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Nursing Notes

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N305 Health Assessment 9/5/2014 7:31:00 PM
Introduction to health assessment:

What is health?
• “a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity.” –WHO (1946)
• 1986-Ottawa Charter affirms social, economic and environmental
aspects of “health”
• A relative state where a person lives to their potential and includes 6
facets: physical, emotional, social, cultural, spiritual, developmental.
Health is the summation of these 6 facets and is simply not the
absence of disease.
• Our health is also determined by how well we can adapt to changes in
our environment
◦ How well we adapt
-immune system, stress relief techniques, support systems
 ADL (activities of daily living)
Health is not a constant. A healthy person feels good on all levels.

What contributes to health:
Lifestyle, family history, genetics, environment, socioeconomic, occupation,
education, culture, spirituality, age, access to health care, nutrition, RNs!!!!!!

Determinants of Health:
1. income and social status
2. social support networks
3. education and literacy
4. employment/working conditions
5. social environments
6. physical environments
7. personal health practices and coping skills
8. healthy child development
9. biology and genetic endowment
10. health services
11. gender
12. culture

Diet is embedded in many of the 12 determinants of health.
Age isn’t part of it.

Florence Nightingale

1860/1969 (individual/environment)
“what you want are facts, not opinions…the most important practical lesson
that can be given to nurses is to teach them what to observe and how to
observe…” (p.105)
“And nothing but observation and experience will teach us the way…”

Why Health Assessment?
-information about patient, knowledge that leads to best course of action for
patient care
-health promotion makes RNs different

How are you?
-illness, injury, disease, alterations in health, health, wellness, wellbeing
- interested in both ends of the spectrum of health and illness

Professional Lens
Professional and Practice Considerations
- situational awareness’
- context dependent
- general survey
- clinet assessment
- priority setting
- nursing knowledge and judgment
- nursing process
- clinical reasoning
- interprofessional collaboration

The Nursing Process
The information obtained throughout the health assessment should be doc-
umented in a clear, concise manner. This information is collated in the
patient’s medical records. The ability of the nurse to extrapolate the
findings, prioritize them, and finally formulate and implement the plan of
care is the overall goal. This is called “the Nursing Process.”

Client Assessment strategies and scopes vary significantly.
Individual Depends on the client, purpose, context, setting etc.
Family Determines nursing care plan and interventions
Aggregate Contributes to interprofessional plan and strategies.

Also need to consider:
- professional approach
o with clients and team members
- communication
o empathy, caring, effective
o therapeutic
- Professional relationship
o Boundaries
o Touch, space, dignity, respect, comfort, safety, privacy

Three effective verbal communication skills
- Active listening
o The ability to focus on patients and their perspectives
- Restatement
o The content of communication
- Reflection
o Identify the themes of communication and what the patient may
be feeling.

Individual Assessment: assessing social, env, econ, health, physical,
mental, social, family, community
60-sec assessment
- purpose, directions
ABC without touching the patient
Tubes and lines
Respiratory equipment
Patient safety survey
Environmental survey

Lab and Diagnostic
 Examples: blood work (CBC), x-rays, angiogram
 Role and responsibility of RN
o Understand or clarify purpose of test
o Inform client or others
o Prepare client or others
o Understand or report pertinent findings
o Discuss or relay information with client.

Health Hx: Components
Interview: Phases and Process
 Preparation/Preinteraction phase
o Collect data (if possible)
o Create setting: private, comfortable, safe
 Initial/ Introductory phase
o Introduce: name, role and purpose
 Working phase
 Summarizing phase

Client Considerations
- Age
- growth and development
- sensory
- language
- culture
- gender
- emotional state

Perceptions and Concerns
- subjective
- “self-report”
- what does client perceive?
- What is of concern?
- Attend to statements, inferences, possibilities, lead, cues
- Consider potentially sensitive topics and vulnerability
o What might they be?
o What might they depend on… gender, age, culture

Assessnebt types, Depth, Scope
- emergent/urgent
- unstable, life threatening, at risk
- health history, phys exam, lab/diag
-head to toe regions and sustems
-systems: CNS, CVS, Resp, GI/GU, MSK/Integ
- focused. Issue-oriented
-narrow scope
 -in depth relationto concets of client, rn
- functional
 health patterns/aspects

Organizing Frameworks
 functional
 head-to-toe
 body systems

Individual Assessment
 Findings
o Normal
o Abnormal
o Expected
o Unexpected
 Ongoing

Communication of Findings
-among and between team members
 S: situation (name, role, overview of issues)
 B: background (pertinent history)
 A: assessment (summary of facts and assessment)
 R: recommendation (actions asking for, what do you need or
want to happen next)
Health Care Team (interactions with certain professionals)

What is health assessment?
 The purpose of the nursing health assessment is to determine a
patient’s health status, risk factors, and need for health education
as a basis for developing a nursing plan of care.
 Three types: emergency, comprehensive (physical), patient history

The extent of health assessment depends on the acuity of the
patient’s condition.

