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Introduction to Advanced Health Assessment


Health care succeeds only with cooperation with other sectors. Improvement ... Asking a series of questions, one at a time. Offering multiple choices for answers ... – PowerPoint PPT presentation

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Title: Introduction to Advanced Health Assessment

Introduction to Advanced Health Assessment
  • Debbie King MSN, APRN, CFNP, CPNP
  • Fall 2009
  • Advanced Health Assessment
  • 7735

Healthy People 2010

Back Ground National health policy Originally
published as Health People 2000 in 1990 Response
to Growing Evidence that Health Promotion
worked (since the 70s) To the popular
Wellness Movement
Healthy People 2010
  • 1)Increase quality and years of healthy life
  • 2)Eliminate health disparities
  • Objectives
  • with twenty-eight focus areas
  • Leading Health Indicators
  • Physical Activity
  • Overweight /Obesity
  • Tobacco Use
  • Substance Abuse
  • Responsible Sexual Behavior
  • Mental Health
  • Injury and Violence
  • Environmental Quality
  • Immunizations
  • Access to Health Care

Healthy People 2010 28 Focus Areas
  • 1. Access to Quality Health Services2.
    Arthritis, Osteoporosis and Chronic Back
    Conditions3. Cancer4. Chronic Kidney Disease5.
    Diabetes6. Disability and Secondary
    Conditions7. Educational and Community-Based
    Programs8. Environmental Health9. Family
    Planning10. Food Safety11. Health
    Communication12. Heart Disease and Stroke13.
  • 14. Immunizations and Infectious Diseases
  • 15. Injury and Violence Prevention16. Maternal,
    Infant, and Child Health17. Medical Product
    Safety18. Mental Health and Mental Disorders19.
    Nutrition and Overweight20. Occupational Safety
    and Health21. Oral Health22. Physical Activity
    and Fitness23. Public Health Infrastructure24.
    Respiratory Diseases25. Sexually Transmitted
    Diseases26. Substance Abuse27. Tobacco Use28.
    Vision and Hearing

Nurse to Nurse Practitioner
  • Nurse

Nurse to Nurse Practitioner
  • NP

Ethical Role
  • Medical Ethics
  • Neither static nor simple
  • Does not provide answers
  • Does offer a disciplined approach to
  • Terms
  • Autonomy
  • Patients have the right to determine what is in
    their own best interest
  • Beneficence
  • Dictum that the clinician needs to do good
  • Nonmaleficence
  • first, do not harm
  • Confidentiality
  • Clinicians are obligated not to repeat what you
    learn from or know about a patient

Ethical Role
  • The Tavistock Principles
  • Rights
  • To have health care
  • Balance
  • Between individual patient and the population
  • Comprehensiveness
  • Treat illness ,ease suffering, prevent disease
    and promote health
  • Cooperation
  • Health care succeeds only with cooperation with
    other sectors
  • Improvement
  • Serious and continuing responsibility
  • Safety
  • Do no harm
  • Openness
  • Open, honest and trustworthily in health care

  • Professional Dress to enhance openness
  • Well groomed
  • Modest dress
  • White short lab coat (except in Pediatrics-NO
  • Listening
  • Is the Key!

  • Establish Rapport
  • Elicit information
  • Providing information
  • Negotiation treatment plans
  • Counseling about disease preventions
  • Health People 2010

  • Techniques of Skilled Interviewing
  • Active listening
  • Guided questioning
  • Nonverbal communication
  • Empathetic responses
  • Validation
  • Reassurance
  • Partnering
  • Summarization
  • Transitions
  • Empowering the patient

  • Guided Questioning
  • Moving from open ended questions to focused
  • Questioning that elicits a graded response
  • Asking a series of questions, one at a time
  • Offering multiple choices for answers
  • Clarifying what the patient means
  • Encouraging with continuers
  • Echoing

The Intelligent Repose for Communication
  • Review the Chart before entering the room
  • Clarify your own mindset
  • Discreet note taking
  • Logical Question Order
  • Direct Non-leading Questioning
  • Confidence
  • Sit down when possible

