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UNIT 6 IN THIS UNIT • General Assessment • Use expression for collecting demographic data • Use questions to collect current and past health-illness data

1 General Assessment Direction: ❖ A comprehensive admission assessment, also referred to as an initial database, nursing history, or nursing assessment is completed when the client is admitted to the nursing unit. ❖ These forms can be organized according to body systems, functional abilities, health problems and risks, nursing model, or type of health care setting. ❖ Complete the nursing assessment form which include vital signs, height, weight, allergies, drug, health history, a list of his belongings and those sent home, the result of your physical assessment and a record of specimens collected for laboratory tests. ❖ The basic components of the complete health history (other than biographical information) include: ♦ Chief complaint ♦ Present health status ♦ Past health history ♦ Current lifestyle ♦ Psychosocial status ♦ Family history ♦ Physical assessment (review of system/head to toe) Common Terminology Provocative : What makes the symptom(s) better or worse? What have you done to get relief? Quality : Describe the symptom(s). When did it begin? How long does it last? Region : Where is it? Does it radiate? Does it spread? Severity : How bad is it? On a scale of 1-10, (10 being the worst) Timing : What other symptoms occur with it? Does it occur in association with something else? When did the symptom begin? How long does it last? How often does it occur? Is it sudden or gradual?

Vocabulary : 1. Surname 2. Next of kin 3. Assest 4. Assessment

: ……………….. : ……………..… : ……………….. : ………………

2 Use expression for collecting demographic data 1. Implementation step Study these expression to initiate communication. Explaining what you are going to to immediately. • It is time for me to ………… • I just want to …………. • I would like to ……….. • I am going to ………. • I reed to …………. 2. Question to collect demographic data elements 
 Study and practice these useful expressions Questions to ask Name Age Address

What is your name ? What is your complete name ? What is your sure name ? How old are you ?

Marital status

What is your address ? Where do you live ? Your phone number, please ? What is your phone number ? Do you have a mobile phone number ? Are you married ?

Health insurance

Do you have any health insurance ?

Occupation & tittle

What is your occupation ? Do you have any academic tittle ? What is your title ? What do you do ? Who is your next of kin ? What brings you in this hospital ? Who sends you to this hospital ? What makes you come to this hospital ?

Phone

Next of kin Reason for contact *)

*it is reason that make you come to the hospital, it can be a chief complain, medical check up.

3 Use questions to collect current and past health-illness data CURRENT HEALTH STATUS • What do you think about your health ? • Would you tell me about your health condition recently ? Sample of patient’s response : “ I am usually healthy, have usual cold and have to take medicine for high blood pressure” ELIMINATION PATTERN • Would you tell me about your ....... ? • Do you have any problem with your ....... ? (bowel movement, waterworks) • Is the stool formed or loosed ?

Assessment Step : Asking Common Communicable Disease • Have you ever had + a kind of disease ....... ? Response : Yes, I have / no, I haven’t • How old are you when you got it ? Response : I was about ..... years old • Are you allergic to ....... (a certain food/medication) Example : Are you allergic to antibiotic/penicillin Kinds of disease : measles, mumps, chicken pox, rubella, rheumatic, fever, diphtheria, scarlet fever, polio, tuberculosis • Have you ever been immunized againts + (a kind of disease) ? • Have you ever got ....... + (a kind of disease) ....... immunizations ? Example : Have you ever got polio immunizations ?

4 Patient Assessment

Subjective data : what the patient tells the nurse, it is the patient’s perception. (i.e. description of pain, perceptions, feelings or experiences). Objective data : the nurse’s observations that are measurable and verifiable. observations such as vital signs, odours, redness of a wound, hostile behaviour, and laboratory and medical imaging findings Correlation of subjective and objective data: e.g. is shortness of breath supported by decreased breath sounds on auscultation or dullness to percussion? Subjective

Objective

“I feel dizzy”

BP 90/60 mmHg, pulse 100

“My bladder never seems empty”

Voids 100-150mls/void q 1-2 h.

“I am too fat”

14 yr. old ♀ 150 cm (5’2”) 36 Kg (80 lbs)

1. Inspection When you are using inspection, you are looking for things you can observe with your eyes, ears or nose. Examples of things you may inspect are skin color, location of lesions, bruises or rash, symmetry, size of body parts and abnormal findings, sounds, and odors. 2. Palpation Involve the use of the sense of touch. Giving gentle pressure or deep pressure using your hand is the main activity of palpation. Palpation allows you to assess for texture, tenderness, temperature, moisture, pulsations, masses and internal organs. 3. Percussion Involve tapping the body with fingertips to evaluate the size, borders and consistency of body organs and discover fluids in body cavities. 4. Auscultation Listening to sounds produced by the body