Nursing and medicine both perform health assessments but they
differ! Medicine focuses on diagnoses and treatment of the disease.
Nursing focuses on diagnoses and treatment of the actual or
potential human responses. The nursing assessment identifies many
contributing factors to the individual’s health and wellness. These
include the 6 facets. Deviation or changes in response is noted.

 For nurses it is a comprehensive health history and a physical
examination which aids in the health evaluation to determine the
health status of a person. This aids in how care should be executed
which is unique to each person.
i. Health History: A series of pertinent questions about the
patient and/or family. Use of past medical records. Knowledge
of physical, psychological, social issues, spiritual, cultural
beliefs. The identification of important data is a
systematic process.
ii. Physical Examination: A structured head-to-toe examination
to identify changes in the patient’s body systems. Findings may
support history data or trigger more questions.

General Survey
- height, weight, vital signs
- body frame
- body mass index (BMI)

Situational Awareness
- is the ability to identify, process, and comprehend the critical elements
of information about what is happening to the team with regards to the
mission. More simply, it's knowing what is going on around you

Health Assessment
o curiosity
o observation skills
o knowledge and intellect

General survey
 behaviour, physical appearance, mobility
Questions: Ask how he is, ask about why he is in today,
Notice from health assessment:nutrition, occupation, relaxed, good posture

Man on street: smoking, hygiene poor?, unkempt,
Questions: how long have you been smoking? When did you start smoking?
What are you reading today? Are you feeling comfortable? Do you live
closeby? Note grooming, nutrition, safety.

Health History
When is one anticipated? On admission to hospital, patient coming into
clinic for first time, long-term care, employment physical, before surgery,
admission to medical unit, clinic, surgery
What do we obtain?
Past and present illnesses, chief concern, drinking, drugs, smoking,
sexual health, occupation, family history,
Why do/ would RNs complete one? For plan of care. To inform and
work with other disciplines for plan of care.

Health Hx: Personal Data
Subjective: information
Primary from the client themselves
Secondary from the secondary source

Do own assessment
Get reports
Test-rest validity
EG redo vitals if not sure
Ask what they know –get 2
Subjective pain- most important
Sometimes subjective is the most important.
Reliability is important- know what they are saying
- information getting, need to know is correct, hiding, making up
- clarify, see if misunderstanding

Primary data might not be reliable, e.g., patient with dementia
First language not English might need to clarify

If person insists they have tumor? How do we handle?

Syllabus pp 79-87

Health Hx: Components
E.g., phone number, contacts, address, male/fem, chief concern, sign
sensation symptoms, personal family, social, cultural, medical

Signs- can see
Symptoms- can’t


Refer to pdf from email
Short form mcgill can be used anywhere
Edmonton- more dimensional in terms of symptoms
Sim to ESR but includes distress

Vital Signs:
Bp, pulse, o2 sat

Expected findings: why do numbers vary?

Comment Jensen, p.99
Interventions for fever are dependent on the patient and cause. Most often
rapid cooling is not beneficil or required.

Sites- Adults
Radial, carotid, apical, brachial, femoral, popliteal, dorsalis pedis, posterior
Expected findings
Expected (60-100 sinus rhythm)
Tachycardia- rate over 100
Bradycardia- less than 60

Regular or irregular
Strength/ amplitude

Weak pulse due to blood loss

Rate: expected



Blood Pressure: sys, diastolic, MAP
An increase in volume will
An increase in resistance (called vasoconstriction) will

- sys, diastolic, MAP
MAP should always be over 65

BP: influenced by age, gender, genetics, weight,
exercise, smoking, diet, emotions, medications, position

pulse oximeter
Widely used

Arterial blood gases
More accurate
But more invasive.

45 questions
1 hour

Guest speaker- Kathleen Hunter

Oliver Sacks
Physician, author
Awakenings, Musicophilia: tales of music and the brain, the man who
mistook his wife for a hat

Alice Munroe

Ida Keeling
Athlete, world record holder for running at age 95

John Mendes
93 yr old marathon runner

Olive Riley
107, writing a blog

Nelson Mandela
President of South Africa (94-99) office at 75
Formed the elders.