Impedance to Communication
  • Curiosity about the provider
  • Anxiety
  • Silence
  • Depression
  • Crying
  • Manipulation
  • Intimacy
  • Compassionate moments
  • Seduction
  • Anger
  • Dissembling
  • Money

Tackling Sensitive Topics
  • Be Non-Judgmental
  • Use Specific Language
  • Be Aware of Your Own Bias
  • Orient Patient to Need for Sensitive Information

Interviewing Milestones
  • Getting ready
  • Learning about the patient
  • Building the relationship
  • Adapting your interview to situation
  • Sensitive topics that call for special skills
  • Societal aspects of interviewing

The Interview Process
  • Self Reflection-be open minded
  • Review the Medical Records in advance
  • Setting goals for the interview- balance what you
    expect and what the patient expects
  • Reviewing your clinical behavior and
    appearance-professional, unhurried, calm
  • Adjusting the environment-assure comfort
  • Taking notes-varies based on experience and the

Sequence of the interview
  • Greeting the patient and establish rapport
  • Establishing the agenda
  • Inviting the patients' story
  • Id and respond to emotional cues
  • Generating and testing diagnostic hypotheses
  • Creating a shared understanding of the problem
  • Negotiation a plan
  • Planning the follow up and closing

Medical Records
  • Should be Consistent
  • Well-Organized
  • Reflect the Assessment,
  • Decision Making Process
  • Interventions
  • Patients Response to Treatment

History and Exam
  • Comprehensive Assessment of history and exam
  • New patients and some yearly checkups, provides
    fundamental knowledge, strengthens relationship,
    IDs or rules out physical problems, provides
    baselines, develops proficiency in skills. A
    complete history is obtained and a head to toe
    exam is preformed
  • Focused or problem oriented Assessment of history
    and exam
  • Used for established patients with urgent care
    visits, addresses focused concerns, CC, HPI,
    restricted to a specific system IE cough- will
    listen to lungs/heart and look one system above
    and one below

SOAP info to be included on each patient
  • Demographics
  •         Initials (never use names for school
  •         DOB
  •         Age
  •         Sex
  •         Medical Record Number
  •         Insurance (if Applicable)

Elements of a Focused Assessment
  • Subjective Findings
  • chief complaint
  • history of present illness
  • pertinent health history and family history and
    social history
  • IE Chest pain ask pt does he smoke and family
    history for MI, ect
  • limited ROS just address they body systems
    mentioned in HPI
  • IE Headache- ask neuro questions and ENT
  • Objective Findings
  • Exam findings and pertinent negatives
  • Chart- normal heart sounds, normal pulses,
    normal CR, L-CTA, tenderness with palpation of
  • Assessment
  • Diagnosis
  • May include differential diagnosis
  • MI, GERD, Costochondritis
  • Plan
  • Management

  • Type of Patient Visit Determines How To Chart
  • Child Health Supervision
  • Sports Participation Examination
  • Acute Illness/ Urgent Care
  • Periodic Health Evaluation in Adults
  • Well Woman
  • Perinatal Evaluations

Skills to Taking a History
  • Provide Privacy
  • Do not waffle-be direct
  • Do not apologize for asking a question
  • Do not preach
  • Use language that is understandable
  • Do not push too hard
  • Document carefully, using the patients words
  • Use open ended questions
  • With introductions
  • With sensitive areas

Complete Health History
  • The following information is to included in every
    complete health history
  • Chief Complaint
  • History of present illness
  • Past medical history
  • Health maintenance
  • Family history
  • Personal and social history
  • Review of systems

Complete Health History
  • Chief Complaint
  • Here for a yearly physical, or new patient

Complete Health History
  • History of Present Illness
  • Reveal the patient's responses to his or her
    symptoms and what effect the illness has had on
    the patients life.
  • Remember-the data flow spontaneously from the
    patient, but the task of oral and written
    organizations is yours
  • Each symptom merits its own full description
  • See next slide for steps to follow in writing up
    the symptom

Seven Attributes of a Symptom
  • Location
  • Quality
  • Quantity or severity
  • Timing
  • Setting in which it occurs
  • Remitting or exacerbating factors
  • Associated manifestations

Complete Health History
  • Past medical history
  • Childhood illnesses
  • Chickenpox, measles, ECT
  • Adult illnesses
  • medical
  • surgical
  • OB/Gyn
  • Psychiatric
  • Health maintenance
  • immunizations
  • paps
  • occult blood
  • cholesterol screening

Complete Health History
  • Family Medical History
  • Blood Relations
  • 2 to 3 Generations- include parents,
    grandparents, siblings, children and
  • conditions- Genetic Disorders, HTN, CAD,
    elevated cholesterol, stroke, DM, ECT.
  • Genogram
  • a pedigree of at least 3 generations
  • use common pedigree symbols
  • ex male is square and female is circle, ECT
  • http//
  • page 32 in Bates 10th ed.

