Shahzad Bashir

Lecturer NMC,ION

3/20/2014

1. Identify purpose of
health appraisal for comprehensive visits

Develop own clinical objectives Identify pitfalls

20m

Discussion/Case study

2.Able to use correct technique of examination 40m Demonstration 3.Utilize various interviewing techniques appropriately with correct documentation 40m Peer group activity

Inspection, Palpation, Percussion, Auscultation.

Differentiate components of a health history Obtain information on each system

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Lets Review what we know!

Differentiate

between health, illness, disease and wellness a diabetic client be called healthy?

Can

What

is the difference between an illness and sickness

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Answers
A state of complete physical, mental & social wellbeing, not merely the absence of disease. (WHO def) Wellness: Level of wellbeing, a person perceives of being healthy Disease: Alteration of structure and function of body. ( Dis ease) Illness: A response a person has to a disease 3/20/2014
Health:

Cont
The new definition, considers health as a dynamic state of well being with different levels of functional abilities at different point in time. So a diabetic patient no doubt has a disease, but there are times when the client feels well and can be called healthy. Illness is a response to a disease and sickness is the individual perception of its illness. Thus it is possible that a person has a disease DM, has hypoglycemia sometimes, but still feels that he is normal so thus does not feel sick.
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Scenario

A 55years old man comes to the clinic with complain of persistent dry cough. GP takes history and performs physical examination. Patient is hypertensive, non-smoker, has no history of chest infection, fever, weakness or body ache. Chest is clear. Allergy is not known. Physician suspects him of having allergy and prescribes anti-allergic for 2 days. But cough does not relieve, patient comes again with persistent cough on next morning. GP refers him to a consultant for specialized consultancy. The consultant takes history and examined the patient. He finds nothing wrong with patient but a lapse in taking complete history by the GP. What was the component of history which was let pass and patient was missed-diagnosed?
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Health history ,techniques to examine, systems PE, identifying abnormalities and documenting findings Systemic approach based on detail and critical thinking to gather information about health status and to analyze these information to find ways to manage health problem.

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Components of Health Assessment

Health Assessment

Health History

Physical Examination

History of present illness Past /present Medical history Family History, social Hx 3/20/2014

Inspection Palpation Percussion Auscultation

Importance of HA
Accurate

diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a competently performed physical examination.

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Purposes of Health Assessment

Nurses

use health assessment skills to:

Develop (obtain baseline data) and expand the data base from which subsequent phases of the nursing process can evolve To identify and manage a variety of patient problems (actual and potential) Evaluate the effectiveness of nursing care Enhance the nurse-patient relationship Make clinical judgments

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Assessment tool/format

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HA vs AHA
HA

AHA

To identify and manage a variety of patient problems (actual and potential) obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve Evaluate the effectiveness of nursing care

Obtain detailed data base to help and justify diagnostic procedures. Integration data obtained by PE and History taking into broader aspect of nursing diagnosis, medical diagnosis, nursing as well as medical manage.

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Data collection and data clustering

What is data clustering? What is a data?? Processing data by organizing Information, clue, observation, prioritizing, comparing the finding, sign and symptom. norms, hypothesizing, Data - complete and accurate. analyzing and concluding it Type - Subjective and objective as significant data. It requires clinical reasoning skill. Source Primary or secondary What is this data telling you: Which one is data here: Pulse 98/min, fever, SOB, pulse, Doppler machine, cough and weakness Diarrhea, temperature, 90% oxygen saturation, fever, SOB, abdominal girth, weakness, 3/20/2014 13 cough.

systemic approach of using five senses applying different techniques to gather data base to identify and manage health problem

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Principles of PE
the stage Environment Brief explanation in start Head to toe approach Standing on right side Less threatening to invasive External then internal Normal to affected area Body symmetry from both sides 3/20/2014
Set

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Self preparation
Anxiety Organization Mannerisms

Safety
Gentleness Competence

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Equipment preparation
Within

reach and ready Arranged as per need Extra supplies / equipments Clean & warm equipment

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Patient preparation
Explain

when, where and why the assessment will take place Keep appointment Properly covered Comfort Help the client prepare:
Empty bladder Change clothes Change into gown Properly covered

