Introduction to Advanced Health Assessment

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Introduction to Advanced Health Assessment

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

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Healthy People 2010

• www.health.gov/healthypeople
• www.cdc.gov/nchs/about/otheract/hpdata2010

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
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Healthy People 2010

• MAIN GOALS
• 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

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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.
  HIV
• 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

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Nurse to Nurse Practitioner

• Nurse

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Nurse to Nurse Practitioner

• NP

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Ethical Role

• Medical Ethics
• Neither static nor simple
• Does not provide answers
• Does offer a disciplined approach to
  understanding
• 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

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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

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Communication

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

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Communication

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

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Communication

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

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Communication

• Guided Questioning
• Moving from open ended questions to focused
  question
• 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

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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

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Impedance to Communication

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

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Tackling Sensitive Topics

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

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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

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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
  patient

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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

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Medical Records

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

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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

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SOAP info to be included on each patient

• Demographics
•         Initials (never use names for school
  SOAPS)
•         DOB
•         Age
•         Sex
•         Medical Record Number
•         Insurance (if Applicable)

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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
  questions
• Objective Findings
• Exam findings and pertinent negatives
• Chart- normal heart sounds, normal pulses,
  normal CR, L-CTA, tenderness with palpation of
  sternum
• Assessment
• Diagnosis
• May include differential diagnosis
• MI, GERD, Costochondritis
• Plan
• Management

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Charting

• 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

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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

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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

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Complete Health History

• Chief Complaint
• Here for a yearly physical, or new patient
  visit

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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

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Seven Attributes of a Symptom

• Location
• Quality
• Quantity or severity
• Timing
• Setting in which it occurs
• Remitting or exacerbating factors
• Associated manifestations

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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

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Complete Health History

• Family Medical History
• Blood Relations
• 2 to 3 Generations- include parents,
  grandparents, siblings, children and
  grandchildren
• 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//www.genopro.com/genogram/symbols
  /
• page 32 in Bates 10th ed.

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Tools to Enhance the History

• Suicide
• Clues
• Ask
• Alcohol
• CAGE
• GRAFFT-adolescents
• TACE
• Domestic Violence
• HITS
• Spiritual
• FICA

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Complete Health History

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

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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

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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

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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

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SOAP

• 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

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SOAP

• Objective- information directly observed by the
  provider
• 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
  Bates
• Abnormal findings include location, grading,
  discharge

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SOAP

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

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SOAP

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

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SOAP

• 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
  list
• If minor symptoms increase later they may then be
  added to the problem list
• Be sure and include Health Maintenance on your
  problem lists

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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!!

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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

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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

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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

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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

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General PE Techniques

• Inspection
• Palpation
• Percussion
• Auscultation

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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
  consultation
• 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
  propriety

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Olfactory Inspection

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

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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

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Palpation

• Gathering information by touch
• Some parts of the hand are better for certain
  tasks
• 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

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Percussion

• Sounds produced when the fingers strike the
  patient
• Density affects the resulting sounds-
• denser tissues muffle sounds
• lighter or hollow tissues have louder percussive
  sounds
• 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

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Auscultation

• 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

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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

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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
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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
  inserted
• The pneumatic attachment is used to evaluate the
  tympanic membrane ability to move
• (hardest tool to learn to use)

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Tools for the exam

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

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Tools for the exam

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

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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
  staff
• Seat patient to examine
• Begin with general survey
• Head and Face
• Eyes Mouth and pharynx
• Ears Neck
• Nose Upper extremities

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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

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Examination Sequence

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

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Examination Sequence

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

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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
  psychopathologic
• Make hypotheses about the nature of the problem
• Using evidence based decision making
• Test the hypotheses and establish a working
  diagnosis
• 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

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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
  differentials
• Patho of the diagnosis
• Management
• Treatments required- therapeutic and medicinal
• Education
• Referrals
• Follow-up/Monitoring progress
• Prognosis

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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
  automatic
• 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
  features
• (Refer to list for all 7)What makes it
  better/worse
• Last, the yes-no questions or pertinent positives
  and negatives
• Do you also have a headache or stomach
  ache-yes-strep?
• Have you been coughing with this illness- yes-not
  strep?

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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

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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
  violence
• 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

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Vital Signs and Anthropometrics

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

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The Pulse

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

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Language Used To Describe Pulses

• Regular Rate and Rhythm
• Graded
• 0 Absent
• 1 Diminished, Palpable only with
  Concentration
• 2 Normal, Expected
• 3 Full, Increased from Expected
• 4 Bounding

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Respirations

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

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Language Used To DescribeRespiration

• Dyspnea
• Orthopnea
• Tachypnea
• Hyperpnea
• Hypopnea
• Apnea
• Stridor
• Retractions
• Periodic Breathing
• Prolonged Respirations

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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
• REVIEW HOW TO TAKE A BP-Chapter 4

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Temperature

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

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Height

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

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Weight

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

77
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
  percentage
• 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

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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
  Shape.
• W2HR waist ? hip

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Pain

• 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
  multifactorial
• Involves sensory, emotional, and cognitive
  processing, but may lack a specific physical
  etiology
• Types of Pain
• Nociceptive or somatic
• Neuropathic
• Psychogenic and idiopathic

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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
  symptom
• Attempted Treatment
• Health Disparities

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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