SJOG Subiaco Hospital: Advanced Health Assessment
•
6 likes•2,482 views
Thank you for the feedback. I will focus on providing more concise yet comprehensive summaries in 3 sentences or less going forward.
Recommended
More Related Content
What's hot
What's hot (19)
Viewers also liked
Viewers also liked (20)
Similar to SJOG Subiaco Hospital: Advanced Health Assessment
Similar to SJOG Subiaco Hospital: Advanced Health Assessment (20)
Recently uploaded
Recently uploaded (20)
SJOG Subiaco Hospital: Advanced Health Assessment
- 1. Advanced Health Assessment NUR 409 Post graduate certificate in clinical nursing 2012
- 2. Learning Outcomes • Outline the process of an advanced health assessment • Identify different breath sounds • Identify normal heart sounds • Discuss the A to E assessment • Discuss the importance of effective communication • Discuss the potential barriers to communication • Explain the importance of teamwork • Describe the SBAR format of communication
- 3. Current Health Status Presenting Problem • When • What • Where • How • Why
- 4. Past Medical History • Medical conditions • Previous surgeries, incl. dates, treatment and complications • Allergies • Medications • Treatments
- 5. Family History • History of heart disease, hypertension, cancer, diabetes, asthma, TB • Major genetic disorders & health problems • Parents • Siblings
- 6. Skin • Turgor • Colour • Wound • Skin breakdowns – Rashes, lumps, sores, bruising, abnormal growths
- 7. Head Eyes – Lesions, discharge or inflammation – Symmetry Eyes – Vision – Cataracts, glaucoma
- 8. Head cont. • Mouth & throat – Hoarseness, sore throat, gum problems, tongue lesions • Ears – Hearing loss, discharge, infection tinnitus, vertigo • Neck – Lumps, swollen glands, goitre, tenderness
- 9. Neurological • Level of consciousness • Orientation • Pupils • Extremities • Speech • Dizziness / blackouts • Seizures • Numbness, tingling
- 10. Respiratory • General appearance – Workload – Position – Ability to speak – Check for surgical scars • Rate of respirations • Skin colour
- 11. Respiratory (cont.) Accessory Muscles = Distress • Inspiratory – Sternacleidomastoids – Scalenes – Trapezius • Expiratory – Internal intercostals – Abdominal muscles
- 12. Respiratory
- 13. Respiratory • Palpation – Predominantly used to find traumatic injuries – Tenderness, pain – Subcutaneous emphysema
- 14. Respiratory • Auscultation • Breath sounds – Produced by air passing through respiratory system – Sound on inspiration – Expiration
- 15. Respiratory • Normal Breath Sounds Breath Sound Location Description Bronchial Heard over trachea Loud, harsh, high pitched Broncho-Vesicular Anterior: 1st & 2nd IC spaces Soft, breezy Posterior: between Pitch is lower than scapulas bronchial Vesicular Lungs periphery Softer, swishy Pitch is lower than broncho-vesicular
- 16. Respiratory • Listen – Breath sounds to the bases – Equal breath sounds – Inspiration – Expiration – Abnormal breath sounds
- 17. Respiratory • Crackles – Most common cause air passing through fluid – Fine = smaller airways – Coarse = larger airways – Predominantly heard on inspiration – Can be equal both lungs – Can be isolated to one area http://www.youtube.com/watch?v=9C5RFb1qWT8&feature=related
- 18. Respiratory
- 19. Respiratory • Wheezes – Air forcing its way through narrowed airways – High pitch musical sounds heard on expiration – Can be heard on inspiration Smooth muscles irritation = Bronchoconstriction http://www.youtube.com/watch?v=YG0-ukhU1xE&NR=1
- 20. Respiratory • Stridor – High pitched continuous crowing sound – Trachea and larynx – Best heard over neck – Partial airway obstruction http://www.youtube.com/watch?v=UvqFmjvmXl4&feature=related
- 21. Respiratory • Pleural Rub – Constant grating sound heard on inspiration and expiration – Parietal and visceral pleura rubbing together – Pleura inflamed (loss of serous fluid) – Usually localised http://www.youtube.com/watch?v=t2QE0O_exAQ