Tools to Enhance the History
  • Suicide
  • Clues
  • Ask
  • Alcohol
  • CAGE
  • GRAFFT-adolescents
  • TACE
  • Domestic Violence
  • HITS
  • Spiritual
  • FICA

Complete Health History
  • Social History
  • Personal status/Married
  • General life info/hobbies
  • Education Stress level
  • Habits/Patterns
  • nutrition sleep drugs
  • Exercise
  • Tobacco-alcohol
  • regular self-exams
  • herbal remedies
  • Sexual history
  • Home conditions
  • Occupation/Military Hx
  • Travel/exposures
  • Religious preference
  • Cultural requirements
  • Cost of care

Complete Health History
  • Review of Systems page 10 of 10th Ed. Bates
  • In a Complete HP the Questions Asked are
    Comprehensive and Include All Systems and Serve
    as a Sort of Screen
  • In an Acute or Follow-Up Visit the Questions are
    More Focused on the Problem at Hand or
    Characteristics Unique to the Patient. Reported
    in the subjective section of the SOAP
  • Constitutional Gastrointestinal
  • Diet Endocrine
  • Females Males
  • Genitourinary Musculoskeletal
  • Neurologic Psychiatric
  • Integument Head/Neck-HEENT
  • Lymph Nodes Chest and Lungs
  • Breast Heart
  • Peripheral vasculature
  • Hematologic

Symptom vs Sign
  • The word symptom refers to what the patient
    feels. Symptoms are described by the patient to
    clarify the nature of the illness.
  • Example Its hard to breath
  • The word sign refers to that which the examiner
    finds. Signs can be observed and quantified
  • Example wheezing

Subjective vs Objective Data
  • Subjective data
  • What the patient tells you
  • Includes the chief complaint through the review
    of systems
  • Objective data
  • What you detect during the exam
  • Includes all physical examination findings

  • Subjective information gathered from the
    patient (or family)
  • Chief Complaint CC
  • History of Present Illness HPI
  • Past medical history
  • Personal and Social History
  • Family History
  • Review of systems

  • Objective- information directly observed by the
  • Examination- divided into body areas for charting
  • See
  • Hear
  • Smell
  • Touch
  • Vital signs
  • Previous lab or tests results
  • Charting of the findings
  • Normal findings-standard charting terms!!
  • Examples of terms used for charting are located
    in each chapter . IE- HEENT page 245 10th ED
  • Abnormal findings include location, grading,

  • Assessment
  • Your interpretations and conclusions
  • Make a list of differential diagnosis
  • Your rational
  • Findings that back up your diagnosis from your
  • Include positive findings as well as pertinent
    negative findings
  • Diagnostic possibilities
  • Tests needed to confirm or disprove your
  • Present and anticipated problems
  • explain and plan for current and possible future

  • Plan
  • Includes all plans to be completed now and later
  • A separate plan must be written for each
  • Areas to include
  • Explanation of the diagnosis to the
  • Diagnostic testing or consultation
  • Therapeutic modalities
  • Referrals
  • Education for the patient/family- includes
  • Anticipatory Guidance
  • The rationale for the diagnosis may be included
    here and the problem list is updated now

  • Problem List
  • Summarizes the patients problems
  • List the most active and serious first
  • Record their date of onset
  • Allows other members of the health care team to
    review the patients history at glance
  • Problem lists with too many relatively
    insignificant items diminish the value of the
  • If minor symptoms increase later they may then be
    added to the problem list
  • Be sure and include Health Maintenance on your
    problem lists

Preparing for the physical exam
  • Reflect on your approach to the patient
  • ID your self as a student!!
  • Beginners take longer
  • Go back if you forgot something
  • Explain why you are taking longer on a heart
    exam- you are new
  • Remember the patient may also be nervous
  • Be thorough but do not waste time
  • Exam each body area, but assess the whole patient
    at all times, look for signs of stress, ECT
  • AVOID interpreting your findings to the patient
    during the first semester!!