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Environment preparation
Privacy Noise

Control Drapes Adequate light Room temperature Client position

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Cont
Easy

access to a restroom. A door or curtain that ensure privacy. Adequate warmth for client comfort. A padded, adjustable table or bed. A lined receptacle for soiled articles. Sufficient room for moving to either side of the client. A clean counter for placing examination equipment.
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Positioning
Positions

used during nursing assessment, medical examinations, and during diagnostic procedures:
Dorsal recumbent Supine Sims Prone Lithotomy Genupectoral

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Techniques of PE
Inspection Palpation Percussion Auscultation

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Inspection
Critical

observation

Take time to observe with eyes, ears, nose Use good lighting Look at color, shape, symmetry, position Odors from skin, breath, wound Develop and use nursing instincts

Inspection

is done alone and in combination with other assessment techniques

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General Survey
General

appearance, gait, nutrition status, state of dress, body build, obvious disability, speech patterns, affect (mood), hygiene, body odor, posture, race, gender, height, weight, vital signs Height up to age 2 is recumbent
Add head circumference if child is less than 2 years old

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Palpation
Touch With

with different parts of hands

Dorsum / finger / ball of hands

different degree of pressure

Light: 1-2 cm Deep: 4-5 cm Bimanual: using both hands to trap organ
To

identify size, shape, texture, mobility, mass, quality of pulses, joints & bones condition, tenderness, temperature, moisture, fluid & edema, & chest wall vibrations
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Percussion

Striking the body surface sharply to create sound waves Sound produced determines the feature of underlying organ Useful to identify organ position, size and density Useful to detect fluid or air in a cavity

Types of percussion
Mediate Immediate Fist Percussion notes: Flatness Dullness Resonance Hyper resonance 3/20/2014 Tympany

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Auscultation
Listening to sounds produced by the body Direct auscultation sounds are audible without stethoscope Indirect auscultation uses stethoscope

Know how to use stethoscope properly (practice) Fine-tune your ears to pick up subtle changes (practice) Describe sound characteristics (frequency, pitch intensity, duration, quality) (practice)
Flat diaphragm picks up high-pitched respiratory sounds best Bell picks up low pitched sounds such as heart murmurs, bruits, aortic aneurysm Practice using BOTH diaphragm
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Breath sounds
Bronchovesicular normal breath sound Wheezing

Narrowing/spasm of bronchioles Asthma, COPD

Crackles

fluid accumulation > PE, Pneumonia

Friction

rub

inflammation of pleura > pleuritis, pneumonia

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Problem Oriented Recording (POR

Type of format for documentation where a data base leads to a problem list and plan for some interventions i.e. diagnostic, therapeutic, educational. S Subjective O Objective A Assumption / Diagnosis P Planning I Intervention E Evaluation 3/20/2014 R Revision

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Documentation of PE findings
avoid vague terms Concise use short simple words Complete entry with date & sign Describe observation clearly Use standard abbreviations only Record exact size, position of lesions Use illustration Use black pen
Specific
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General survey documentation

Elderly women, oriented to person and place only, appears weak, unable to stand, guarding abdomen, skin flushed, pt is shivering. A 45 years old male, looks younger than his age, skinny, alert, oriented to x3. appears healthy and in no acute distress, well groomed, respond appropriately and cooperative. No gross abnormalities apparent. Young lady of 25 years old seated on wheel chair, constantly shifting position and picking at the paper on the table. Disoriented to time, place and person (require frequent orientation to the examination process). Is thin and unkempt. Eye contact minimal. Talked throughout the examination.
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a collection of subjective data Provided by the client and compiled by the nurse It provides information about clients present and past health status, practices, perceptions, knowledge, and attitudes about their health. Approach of health history is taking interview 3/20/2014 41

Is

Interview
It is goal directed purposeful interaction between two people. Purpose: Gather information to base nursing care Establish a helping relationship Identifying health status, concerns, & problems Screening purpose education
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Phases of Interview
Introductory Phase; Orientation, time/comfort Purpose Interview Environment
Psychological (Non Judgmental & Respectful) Physical (Privacy, Noise, seating, light, temp)

Working Phase; Build trust & rapport Patient readiness (less sensitive topics first) Use of therapeutic self (comm. techniques) Goal in mind.
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Cont
Termination Phase; Closure/summarize Plan for future Goal achieved/not

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Questioning Techniques
Directive: Formal & structured to collect wide range of information Usually content focused In-Directive: Informal, & focused on specific area of concern freedom, open ended

Balance between them.