- 22. Respiratory • Oxygenation • Activity tolerance • Sputum • Smoking
- 23. Cardiovascular • Heart Assessment – Blood pressure – Pulse – Capillary refill – Colour
- 24. Cardiovascular • Heart History – Chest pain – Irregularities of rhythm – Dyspnea – Syncope – Fatigue – Dependent oedema – Cyanosis
- 25. Cardiovascular Heart Sounds – 1st sound closure of the tricuspid and mitral valves – 2nd sound closure of aortic and pulmonary valves Best heard at apex, 5th intercostal space in mid-clavicular line http://www.youtube.com/watch?v=xS3jX1FYG-M
- 26. Cardiovascular Systole S1 S2 Mitral, tricuspid Aortic, pulmonic valves close valves close Diastole
- 27. Cardiovascular • Peripheral Vascular Assessment – Arterial pulses – Carotid: bruites and thrills – Abdominal
- 28. Cardiovascular • Peripheral Vascular History – Pain – Skin temperature and colour – Oedema – Ulceration – Emboli – Stroke – Dizziness – Exercise tolerance
- 29. Gastrointestinal • Nutrition – Appetite – Digestion intolerance, heartburn, N & V – Haematemesis • Bowels – Irregularity – Stool appearance – Flatulence / belching – Jaundice
- 30. Gastrointestinal • Bowels sounds – Hyperactive or hypoactive • Abdomen – Masses, rashes, scars • Tenderness (palpate) – Guarding or masses – Gallstones – ulcers
- 31. Musculoskeletal • Inspection • Palpation • Passive & active range of movement • Muscle strength • Gait • Spine
- 32. Endocrine • Thyroid enlargement/tenderness • Heat/cold intolerance • Unexplained weight change • Diabetes signs and symptoms
- 33. Genitourinary • Assess normal patterns of voiding – Frequency – Urgency – Nocturia – Haematuria – Stress incontinence – Dysuria – Pain – Urine – amount, colour and urinalysis
- 34. Reproductive • Male • Female – Prostate – Menses – regularity – Testicular pain or masses – Dysmenorrhea – Hernias – LMP – Lesions/discharge – Last Pap and results – Sexual activity – Discharge/lesions – Menopause
- 35. Psychosocial • Mood • Verbalisation • Eye contact • Support • Concerns
- 36. Clinical Examination • Vital signs • Neurological examination • Weight • BMI • Pain scores • Risk Scores • MSU
- 38. A to E Assessment • Airway • Breathing • Circulation • Disability • Exposure
- 39. Airway • Examination: Listen: – Look: Breath sounds • Noisy breathing: Obstructions stridor, wheeze • Swelling Able to speak in • Secretions sentences • Accessory muscles • See sawing Feel: • Check for airflow Cyanosis or breaths at the mouth and nose
- 40. Airway • Management: – Position - head tilt, chin lift, jaw thrust – Recovery position – Suction – MER – Reassess if your intervention has been effective
- 41. Breathing • Examination: Listen: – Look: Speaking in full • Respiratory Rate sentences • Use of accessory Orientated or muscles confused • Sweating Rattling breathing • Abdominal breathing Wheeze • Shallow breathing Stridor • Unequal chest movement Auscultate with • Oxygen saturations a stethoscope
- 42. Breathing • Feel: Management: • Palpate position of Palpate chest trachea High flow oxygen • Palpate chest wall Position for subcutaneous Nebulisers emphysema or Oxygen saturations crepitus Arterial blood gases • Assess depth and Physiotherapy equality of chest All deteriorating patients wall movement should receive oxygen before progressing to • Percussion any further assessment
- 43. Circulation Look: • Listen: Sweating Blood pressure Colour – pale, flushes, • Feel: cyanosis Pulse character, rate Haemorrhage Pulse – central versus Urine output peripheral Any evidence of Temperature infection Capillary refill time
- 44. Circulation • Management: Give fluids No evidence of heart failure Evidence of heart failure Assess response
- 45. Disability • Look, Listen and Feel: Drowsiness/Lethargy Glasgow Coma Score Limb weakness Check pupils Change in Check blood glucose mood/agitation Assess pain using an Spontaneous eye objective scoring tool opening Pupil size and reaction Seizures
