Advanced Health Assessment

1
Advanced Health Assessment

• Heather Hull, ARNP, PNP
• Lesson 1

2
Welcome

• This theory course has been previously offered
  both in traditional classroom interactive
  television formats..
• The theory course is now being offered in a web
  based format.
• This web based course is accompanied by a lab
  section, which is offered on the campus site.

3
New Technology

• Course materials are offered online
• Lecture notes outlines
• PowerPoint outlines
• CD-ROM lecture presentations with video streaming

4
Questions?

• Contact me numbers addresses in syllabus
  Course Description Faculty
• Discussion board will also be used for
  communication
• I will return your calls messages ASAP
• Scheduled office hours vary each semester posted
  in the Faculty section

5
Graduate Program Questions

• Contact Graduate Program Secretary
• Lori Griswold
• Her contact numbers are listed in the syllabus,
  Faculty section

6
Class Schedule

• The course is designed for one semester (8 or 16
  weeks)
• Sixteen lessons
• Lesson and lab sequence is concurrent
• Lab schedules are individual for each campus site

7
University Sites

• The class originates from Wichita State
  University
• School of Nursing
• Media Resource Center

8
Web Address

• http//nursing.twsu.edu/advhealth
• Course Home
• Overview
• Discussion
• Resources
• Lessons
• Instructor

9
Major University Sites

• Wichita State University (WSU)
• Kansas University Medical Center (KUMC)
• Fort Hays State University (FHSU)
• Pittsburg State University (PSU)

10
Exams

• Two multiple choice exams
• Mid-term
• Final
• Scheduled proctored at each site

11
Exams Material Covered

• Mid-Term Material discussed during first part of
  course
• Final Material discussed during second part of
  course not comprehensive exam for all course
  material

12
Advanced Health Assessment Theory Course 2
Credit Hours

• The focus of theory course over-all aspects of
  health assessment, with emphasis on
  differentiating abnormal from normal findings,
  common differential diagnosis
• We will be looking for Horses not Zebras of
  differential diagnosis

13
Advanced Health Assessment Lab Course 1 Credit
Hour

• Lab course is complimentary to theory course.
• Focus is more on technical aspects of conducting
  complete health assessments

14
Major Course Objectives Assessment Across the
Lifespan

• Health History
• Communication Skills
• Physical Assessment
• Documentation
• Differential Diagnosis

15
History

• Collect interpret data related to the health
  history, chief complaint history of the present
  illness
• Comprehensive history essential for establishing
  diagnosis (at least 80 of the time)

16
Communication Skills

• Analyze communication methods for obtaining the
  health history
• Effective communication styles interview
  techniques important elements for obtaining
  historical data setting tone for therapeutic
  relationships

17
Physical Assessment

• Differentiate between variations of normal
  abnormal assessment data
• Differential Diagnosis distinguishing abnormal
  from normal findings in 3 major areas of
  assessment
• History
• Physical Exam
• Laboratory Data Diagnostic Tests

18
Document Assessment Findings

• Accurate, systematic documentation, using
  standardized formats
• Promotes continuity of care follow-up
• Clarifies communication referral requests
  amongst professionals,
• Provides accurate records for medico legal
  purposes

19
Differential Diagnosis

• Analyze interpret data gathered during physical
  assessment
• Focus critical evaluation of assessment data
  utilizing standard criteria for differential
  diagnosis of common health problems. Physical
  assessments will be practiced in lab.