Preparing for the physical exam
  • Check your equipment
  • Ophthalmoscope/otoscope
  • Penlight
  • Tongue depressors
  • Ruler
  • Thermometer
  • Watch
  • BP cuff
  • Stethoscope
  • Reflex hammer
  • Tuning fork
  • Objects for two point discrimination and sharp/
    dull sensation
  • Object for stereognosis
  • Cotton
  • Paper and pen
  • Odorous substance

Preparing for the physical exam
  • Adjust the lighting and the environment
  • Set the stage
  • Adjust the bed
  • Good lighting
  • Tangential lighting is best for inspecting areas
    such as
  • Jugular venous pulse, thyroid gland, apical
    impulse of the heart

Preparing for the physical exam
  • Make the patient comfortable
  • Show concern for privacy and modesty
  • Close doors
  • Draw curtains
  • Draping with gown or sheet
  • Visualize only one body area at a time
  • Describe what you are going to do next in a
    courteous and clear manner

Preparing for the physical exam
  • Choose the sequence of exam
  • Maximize the patients comfort
  • Avoid unnecessary position changes
  • Enhance clinical efficiency
  • Move from head to toe
  • Develop your own sequence

General PE Techniques
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

Visual Inspection
  • Begins as the provider enters the room
  • Imparts a sense of attendance of the
    practitioner to the patient
  • Useful in judging the patients demeanor and
    resolving conflicts between what you hear and
    what you see
  • Useful in judging how the patient perceives the
  • Focus and pay attention to details
  • Chart observations directly
  • Respect the patients sense of modesty but dont
    sacrifice accuracy out of a misguided sense of

Olfactory Inspection
  • Begins as the provider enters the room
  • Useful in judging the patients attention to
  • Chart observations directly
  • Examples of Importance
  • Strep
  • BV
  • FB

Smell the Breath
  • Examples
  • Burned rope is marijuana
  • Halitosis is amphetamine
  • Bitter almond is cyanide
  • Metallic is iodine
  • Fruity is ethyl alcohol, phenol
  • Clorets sign is to cover up telltale orders

  • Gathering information by touch
  • Some parts of the hand are better for certain
  • dorsum to judge temperature, palmar surface of
    fingers to feel masses, finger tips to feel
    textures, pulses
  • It usually begins the exam and therefore is the
    point that we invade the patients space
  • Start with light palpation, proceed with deep
    palpation. Gentle approach but dont sacrifice
    accuracy with a cursory exam

  • Sounds produced when the fingers strike the
  • Density affects the resulting sounds-
  • denser tissues muffle sounds
  • lighter or hollow tissues have louder percussive
  • The quality of the sound is best appreciated by
    percussing over a large area and listening the
    difference in the sounds as you move
  • The change in quality of sound is better
    appreciated when moving from resonant to dull
    than when moving from dull to resonant
  • Accomplished by wrist action tapping of the tip
    of middle finger of one hand onto the middle
    finger of another hand that lies flat on the body

(No Transcript)
  • Listening
  • Use a good stethoscope
  • Have a quite environment
  • The stethoscope is applied to bare skin
  • Pick a quality and focus on it
  • Pitch Duration
  • Intensity Quality

Tools for the exam
  • Ophthalmoscope
  • Start with the light reflex, use the lighting in
    the room, make sure the ceiling light reflects in
    the same part of the eye bilaterally
  • Next examine the red reflex, stand one foot away
    look at both eyes at once and compare the
    redness, they should be the shade of red
  • To exam the optic disk, cup, vessels examine
    the patients right eye with your right eye,
    patients left eye with your left eye
  • Place one hand on the patients head
  • Get the red reflex and continue to move closer to
    the patients head until you can see vessels. You
    can then follow vessels to the optic disk