- 46. Disability • Assessment: Management: A - Alert Protect and manage the airway V - Voice Correct hypoglycaemia P - Pain Control seizures U - Unresponsive Control pain Reversal of Drugs
- 47. Exposure • Head to toe examination Check for rashes Check surgical wounds Drains/stoma output Abdominal distension Evidence of haemorrhage Calf swelling
- 48. A to E Assessment • A – Airway: ok or compromised • B – Respiratory Rate, SaO2, O2 Therapy • C – BP, HR, Temp, Capillary refill, Urine Output • D – Consciousness, Pupils, GCS, Blood Sugar • E – Bleeding, Rashes, Swelling
- 49. Aims of Communication • To convey information • To build and maintain • To influence a persons relationships behaviour • Solve problems/resolve • To express feelings, ideas conflict and thoughts • Achieve goals and • To explain/rationalise desired outcomes behaviour • To stimulate interest in self or others
- 50. Types of Communication • Verbal – face to face, phone, messages via third party • Written • Body Language • Advantages and disadvantages to all types
- 51. Barriers to Communication • Language • Cultural differences • Sensory impairment • Physical impairment • Sedation/drugs • Lack of trust • Stress
- 52. Effects of Poor Communication Communication problems: a factor in 80% of adverse events & near misses in hospitals • Lack of Situational Awareness • Patient not reviewed in a timely manner or not reviewed at all • Incorrect/inappropriate treatment • Poor task management • Difficulty in prioritising • Clinical risk
- 53. Teamwork • Very Important skill! • Collaboration towards common goals • More than the sum of its parts – Pooling of professional expertise – Understanding/appreciation of roles/expertise • Best when role within experience & expertise • Communication a key factor
- 54. Act one, Scene one Setting: • Ward 8 1600 hrs. Respiratory Ward Cast: • RN Black: First time coordinating, short staffed, on with an agency nurse and 4 students • Dr Green: Junior RMO, busy all day on ward rounds, trying to catch up on ‘ward jobs” • Student Nurse: • Background: • Mr Blue is a 65 year old male admitted yesterday with pneumonia • The student nurse tells RN Black that he doesn’t look well. RN Black asks the student to phone the RMO while she has a look at him.
- 55. Act one, Scene two • Setting: Ward 9 1600 hrs. Surgical Ward • CN Satan: Known as a battle-axe, very experienced, already 2 emergency admissions and has patients still waiting for surgery, 2 senior staff off sick leaving the ward short staffed • Dr Fixit: RMO, on ward round with Mr Snatchit – renowned grumpy surgeon • Background: • Mrs Frisk is a 40 yr old lady admitted with right upper quadrant abdominal pain. • Pain has becoming increasingly worse and observations have continued to deteriorate. • CN Satan decides she can’t wait for ward round and page RMO. No answer so tries again -twice – finally gets an answer
- 56. Act one, Scene three • Setting: Ward 4 1600 hrs. Surgical Ward • Cast: • Graduate Nightingale: has attended the Advanced Health Assessment Study Day • Dr Spock: • Background: • Miss Swift is a 30 yr old lady admitted overnight with an acute exacerbation of her asthma. • Her breathing is becoming increasingly worse and her observations have continued to deteriorate
- 57. Communication • S Situation • B Background • A Assessment • R Recommendation
- 58. Communication • Situation: What is the current situation, concerns, observations, etc. • Background: What is the relevant background. This helps set the scene to interpret the situation above accurately.
- 59. Communication • Assessment: What do you think the problem is? – A – airway: ok or compromised – B – Respiratory rate, SaO2, O2 Therapy – C – BP, HR, Temp, Capillary refill, Urine Output – D – Sedation, Pupils, Blood sugar – E – Bleeding, Rashes, Swelling
- 60. Communication • Recommendation: – What do you need them to do? – What do you recommend should be done to correct the current situation. – How urgent? – Is there anything you can do in the interim?