20
References

• Lecture notes CD-ROM presentations
• Required textbooks
• Optional References
• Library-Building suggestions
• Web sites

21
Required Textbooks

• Swartz, Mark H. (1998) The Textbook of Physical
  Diagnosis History and Physical Examination, 3rd
  Edition, Philadelphia W B Saunders (ISBN
  0-7261-7514-X)
• Swartz, Mark H. (1998) Pocket Companion to
  Textbook of Physical Diagnosis, 3rd Edition,
  Philadelphia W B Saunders (ISBN 0-7216-7517-4)

22
Resources

• Audiovisual resources available at WSU
• Related links of interest
• CD-ROM information

23
Grade

• Health History 20
• Audio-taped interview
• Dictation
• Written documentation

24
Grade

• Pediatric /or Geriatric Assessment 20
• Written documentation
• History
• Development - Function
• Physical Assessment

25
Grade

• Midterm Exam 25
• Multiple choice
• Scheduled, proctored

26
Grade

• Scheduled Assignments 10
• Each class
• Quizzes
• Extra videotapes
• Focus on major subjects

27
Grade

• Final Exam 25
• Last week of class
• Scheduled, proctored

28
Topical Outline

• Content
• Sequence

29
QuickView Course Calendar

• Content
• Sequence with dates
• Assignment due dates

30
Course Calendar Detail

• Lesson by number topic
• References
• Assignments

31
Major Assignments

• Health History outline grade guide
• Pediatric outline of focal points grade guide
• Geriatric outline of focal points grade guide

32
Health History Documentation

• Full, detailed history. The interview audio
  recording should not exceed 30 minutes the
  dictation should be limited to no more than 20
  minutes. A complete written documentation is to
  accompany the audio-tape, including a genogram
  and ecomap.

33
Health History Documentation

• The small audiocassettes for pocket recorders are
  preferred for recordings when possible.
• Exceeding the time limits late submission of
  the assignment are subject to grade deductions.

34
Pediatric Assessment

• A written documentation of a full assessment.
• Pediatric outlines in the syllabus may be
  followed, as a guideline.

35
Pediatric Assessment

• Major areas include
• History (genogram ecomap included)
• Development
• Measurements
• Physical Assessment
• Assessment interpretation health plan

36
Geriatric Assessment

• A written documentation of a full assessment.
• Geriatric outlines in the syllabus may be
  followed, as a guideline.

37
Geriatric Assessment

• Major areas include
• History
• Adult Development
• Functional Assessment
• Physical Assessment
• Assessment interpretation health plan

38
Questions?

• Some questions can be answered by instructors at
  each class site
• Feel free to contact me by phone, e-mail or on
  discussion board

39
Advanced Practice Nursing Role Change

• A public relations image may be important in a
  different way
• ARNPs become their own public relations agents
• Clients may choose an ARNP as their health care
  provider

40
Advanced Practice Nursing Role Change

• First impressions are significant factors
• ARNPs may need to market their services

41
Communication Issues

• Depersonalization of technology
• Health care as a business
• Patient confidence in ARNPs as health care
  providers
• Changes in collegial relationships with other
  professionals

42
Use of Descriptive Terminology

• Be specific in documentation communication with
  colleagues
• Use specific anatomy physiology terms
• Review anatomy as appropriate

43
Appearance

• ARNPs may not be in traditional roles or
  uniforms
• Attire needs to be neat, clean professional,
  fitting the clinical setting
• Care, friendly attitudes remain important

44
Appearance

• The professional image includes more than
  scrubs, including accessories, face, hands
  nails, shoes
• Student jackets name tags are to be worn for
  clinical practicums

45
Assessment Data Obtained From

• History
• Physical Assessment
• Laboratory other diagnostic tests

46
The SOAP Format

• A method of organizing assessment date
  treatment plan
• A standard summary format

47
S - Subjective

• Symptoms that the patient reports
• What the patient feels
• The history

48
O - Objective

• Signs that can be observed by the examiner
• Physical examination findings
• Laboratory data other diagnostic tests

49
A - Assessment

• Interpretation evaluation of data
• Differential diagnosis
• Medical diagnosis
• Problem list
• Needs to correlate with an insurance code

50
P - Plan

• Diagnostic studies
• Therapeutic regimen
• Patient education

51
Goals/Purpose of Health History Interview

• Establish a therapeutic relationship
• Gather pertinent information
• Evaluate the dynamics
• Formulate a treatment plan

52
Significant Points for Establishing Rapport

• Attitude friendly, relaxed, attentive
  interested
• Respectfulness concern, compassion,
  confidentiality awareness of patient comfort