Tools for the exam
  • Vision Screening Tools

Snellen Charts Test Far Visual Acuity Near
Vision Charts Test Near Visual Acuity Amsler
Grids Test for Retinal Macular
Problems Read in the Text on How to
Administer These Tests
Tools for the exam
  • Otoscope
  • Use biggest speculum that can be comfortably
    inserted into the patients ear, and another one
    for the nares
  • The glass window is the magnifying lens and can
    be moved aside to allow for a cerumen spoon to be
  • The pneumatic attachment is used to evaluate the
    tympanic membrane ability to move
  • (hardest tool to learn to use)

Tools for the exam
  • Tuning Fork
  • Used to test hearing and vibratory sense
  • Tap gently onto the heel of the hand to activate

Tools for the exam
  • Reflex Hammer
  • Used to test deep tendon reflexes
  • Wrist snap with hammer loosely held so that it
    can pivot

Examination Sequence
  • General inspection
  • Begins with entering the room for introductions
  • Look for signs of distress, facial expression,
    odors, posture, hygiene
  • Preparation
  • Undressing/gowning
  • Measurements- usually already done and charted by
  • Seat patient to examine
  • Begin with general survey
  • Head and Face
  • Eyes Mouth and pharynx
  • Ears Neck
  • Nose Upper extremities

Examination Sequence
  • Patient Seated, Back Exposed
  • Back and posterior chest, including Skin
  • Lungs
  • Patient Seated, Chest Exposed
  • Anterior Chest, Lungs, Heart, Skin
  • Breasts
  • Patient reclining 45 degrees
  • Chest
  • Jugular venous pulsation
  • Breast
  • Heart

Examination Sequence
  • Patient Supine, Abdomen Exposed
  • Abdomen
  • Inguinal area
  • External genitalia-deferred
  • Patient Supine, Legs Exposed
  • Feet and legs
  • Hips

Examination Sequence
  • Patient Sitting, Lap Draped
  • Musculoskeletal
  • Neurologic
  • Patient Standing
  • Spine
  • Neurologic
  • Hernias-deferred for our video

Combining the History and the Physical Exam
  • Clinical reasoning
  • Identify abnormal findings
  • symptoms and signs
  • Localize findings anatomically
  • Chest pain can be cardiac or musculoskeletal
  • Interpret findings in terms of probable process
  • Pathologic process vs pathophysiologic vs
  • Make hypotheses about the nature of the problem
  • Using evidence based decision making
  • Test the hypotheses and establish a working
  • Further history or further physical exam or lab
    and x-ray
  • Develop a plan agreeable to the patient
  • Create a plan for each problem, include the
    patient in this process

Combining the History and the Physical Exam
  • Differential Diagnosis
  • Critical thinking allows you consider and discard
    a variety of possible diagnoses
  • Diagnoses
  • Workup to prove the diagnoses and to disprove the
  • Patho of the diagnosis
  • Management
  • Treatments required- therapeutic and medicinal
  • Education
  • Referrals
  • Follow-up/Monitoring progress
  • Prognosis

Differential Diagnosis
  • The skill of clinical reasoning
  • Generate and test diagnostic hypotheses
  • Knowing what data you are listening for and
    asking for further information- will become
  • For example- the CC is sore throat
  • Start with open ended questions
  • Describe how your throat feels
  • Then more specific questions to answer the 7
  • (Refer to list for all 7)What makes it
  • Last, the yes-no questions or pertinent positives
    and negatives
  • Do you also have a headache or stomach
  • Have you been coughing with this illness- yes-not

Documentation of the History and Physical
  • Charting
  • If you do not chart it you did not do it
  • Legal document
  • Appropriate medical terminology
  • Tradition organized style
  • Problem-oriented medical record (POMR)
  • SOAP
  • PDAs and Palm
  • Resource in recording process

Checklist for a clear and accurate record
  • Clear order
  • Clear headings
  • Organize with indentations and spacing
  • Arrange the Present illness in chronologic order
  • Dated included contributes to the Assessment
  • Spell out the supporting evidence including both
    positive and negative information
  • Describe pertinent negatives specifically
  • Example lady with bruises- note no injury or
  • Avoid over generalizations or omission
  • Not recorded not done
  • Avoid too much detail
  • Avoid repetition or redundancy
  • Omit negative findings unless they relate
    directly to complaints