Editor's Notes
- When: last well, Onset, duration and chronologic sequence of symptoms What: Quality, intensity, related symptoms Where: location, range of symptoms How: Associated factors Why: possible solutions, treatment INCORPORATE AGE RELATED DIFFERENCES
- Wound: surgical or traumatic . infections, redness, swelling, discharge, unusual odour Breakdowns: relation to wound or pressure
- Skin – tattoos, piercings Eyes, eyelids, conjunctiva, sclera and lacrimal ducts for lesions, discharge or inflammation Symmetry of eyelids and eye movement, eye medications Lips - Inspect the lips, buccal mucosa, teeth, tongue, tonsular area for inflammation, discharge, lesions, or odours Assess for adequate oral hygiene Mucous membranes – inspect for lesions, discolouration, dryness, ulcers
- Palpate lymph nodes, look for asymmetry, pain, enlargement of thyroid, deviation of trachea
- LOC: based on alertness, disorientation, excessive drowsiness, responsiveness to speech Orientation: ensure appropriateness to age and mental condition Pupils: response to light, symmetrical, photophobia Extremities: ability to move all limbs, allowing for surgery, pain etc. Follow instructions, equal strength Speech: confusion, appropriate answers, dysphagia, aphasia, excessive salivation
- Workload – accessory muscles – trapezius, sternomastoid, scalene, or abdominal muscles Skin colour Normal range of respirations varies by each individual and can be anywhere between 12-24 breaths/minute. Regularity is considered to be a steady inspiration and expiration pattern. Breathing should be effortless at rest. Age can also effect the respiratory rate..know the ranges. Babies and children have higher respiratory rates pending their age A respiratory pathology such as Emphysema which activates accessory muscles of respiration will require more oxygen to work. If it appears as though the patient seems to have abnormal respirations ask them if they are having problems or if this is their normal breathing pattern
- Normal 12-24 Expirations normally a passive process These muscles aid of the diameter if the chest Accessory muscles are used when the body needs increased oxygenation, or in certain disease states that require forced inspiration and active expiration. Such as emphysema Inspiratory accessory muscles include: the sternocleidomastoid muscles located at the side of the neck are used to help raise the sternum the scalene muscles in the neck elevate, and expand the upper chest The trapezius muscles in the upper back raise the thoracic cage These muscles aid in expanding the diameter of the chest so more oxygen can be inspired With forced expiration, the internal intercostal muscles contract to shorten the chests transverse diameter (or squeeze the chest) and the abdominal rectus muscles pull down the lower chest, depressing the lower ribs. Use of accessory muscles..means With normal inspiration, the major muscle utilized is the diaphragm with assistance by the intercostal muscles …expiration is normally a passive process… more oxygen demand to feed theses muscles…this results in an increased workload on an already stressed system
- This picture shows obvious signs of respiratory distress. Note the lack of adipose tissue on the patients chest…the process of breathing for this person requires an increased caloric value… therefore they are using up all of their calorie intake just to breath. “Pink Puffers” do not tend to be obese.
- Different depending on location
- Generally, breath sounds are more audible during inspiration Smaller to larger = less turbulence therefore quieter The purpose of auscultation is for the evaluation of Normal breath sounds identification of abnormal breath sounds Breath sounds are best auscultated with the patient sitting upright if possible and breathing deeply and slowly through their mouth. Auscultation should be thorough and done systematically from side to side UNDER clothing. Air creates turbulence as it passes through the respiratory system. Air travels through the large areas of the tracheal tree to the smaller areas on inspiration. During expiration it travels from the smaller areas in the tracheal tree to the larger ones, creating less turbulence…because of this , sounds are a louder on inspiration as opposed to expiration Normal breath sounds are different depending on their location. Bronchial breath sounds are heard only over the trachea…they are high pitched, loud and have a long exhalation period…remember this is the largest part of the tracheal tree..so there will be more turbulence generated here Bronchovesicular sounds are heard anteriorly near the first and 2nd intercostal space and posteriorly between the scapulas….it has a medium pitch, is lower than the bronchial sounds and exhalation is equivalent to inhalation Vesicular breath sounds are heard over most of the lung field.. It has a softer swishy sound to it with the pitch being the lowest of the three….vesicular sounds have a soft and short exhalation and a long inhalation period
- Crackles are short discrete popping or crackling sounds produced by fluid in the small airways or alveoli or by snapping open of collapsed airways during inspiration. They can be heard predominantly on inspiration but can be heard on expiration and may clear with coughing. Crackles can be further classified as fine, medium, or coarse, depending the airways affected.