53
Significant Points for Establishing Rapport

• Listening listen more, talk less, interrupt less
  focus on patients agenda (permit telling
  their story)
• Nonjudgmental attitude about values, beliefs
  behaviors

54
Significant Points for Establishing Rapport

• Matter-of-fact attitude that conveysyou can
  listen to human problems
• Environment quiet, private, comfortable

55
General Approaches

• Begin with open-ended questions
• Follow-up with direct questions for more specific
  information, as in ROS
• How come? or In what way? questions are
  easier to answer than Why? questions
• Introduce easiest subjects first, before
  sensitive or painful issues

56
General Approaches

• Avoid leading questions, which suggest a
  desired or expected answer
• Avoid questions leading to yes or no response
  (grade responses yield more information)
• Keep note-taking to essentials during the
  interview

57
Nonverbal Communication

• Active listening includes eye contact
  attentive posture
• Cultural orientation can be a guideline for
  interpersonal distance
• More than 5 feet impersonal space
• Less than 3 feet private space

58
Hindrances for Interviewer

• Fatigue
• Anxiety
• Bias
• Personal problems

59
Interview Stages

• Introductory establish rapport define
  expectations
• Working develop diagnostic hypothesis shared
  understanding of the problem
• Termination negotiate a plan close the
  interview

60
Approaches to the Interview

• Facilitation - encourage patient to say more
• Reflection - repeat patients words to encourage
  more detail
• Clarification - request or restate to clarify
  meaning
• Summarization - clarify or interpret what has
  been said

61
Approaches to the Interview

• Validation - recognize patients feelings, or
  experience
• Empathy - identify with patients feelings
• Support - premature reassurance can block
  communication
• Transitions - organize the flow or control
  rambling

62
Avoid Roadblocks

• Reassuring cliches, or stereotyped comments
  (false reassurance)
• Advice, especially if premature
• Approval/agreement or disapproval/disagreement
• Leading questions multiple questions

63
Avoid Roadblocks

• Interpreting
• Belittling or minimizing feelings or situations
• Acting defensively
• Abruptly changing the subject

64
Examples of Sensitive Topics

• Bias cultural differences
• Alcohol drugs
• Sexual history
• Domestic violence
• Mental illness
• Death dying
• Sexuality in clinician - client relationship

65
Special Situations

• Use of silence
• The talkative patient
• Patients with multiple symptoms
• Anxious patients
• Intoxicated patient
• Crying

66
Special Situations

• Confusing behaviors or histories
• Patients with limited intelligence
• Limited or no ability to read
• Language barriers
• Working with an Interpreter

67
Special Situations

• Patients with sensory deficits (hearing, vision)
• Talking with families or friends

68
Health History Format
69
Biographical Data

• Name, age, gender, family/marital status,
  religion, ethnic group
• Date, address, occupation, HEALTH INSURANCE
• Referral source, informant (reliability)
  (document)

70
Chief Complaint

• Purpose of visit
• Brief, 1-2 symptoms duration
• Pertinent

71
Present Illness (Problem) or Current Health
Status

• PI Illness or focused history
• Initial wellness history
• Interval history

72
PI Analysis of a Symptom

• Onset
• Characteristics
• Course since onset
• Pertinent negative information

73
PI Analysis of a Symptom

• When Last well Onset, duration chronological
  sequence of symptoms
• What Quality, intensity, related symptoms
• Where Location, range of symptoms

74
PI Analysis of a Symptom

• How Associated factors, communicable exposure
• Why Possible solutions, treatment,
  (aggravating/alleviating factors)

75
Alternative Methods for Present Illness PI
76
PI Bates

• Location
• Quality
• Quantity or severity
• Timing (onset, duration, frequency)
• Setting in which symptoms occur

77
PI Bates

• Factors that aggravate or relieve
• Associated manifestations
• Significant negatives (absence of symptoms that
  aid in differential diagnosis)

78
PI OLD CART

• O - Onset
• L - Location
• D - Duration
• C - Causative factors
• A - Associations
• R - Reactions to what has been tried
• T - Treatment

