Both

Chapter One Review

Overview of Nursing Research

On completing this chapter, you will be able to:

Describe why research is important to nursing and discuss evidence-

based practice

Research is important to nursing because it answers questions, solves

problems and builds upon knowledge.

All this knowledge acquired by the nurse (clinical evidence) helps in the bestcourse of action for care.

Describe historical trends and future directions in nursing research

Historical trends: Nightingale founded nursing research in 1859 Notes on

Nursing. Focus of paper on environmental factors that influence emotional

and physical well-being.

Describe alternate sources of evidence for nursing practice

Describe the main characteristics of the positivist and naturalistic paradigms,

and discuss similarities and differences between quantitative and qualitative

research

Identify several purposes of qualitative and quantitative research

Define new terms in the chapter



Research: a systematic inquiry that uses rigorous methods to answer

questions or solve problems. The ultimate goal of research is to develop,

refine, and expand knowledge.

Nursing research: is designed to develop evidence about issues of

importance to various stakeholdersEvidence-based practice (EBP): EBP is broadly defined as the use of the

best clinical evidence in making care decisions.



N303- Nursing Theory 9/5/2014 7:31:00 PM

1. Religious Nursing

2. Florence Nightingale

3. Schools or Nursing

4. Rise of Professional Nursing

5. Public Health Nursing 1920s-1950s6. Hospital Nursing 1965

7. 1980s

pine needle drink from natives to fight survey

Jeanne Mance

- nurse, not a sister

- considered a founder of Quebec

- founded L’hotel dieu

- Grey Nuns not Cloistered

- Grey means colour and tipsy

ferry, brewery money for hospital and for employment for handicapped

Surgeons

barbersGrey Nuns in Quebec City, Winnipeg, Edmonton. Followed colonization and

fur trade. Not in Ontario or New England due to English.

First school of nursing in St. Catherines. First school of nursing in Alberta

(Medicine Hat). Properties of hospital. Lectures in evening.

Hospitals owned by mining companies in Alberta.

Nurse groups

- organizations (international)

Victorian Order of Nurses

Yukon- gold rush VONs and sisters went too!



Edith Cavell

- angel glacier

- nurses were viewed as “angels of mercy”

Health Insurance

- started in Saskatchewan

McGill model of nursing

Int council of nursing 1989

Robert Calman

Roberta McAdams

Lpn after WWII

RPN



N113- Pathophysiology 9/5/2014 7:31:00 PM

Amy- TA

[email protected]

or post on E-class

For games use the two diagrams for pathogen and pathophys.

mailto:[email protected]





N305 lab 9/5/2014 7:31:00 PM

Instructor

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N303 Lab 9/5/2014 7:31:00 PM

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N305 Health Assessment