Chief Dan George
Author, poet, actor
Little Big Man (1970)

Canadian Stats 2011
Those >65 now make up about 15% of the Canadian pop doublt the
5.9% increase for the pop as a whole

Proportion of seniors will continue to increase those 60-64 increased
29.1 % over the past 2006-2011

2015- number of seniors in Canada could surpass the number of children

2063- 25% of the Canadian pop will be seniors most of the shift in the
next 15 years- aging f the baby boomers those over 80 will increase to
5 mill (1.4 mill in 2013)centenarians will increase to 62,000 (about 9x)

WHO: 10 Facts on Aging
WHO article.
 need to reinvent assumptions of old age.
 increase 4x by 2050
 2050- 80% of older people will live in low-middle income countries
higher disease here
 biggest burdens for elderly will be chronic disease
 need for long-term care rising have a broad-view approach
 Primary Care is going to be important
 Need for “age-friendly” communities
 Healthy aging begins prenatallythroughout life

Ageism: the stereotyping of the discriminate against individuals or groups
because of age, attitudes, etc…

National Geographic Article on Aging
- cultures of longevity

Normal changes of aging
-norms of aging vs disease

Concept: decreased reserve
- older adults function well in day to day situations, despite age related
- however, there is decreased reserve to cope with the stress of acute

e.g., lungs less vital capicty, muscles atrophy, utiserious in elderly
(sick fast, loss of function- cognitive and physical) vs. younger

Aging and Brain Power

What changes with cognitive aging:
 decrease in availability of NT (ACH, Dopamine)
 decrease in number/length of dentritic segments in prefront cortex
 decrease in synaptice density, fewer receptors
- diffuse plaques and tangles found in the cortex of non-dement older
- Some memory decline compared to individual prior performance (free
recall more than recognition)
-  no effect on IADLS
- delay in recall
- delay in processing speed
- many older adults continue to be active intellectually and physically

The big threat…
Disease associated with aging such as: diabetes, stroke, Parkinsons
disease, ,dementia
The “lifestyle” diseases- risks include overweight, hypertension, smoking,
what’s good for the heart is good for the head
**could be cardiovascular component to Alzheimer’s**

What is frailty
“frailty is a nonspecific state of increasing risk, which reflects
multisystem physiology change. It is highly age-associated. The
physiological changes that underlie frailty do not always achieve disease
status, so that some people, usually very elderly, are frail without having
life threatening illness” Rockwood and Mitnitski, 2007
 most older adults live independently in the community

Nursing assessment of the older person
- social function, cognitive function, physical function

Geriatric Syndromes: incontinence, impaired cognition, instability
(falls) immobility.

 acute onset of the geriatric syndromes is a red flag.

Social Function
How often do you have contact with friends and family?
Are you satisfied with this? Why ask? Choice?
Do you have someone to call on if you need help with…
Household chores? Getting groceries? Getting to apps?

Assessment tools for Instrumental Activities of daily living
- what does the person do themselves vs what do they need help with
also part of physical and cognitive functional assessment

Food prep, managing money, shopping, cleaning house, doing laundry,
transportation, using the telephone, gardening, yard work, doing minor
home repairs, managing meds
**extra Lawton Instrumental Activies- Daily Living**

Potential Geriatric Sundromes
- impairment of physicial function can lead to:
decreased mobility (adls)

Bathing, toileting, eating, dressing, transfers, mobility

Assessment Tools: ADLs
Katz Index of Independence of ADL
Barthel Index

Timed up and go (TUG) rise from arm chair, walk 3 m, turn and walk back,
sit down (<9sec normed value for those 70-79 years)

A physiotherapist can also add to the assessment of strength and gait. Eg.,
Tinetti Gait and Balance Scale

Cognition and Domains
Attention and concentration
Executive functions- planning, assessing risk
Visuocontructional/visuospatial skills (finding way around an environment)
Conceptual thinking

Potential Geriatric Syndromes

The following may contribute to altered cognition:
Delirium, dementia, depression, (drugs)

Impaired cognitions may have other syndromes as well
 continence issues, falls and impaired mobility.

Screening Tools
Folstein Mini-Mental State Exam (MMSE)
Widely used
For screening- tells you there is a problem, but does not diagnose what the
problem is
Score could be low associate with any of the 4Ds
30 items (orientation, registration, attention and calculation, language)
24 or higher is normal (should adjust for age, education level,
Not a diagnostic tool!!!
Gathering information/interview is important to diagnosis.

MMSE Educational and Age Norms chart

Clock drawing (used to follow dementia over time)
 have the ind fill in the numbers in a circle “like the numbers on a clock”
and indicate a time (e.g., 11:10)
 good for following people over time
 visuospatial test, follow directions and understanding, language

clock drawing delirium
 day one-five recovery

definition: dementia
progressive impairment in cognitive function severe enough to
impair activities of daily living, work, coial and personal
relationships impacts all domains

what is MCI?
Mild cognitive impairment
Some deficits in cognitive function, nbut not enough to interefere with daily
Some people do progress on to dementia from MCI (rate/risk still being

Assessment tool
Montreal cognitive assessment (MoCA)
Used to detect MCI and early dementia, a collection of tools
Has been translated into a number of languages but unfortunately not into
any aboriginal languages yet