Vital Signs and Anthropometrics
  • Pulse
  • Blood Pressure
  • Respiration
  • Temperature
  • Height
  • Weight
  • Ideal Body Weight
  • Body Mass Index
  • Waist to Hip Ratio

The Pulse
  • Assess Rate and Amplitude
  • Assess at a Variety of Locations
  • Examples of Importance
  • Atrial Fibrillation
  • Hypothyroid
  • PVCs

Language Used To Describe Pulses
  • Regular Rate and Rhythm
  • Graded
  • 0 Absent
  • 1 Diminished, Palpable only with
  • 2 Normal, Expected
  • 3 Full, Increased from Expected
  • 4 Bounding

  • Assess
  • Rate
  • Rhythm
  • Effort
  • Use of Accessory Muscle
  • Examples of Importance
  • COPD
  • Bronchiolitis
  • Rib Fracture

Language Used To DescribeRespiration
  • Dyspnea
  • Orthopnea
  • Tachypnea
  • Hyperpnea
  • Hypopnea
  • Apnea
  • Stridor
  • Retractions
  • Periodic Breathing
  • Prolonged Respirations

Blood Pressure
  • Assess
  • Diastolic
  • Systolic
  • Examples of Importance
  • HTN
  • Coarct
  • Hypotension
  • Emotional state
  • JNCVIII BP Classification for people over 18
    years of age
  • Normal is lt120/ lt80
  • Prehypertensive is 120-139/80-90
  • Hypertension stage one is 140-159/90-99
  • Hypertensive state two is greater than or equal
    to (for both numbers) 160/100

  • Assess
  • Core- oral, rectal
  • Site-skin, bone
  • Assess at a variety of sites
  • Examples of Importance
  • Cellulites
  • Fever
  • Osteomyelitis
  • Heat Exhaustion

  • Assess
  • Rate in Infant
  • Amplitude
  • Examples of Importance
  • Developmental Issue
  • Dwarfism
  • Gigantism
  • Height to Weight Ratio

  • Assess
  • Rate of gain in infants
  • Amplitude
  • Examples of Importance
  • FTT
  • Weight to Height Mismatch
  • CHF
  • Nephrotic syndrome

Ideal Body Weight
  • A patients Ideal Body Weight can be determined
    by chart
  • Obesity is defined as someone 20 over IBW
  • Body Mass Index is an approximation of body fat
  • BMI body weight (kg) ? height (m)2
  • Desired BMI is given as lt 25. Grade 1 obesity
    is 25 - 30. Grade 2 obesity is gt 30
  • Waist to Hip Ratio is useful is determining
    relative risk of Type II DM, Hyperinsulinemia,
    Hypertension, Hyperlipidemia, and CAD. Apple
    Shape is associated with greater risk than Pear
    Shape. W2HR waist ? hip

Hip to Waist Ratio
  • Waist to Hip Ratio is useful is determining
    relative risk of Type II DM, Hyperinsulinemia,
    Hypertension, Hyperlipidemia, and CAD. Apple
    Shape is associated with greater risk than Pear
  • W2HR waist ? hip

  • Pain
  • An unpleasant sensory and emotional experience
  • Associated with tissue damage
  • Described in terms of such damage or both
  • The experience of pain is complex and
  • Involves sensory, emotional, and cognitive
    processing, but may lack a specific physical
  • Types of Pain
  • Nociceptive or somatic
  • Neuropathic
  • Psychogenic and idiopathic

Pain Assessment
  • Use a comprehensive approach to pain assessment
  • Listen to the patients description
  • Accept the self report
  • Assess for
  • Location
  • Severity
  • Associated Features- use the 7 attributes of a
  • Attempted Treatment
  • Health Disparities

Pain Treatments
  • Managements
  • Requires knowledge of
  • Nonopioid, opioid, and adjuvant analgesics and
    modalities of behavior a and physical therapy
  • Would need a whole semester to learn this content
  • Effects of treatment should look for the
    following outcomes
  • Analgesia
  • Activities of daily living
  • Adverse effects
  • Aberrant drug-related behaviors