79
Past Medical History

• General health strength
• Major childhood adult illnesses
• Immunizations, dates reactions
• Surgery dates, hospital, Dx, complications
• Injuries
• Disability
• Medial-legal relationships

80
Past Medical History

• Medications current, past, Rx, OTC, herbs,
  alternative therapies
• Allergies medication, environment, food must
  include kind of reaction
• Transfusions reactions, date of units
• Emotional status mood disorders, psychiatric
  attention

81
Family History

• Family members with patients illness
• Age of parents age cause of death
• Age of siblings health status
• History of heart disease, hypertension, cancer,
  TB, diabetes, asthma, STDs, kidney, thyroid
  disease, psychiatric illness
• Major genetic disorders health problems

82
Family History

• Genogram to grandparents

83
Personal Psychosocial History

• Personal status birthplace, socioeconomic group,
  general life satisfaction, interests, sources of
  stress
• Habits diet, sleep, exercise, coffee, alcohol,
  drugs, tobacco
• Sexual History satisfaction. Concerns

84
Personal Psychosocial History

• Home conditions housing, economic conditions,
  safety
• Occupation work conditions or hazards
• Environment Travel, milk water supply
• Military record dates geographic travel
• Religious preference concerns health care

85
Review of Systems ROS

• Variations with age groups
• General fever, chills, sweats, weight changes,
  weakness, fatigue, heat/cold intolerance,
  bleeding, radiation

86
ROS Skin, Hair, Nails

• Rashes, lumps, sores, itching, color or texture
  changes, bruising, abnormal growths

87
ROS Head

• Headaches, injury, dizziness, syncope, LOC, stroke

88
ROS Eyes

• Vision/correction, blurring, diplopia, eye meds,
  trauma, redness, pain, glaucoma, cataracts,
  surgery

89
ROS Ears

• Hearing/loss, pain, discharge, infection,
  tinnitus, vertigo, dizziness

90
ROS Nose

• Smell, obstruction, injury, epistaxis, discharge,
  colds, allergies, sinus pain

91
ROS Mouth Throat

• Hoarseness, sore throats, gum problems, tooth
  abscess, dental care, sore tongue, taste

92
ROS Neck

• Lumps, swollen glands, goiter, pain, stiffness

93
ROS Respiratory

• Pain, dyspnea, SOB, cyanosis, wheezing, cough,
  sputum (color quantity), asthma, bronchitis,
  emphysema, pneumonia, TB/BCG, last CXR
  results, smoking

94
ROS Cardiovascular

• Chest pain/distress, palpitations, SOB, dyspnea,
  orthopnea (pillows needed), paroxsysmal nocturnal
  dyspnea, MI, rheumatic fever, murmur, exercise
  tolerance, ECG or other cardiac tests,
  hypertension, edema, leg pains/edema/coolness/hair
  loss, varicose veins, thrombosis ulcers

95
ROS Gastrointestinal

• Appetite, digestion intolerance, heartburn, N
  V, hematomesis, bowel irregularity, stool
  appearance, flatulence/belching, hemorrhoids,
  jaundice, ulcer, gallstones, abdominal
  enlargement, previous X-ray

96
ROS Endocrine

• Thyroid enlargement/tenderness, heat/cold
  intolerance, unexplained weight change, diabetes
  S/S, striae

97
ROS Male Reproductive

• Puberty onset, erections, emissions, testicular
  pain or masses, hernias, lesions/discharges,
  libido, sexual activity, contraception,
  infertility, prostate, STDs, STE

98
ROS Female Reproductive

• Menses Menarche, regularity, duration amount
  of flow, dysmenorrhea, LMP, last Pap AND RESULTS,
  sexual activity, libido, contraception,
  fertility, menopause, discharge, itching, sores,
  STDs
• Gravida/para SAB, TAB, pregnancies, duration,
  births, problems