- Wheezes are high-pitches squeaking whistling sounds produced by airflow through narrowed small airways.they are mainly heard on expiration but may be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate or severe.
- Stridor usually is an inspiratory crowing-type sound that can be heard without the aid of a stethoscope. It indicates significant narrowing or obstruction of the larynx or trachea and can be caused by epiglottis, viral croup, FBO. Stridorous respirations are best heard over the larynx or trachea. Stridor is an indication of a life-threatening problem.
- Pleural friction rub is a creaking leathery, loud, dry coarse sound produced by irritated pleural surfaces rubbing together. It is usually heard best in the lower anterolateral chest area during both inspiration and expiration. Pleural friction rubs are caused by inflammation of the pleura. Presence of a pleural friction rub could indicate pleurisy, viral infection, TB or a pulmonary embolism.
- BP – compare to previous - note position Pulse – regular or abnormal CP: brisk <3 secs, slow >3 secs Colour: colour of face, hands feet and legs. Is pt is flushed, grey, mottled, pale ,cyanosed or sweaty
- Palpations: Cardiac Thyrotoxicosis Hypoglycemia Fever Anemia Anxiety Rhythm/palpations: May not indicate serious disease Other factors: caffeine, tobacco, drugs Syncope: Vasovagal -vasodepression Micturation - visceral reflex Cough - chronic lung disease Carotid sinus - sensitivity (pressure Fatigue: Decreased cardiac output CHF Mitral valvular disease Anxiety & depression Anemia or chronic diseases
- Murmurs: timing, duration,
- Systole: ventricles contract Diastole: ventricles relax
- Pulses: in all extremities – presence or absences Bruite: a blowing or swishing sound created by turbulence of blood flow due to narrowing arterial lumen in carotid If bruit present, then palpate and feel for thrill – vibrating sensation like a car purring or water running through a hose Abdominal: Ascities, abdominal bruites, anurysuem
- Varicose veins
- ROM: free from pain, or limited by surgery, pain, deformity, paralysis ADLs: Limitation that interfere, disease process or medical intervention Mobility: can they mobilise or limited with pain fear, surgical interventions. Do they need assistance. Back problems, cramps, Weakness Joint stiffness, Carpal tunnel.
- Mood: pt ’s feelings about hospitalisation and treatment. Note inappropriate responses. Difficulty concentrating, Nervousness, tension irritability Verbalisation: comments about condition, hospital, treatment. Reluctance to talk about condition Eye contact: may be normal for some cultural groups Support: family support, Concerns: personal and health issue that pt is concerned about. Can these be alleviated.
- Situation: What is the current situation, concerns, observations, etc. Background: What is the relevant background. This helps set the scene to interpret the situation above accurately. Assessment: What do you think the problem is? A – airway: ok or compromised B – Respiratory rate, SaO 2 , O 2 Therapy C – BP, HR, Temp, Capillary refill, Urine Output D – Sedation, Pupils, Blood sugar E – Bleeding, Rashes, Swelling Recommendation: What do you need them to do? What do you recommend should be done to correct the current situation. How urgent? Is there anything you can do in the interim?
- This is often the hardest part for medical people. This requires the interpretation of the situation and background information to make an educated conclusion about what is going on. B – resp rate, sats, O 2 therapy C – BP, Pulse, Temp, Cap refill, Urine output D – AVPU, pupils, blood sugar E – Any bleeding, rashes, swelling