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Verbal Techniques
Keep Tone neutral Facilitate with go on and what else Paraphrase Clarify Respecting Use open ended questions/ broad opening statements Proceed from general to specific 3/20/2014 Summarize/ review the discussion

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Nonverbal Techniques
Eye

contact Supportive gestures Distance Keep an open mind Supportive facial expression

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Don'ts of Interview
Leading

/ biased questions Judgmental / stereotyped responses Asking Why questions Asking two question at a time Changing topic False reassurance Agreeing, disagreeing, approving & disapproving Interrupting the client
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Barriers in Interviewing

Patients Assumptions / Expectations / Fears Age Gender Confusion Cultural and social barriers Communication Difficulties Language Difficulties
Physical Cultural

Problems affecting social interaction

e.g claustrophobia, agoraphobia.

=>Adapt methods of history taking and examination 3/20/2014 accordingly

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Guidelines for Interviewing

interview starts with a self-introduction Use body language and words that promote trust and good will Before questioning starts, the client should know the kinds of information you are interested in, the use of this information and how much of the client's time you plan to take The environment and time selected are conducive to sharing information 3/20/2014 50
The

Cont
Use restatement to clarify the client's responses when needed Honor the client's request to omit a question Pace of the questioning is unhurried, and comfortable for the client. Use appropriately placed, brief periods of silence so the client can gather her/ his thoughts. Responses to client statements show that you 3/20/2014 51 have been listening

Cont
Invite your client to expand on selected statements. At the end of the discussion, briefly review the areas covered since the start of the interview Express satisfaction with the process the two of you have completed. Thank the client. Ask to either set up the next meeting or plan for the possibility of a future meeting if you need 3/20/2014 52 this to complete your plan

Health History Comprises of

1.

Demographic Data

2.
3. 4. 5.

Presenting Complaint
History of Presenting Complaint Past medical history (PMH) Drug History
a) Allergies / Immunisations

6. 7. 8.
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Social / Occupational history Family History Systemic enquiry /Review of system (ROS)
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Componet-1-History of Present Illness (HPI)

HPI

is a chronological story of what has been happening

Must get details of the problem, therefore must be systematic OLFQQAAT: onset, location, frequency, quality, quantity, aggravating factors, alleviating factors, associated symptoms, treatments tried (include all treatments - Rx, OTC, herbal, folk) COLDERRA Lots of systems find one that works, and use it

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Componet-1-History of Present Illness

Use

whatever system works for you, but use a system (OLFQQAAT, PQRST, pain intensity scales, etc)
Pain, quality/quantity, radiation, setting, timing Rate pain from 1 to 10 Use age appropriate tools (faces)

Culturally

appropriate care

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Component-2

Past Medical History

Drug History
Allergies Tetanus and immunisation for children

Family History where relevant . GENOGRAM Social History

Occupation, hobbies, hand dominance, drugs

CONSIDER Systemic Enquiry necessary ?

Clarification with patient / third party may be necessary
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to ensure correct information

Components 3 Review of System (ROS)

Gastrointestinal Tract Resp Respiratory System CVS Cardiovascular System Uro Urological System Neuro Neurological System Loco Locomotor System
GIT

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In the following examples which data is Subjective and which one is Objective?
Example 1: Mrs. G is an older white female, de-conditioned, pleasant, and cooperative. BP 160/80, HR 96 and regular, respiratory rate 24, afebrile. Example2: Mrs. G is a 54-year-old ,hairdresser who reports pressure over her left chest like an elephant sitting there, which goes into her left neck and arm.
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Genogram

Peer Group Activity

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Documentation
Documentation

forms as per agency

Use

of standardized nursing admission assessment forms

Combines health history and physical assessment

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Principles of documentation

Write notes.