99
ROS Breast

• Pain, tenderness, discharge, lumps, galactorrhea,
  mammogram AND RESULTS, SBE

100
ROS Genitourinary

• Dysuria, pain, frequency, urgency, nocturia,
  hematuria, stress incontinence, hernias, STDs

101
ROS Musculoskeletal

• Joint stiffness, pain, motion restriction,
  weakness, paresthesias, cramps, deformities, back
  problems

102
ROS Hematologic

• Anemia, lymph swelling, bruising/petichiae,
  fatigue, blood dyscrasia, transfusion, radiation

103
ROS Neurologic

• CNS disease, syncope, blackouts, dizziness,
  numbness, tingling, seizures, weakness/paralysis,
  tremors, coordination, memory, cognition,
  headaches, head injury

104
ROS Psychiatric

• Depression, mood changes, difficulty
  concentrating, nervousness, tension, suicidal
  thoughts, irritability, sleep disturbances

105
Concluding Questions

• Is there anything else that you think would be
  important for me to know?
• Offer the opportunity for additions or
  corrections
• Clarification of understanding

106
Analysis of Data

• Identify abnormal findings
• Cluster findings into logical groups
• Localize findings anatomically

107
Analysis of Data

• Localize findings into probable process
• Pathological - such as inflammatory, metabolic,
  degenerative
• Pathophysiological - mal functioning, such as
  congestive heart failure
• Psychopathological - behavioral, mood disorder,
  though process disturbance

108
Analysis of Data

• Construct a working hypothesis from the central
  findings
• Match the findings with all causative conditions
  you know could be associated
• Eliminate hypothesis that fail to explain the
  findings

109
Analysis of Data

• Weigh the probabilities select the most likely
  diagnosis
• Consider life-threatening treatable situations
• Test the hypothesis or obtain further studies
• Establish a working definition of the problem

110
Consider Information Quality

• Reliability - how well an observation repeatedly
  give the same result
• Validity - a close agreement between an
  observation the best possible measure of
  reality
• Sensitivity - the proportion of people with a
  disease/condition who are positive for that
  disease on a given test (true positive)

111
Consider Information Quality

• Specificity - the proportion of people without
  the disease/condition who are negative on a given
  test (true negative)
• Predictive Value of Test - the characteristic
  that is most relevant to the clinical setting

112
Documentation of Data

• Permanent medical legal record of the patients
  health status treatment
• Record pertinent positive findings - abnormal
  findings
• Record pertinent negative findings - normal
  findings, or absence of abnormal findings

113
Physical Examination

• Inspection
• Palpation
• Percussion
• Auscultation
• Measurements

114
Inspection

• Observe for wellness-illness condition
• Identify degree of distress
• Look before you touch
• Provide comfortable, private conditions
• Provide adequate direct tangential lighting

115
Palpation

• Light palpation - gentle pressure, 1cm or 1/2 -
  3/4 inches deep
• Deep palpation - may use bimanual methods, 4 cm
  or 1/5 - 2 inches deep
• Palpate tender areas last

116
Palpation

• Sensitive areas of hand fingers
• Palmar area - discriminatory for touch
• Ulnar area - discriminatory for touch
• Dorsal area - discriminatory for temperature

117
Percussion Sounds Heard

• Tympany
• Hyperresonance
• Resonance
• Dullness
• Flattness

• Gastric bubble
• Emphysema of lung
• Healthy lung
• Liver
• Muscle

118
Auscultation

• Listening to sounds of lungs, heart, blood
  vessels abdominal viscera
• Ear
• Stethoscope
• Diaphragm is held firmly to skin, detects high
  frequency sounds
• Bell is held with light pressure, detects low
  frequency sounds

119
Anthropometric Measurements Vital Signs

• Height
• Weight
• Circumferences Head, Chest Abdomen, Extremities
• Temperature, Pulse, Respiration, Blood Pressure
• Vision Hearing Screening

120
Anthropometric Measurements Vital Signs

• Jugular Venous Distention
• Body Mass Index
• Skin fold thickness
• Goniometer measurements of joint mobility
• Waist to hip ratio