Mention what activity do you for each case listed below No

Activity

Technique

1

Press the distal part of the middle finger of your non-dominant hand firmly on the body part

2

Asking patient to stand up to find wheter there is scoliosis or not

3

Testing deep tendon reflexes using hammer

4

Enlargement may indicate a mass

5

Preparing a good lighting, then he observe the body parts

6

Systemic colour changes

7

To know over the aortic, pulmonic, mitral, and tricuspid valves and over Erb’s point

8

Lightly then deeply noting any muscle guarding, rigidity, masses or tenderness

9

Examining patient’s respiratory

10

Looking for the condition of mouth and throat

11

Pressing her middle finger of non-dominant hand firmly against the patients back. With palm and fingers remaining off the skin, the tip of the middle finger of the dominant hand strikes the other, using quick, sharp stroke

12

Observing the color of the eye

13

Observing the movement of air through the lungs

14

Checking the tender areas with her hand

15

Pressing abdomen deeply to check the condition of underlying organ

What kind of examination technique ?

…………………………………..

…………………………………

………………………………….

…………………………………

5 Patient Record PATIENT RECORD Surname : Grady First name DOB : 2.3.50 Gender Occupation : Retired Marital Stastus : Widowed Place of birth : Miami Next of kin : Son Contact no. : 07765 432178 Smoking intake : n/a Alcohol intake : 30 units per week Reason for admission : Snake bite Medical hsitory : High blood pressure Allergies : None GP : Dr. Parkinson, Central Surgery

: Jim :M

Find words and abbreviations in the patient record with these meanings. 1. Job occupation 2. Bad reaction, for example to certain medications _______________ 3. Family doctor _______________ 4. Closest relative _______________ 5. The amount of something you eat, drink, etc. regularly _______________ 6. Date of birth _______________ 7. Male/female _______________ 8. Past illnesses and injuries _______________ 9. Married/single/divorced/widowed _______________ 10. Not applicable (not question for this patient) _______________ 11. In each (day, week, etc.) _______________

Activity 1 1. Student A and B work together in pairs. You are going to play the role of a patient assessment. Invent the following details. • Full name • Smoking and alcohol intake • Allergies • Marital status • Occupation • Reason for admission • Next of kin • Medical history • Family history • Present health status • Date and place of birth • Past health history
 2. Student A – you’re the nurse. Ask student B, the patient, question to complete the patient record below. 3. Now change roles

PATIENT RECORD

Surname : ............................ DOB : ............................ Place of birth : ............................

Occupation : ............................

Marital Stastus : ............................

Next of kin : ............................

Contact no : ............................

Smoking intake : ............................

Alcohol intake : ............................

Reason for admission : ............................

Medical hsitory : ............................

Family history : ............................

First name Gender

: ...........................

: M / F

Present health status : ………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

Past health history : …………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………….

Activity 2 Complete the table that follows based on Mr. Smith’s case situation . Identify patient problems/limitations supported by the assessment data. Mr. Smith is a 56-year-old widower under your care. He is admitted due to an acute episode of dyspnea. He states that he awakened suddenly with severe shortness of breath that did not respond to his inhalers. In fact his condition seemed to worsen. Mr. Smith said with a panicked, desperate expression, “It’s so hard to breathe…can’t catch my breath.” He reports he smoked one to two packs a day for 40 years but stopped three months ago after his sister died of lung cancer. His sister was also a smoker. Currently, Mr. Smith’s diagnosis is emphysema with possible heart failure. Examination and assessment revealed the following: nonproductive cough, decreased mental acuity; extreme shortness of breath with activity; fatigues easily; nonverbal expression of anxiety/fear, such as moderate sweating, trembling, irritability, and restlessness; extremities mildly cyanotic and cool to the touch; capillary refill sluggish (≥ 4 seconds); greatly concerned that what happened to his sisters might happen to him; worried about losing his job of 30 years due to too many sick days; and lives with a 19 years old granddaughter; unable to complete usual household activities without periods of rest; concerned re limited coverage of health care. Vital signs: BP 178/96, weak pulse of 110, respirations 36/min (labored, irregular o

rhythm), O Sats 87% and temperature 38 C. 2

Patient Problems

Assessment Data

Ineffective breathing Dyspnea, decreased mental acuity, O Sats of 87% 2

Impaired tissue perfusion Increased stress, apprehension, distress, jittery, tremors, fear of consequences Fear Awakening suddenly short of breath, restlessness Activity intolerance States need for rest periods with normal activities, normal routine not maintained, irritable, decreased performance (work related) Altered health maintenance Condition worsened, poor response to inhaler selfadministration At risk for infection O

Temperature 38 C, increased respiratory rate (36), increased pulse rate (110)