Attention to detail
Information Not Recorded = Information Lost

Be relevant

Apply Structure
Apply chronological order of events

Abbreviations

When a mistake is made

Cross it out with a single line, initial and date

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Method of Documentation
Date

and identifying data - name, age, sex, race, place of birth (if pertinent), marital status, occupation, religion Source and reliability of history Chief complaint = reason for visit (succinct) HPI - the long version of the CC (OLFQQAAT) PMH - general health, childhood illness, adult illnesses, psychiatric illnesses, injuries, hospitalizations, surgery, immunizations, habits, allergies
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Cont
FH

- age and health of parents and siblings or cause of death (genogram); HTN, DM, CVD, Ca, HA, arthritis, addictions ROS (subjective head-to-toe review)
General - recent wt. change, fatigue, fever Skin - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nails Eyes - change in vision, floaters, glasses, HA, pain

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Documentation of ROS
Ears - pain, loss of hearing, vertigo, ringing, discharge, infections Nose and sinuses - frequent colds, congestion, HA, nosebleed Mouth and throat - condition of teeth and gums, last dental visit, hoarseness, frequent sore throats Neck - lumps, stiffness, goiter Breasts - lumps, pain, discharge, BSE

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Cont
Respiratory - cough, sputum, wheezing, asthma, COPD, last PPD, last CXR, smoking history (can do here, or with habits) Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease <50 yrs of age GI - problems swallowing, heartburn, vomiting, bowel habits, pain, jaundice, bowel habits Urinary - frequency, incontinence, pain, burning, hesitancy, nocturia, polyuria

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Cont
Genitalia - lesions, discharge, sexual orientation, sexual function, menstrual history, contraception, pregnancy history, TSE Peripheral vascular - intermittent claudication, varicose veins, blood clots. MS - muscle or joint pain, redness, stiffness, warmth, swelling, family history Neuro - fainting, blackout, seizures, weakness

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Cont

Endocrine - sweats, skin change, heat or cold intolerance, excessive thirst (polydipsia), excessive urination (polyuria), weight change, menstrual changes Psychiatric - mental illness, thoughts of harming self or others
All

of ROS is subjective; PE is objective

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Lymph nodes

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Landmark for Lung auscultation

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Lung Auscultation

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Breast Examination

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4 Abdomen quadrants

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9 Abdomen Regions

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Important Tests/Signs
Homans sign Trousseaus sign Romberg' test Weber, Renne & whisper test Phalen test Murphy sign Tactile Fremitus Diaphragmatic excursion
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Cont
Babinski

Plantar Reflex Murphy sing Rebound Tenderness Costovertebral Tenderness Shifting Dullness Psoas Sign Obturator Sign Brudzinski sign
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Cont
Visual

acuity (Snellen Chart) Visual field/confrontation Corneal reflex Extra occular movement (EOMs)

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Growth Chart
Use

growth chart pertinent to specific age & gender to assess the normal growth and development of a child. Best indicator for the growth milestone of infant and children. Easy to use and interpret.

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Anthropometric Measurements

Height Weight Head circumference (children) Upper arm measurement Skin fold BMI

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Height and weight measurement

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Head circumference
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Triceps skin fold

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BMI
The body-mass index (BMI) is calculated by dividing weight (in kg) by the square of height (in meters). A BMI greater than 25 may indicates overweight, while a BMI greater than 30 generally indicates obesity.

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Cont
A BMI of 27.8 for men and 27.3 for women is the cutoff point for obesity. Age Normal BMI 45 to 54 years 22 to 27 55 to 65 years 23 to 28 Over 65 years 24 to 29

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Men
<20.7 20.7 to 26.4 26.4 to 27.8 27.8 to 31.1 31.1 to 45.4 > 45.4

Women
<19.1 19.1 to 25.8 25.8 to 27.3 27.3 to 32.2 32.3 to 44.8 > 44.8 Underweight. Normal, very low risk Marginally overweight, some risk Overweight, moderate risk Severe overweight, high risk Morbid obesity, very high

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References
Bates, B.(1991) A guide to physical examination and history taking (5th ed).Philadelphia: J.B.Lippincott World Wide Page, Nursing Assessment Retrieved from www.http. Google .com on July 12, 2010

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