Types of dementia
Lewy body
B12 deficiency, CJD, AIDS, neurosypillis

Assessment Tools
Many tools (some dementia specific or the associated symptoms)

BPSD in dementia
Wandering, pacing, exit seeking, hoarding, fathering, rummaging,
suspiciousness, apathy, etc…

Psychotic features
Illusions- misperception

Many behaviours are not amenable to pharmacologic intervention
 try alt the env, alter care approach, distraction/activities

Risk factors for dev of Delirium
Age, dementia or depression, severe med illness, etc…

Feat 1: acute onset, fluc course
2- inattention
3- disorganized thinking
4- altered level of consciousness
The diagnosis of delirium by CAM requires the presence of feat 1 and 2 and
either 3 or 4

Mood disorder
Can be mistaken for dementia
Common in older adults theorized to be related to changes in
neurochemical in the brain
Somatizing can be a common feature


Symptoms Premorbid conditions Location Activity Toxins

Take away messages
Older adults are going to be COMPLEXXXXX
Multifaceted and interprofessional approach to assessment and intervention
is best

As an RN need to be knowledgeable about assessment and assessment tools
and play a role in planning care with patients or clients, their families and in
the interprofessional team

September 29

- aware of self and surroundings and responsive to others and
- consciousness requires both cognition and arousal
- arousal- responsiveness which is mediated by RAS (it filters and
prioritizes sensory info
- enable mind to be focused and alert

Set of mental abilities, including memory, judgment and eval, reasoning
and cal, problem solving and decision making, language and speech

Sensation (not assoc with disease) vs symptoms (health care)
What signs, senations, symptoms are particularly prevalent with the
neurological system? Forgetfulness, confusion, gait, balance, mobility,
vision problems, tingling, etc…

Areas of the brain associate with signs, sens, and symp

Pain assessment: PQRSTUV
Particular neurological considerations
Variations (diurnal, circadian, seasonal)

Types of pain:acute, chronic, referred

Pain nociceptive
Acute, chronic, local, general, somatic, visceral, neuropathic

Neuropathic pain: pain related to nerve injury
Other symptoms? Fatigue, depression, nausea, dizziness, weariness,
unable to sleep, lack of appetite
Onset/timing related to cause if known and timing-chronic, acute
Severity. intensity subjective and individual (verify/ explore e.g., if they
report their pain as 4 out of 10, would they describe that as mild,
moderate, severe? P.134

What are points/areas for particular consideration?
-according to individual, focus (history) through lens of RN
-pertinent health determinants and risks (lifestyle- ride bikes without
helmets) (rec drug use, poor lifestyle choices) (alcohol, drugs (Rx and
non), falls, high risk sports/activities
previous injuries (concussions), previous back or neck injury
family or personal medical history (stroke, epilepsy, seizure, migraine,
aneurysm, diabetes, hypertension
medical diagnosis (multimorbidities), lab, diagnostics (advanced and
specialized- x-rays, nuclear medicine, diagnostic imaging), perceptions vs
evidence of “best”, wait and travel

Focused Neuro Exam
- includes vital signs
- higher functions
- cranial nerves (CNS)
- sensory system (assess sens motor in brain and spinal cord)
- motor system
- reflexes
- cerebellum
- meninges
- system survey

Higher Functions: Gait
Expected findings (symmetry in upright position, smooth, even)
Unexpected findings (posture- hunching forward, shuffling, limping, not
moving arms),hemiparesis, protected, shuffling, rigidity, ataxic, steppage,

Higher Functions: Speech
Expected findings: clear, coherent
Unexpected findings

Higher Functions: Mental Status
Expected findings
- Oriented to person, place, time
- Cues appropriate to individual
Unexpected findings
- loss of one or more
- temp or perm loss
- sudden or grad onset
- thought processes, perceptions, content (clear, accurate, relevant)
- recent, remote
- fluctuating, gradual, acute
Cognitive processes
Examples: reasoning, knowledge, vocab, calc, abstractions, judgment

Pupils and Eye Responses
3 CNs involved in pupil responses and eye mvt
Pupils (optic nerve and occulomotor nerve)

Facial Paralysis
Perm or temp
e.g., facial nerve or motor cortex
can be very subtle
often have other symptoms (pain, dizziness, drooling, tearing of eye,
dryness of mouth)

Assessment Risk of Choking
Hypoglossal CN “under” the “tongue”
 Important for speech and swallowing
Glossalpharyngeal and Vagus CNs
 Gag reflex
 Sensory and motor pharyngeal reflex
Vagus X (vagabond=wanderer)
 A mixed sensory and motor nerve
o Wanders into thorax and abdomen
o Parasympathetics innervation of organs
 Pain, heat, cold, light touch, vibration
o Conducted by periph nerves to thalamus
o Important ot compare sides
 Rapidly move up…etc
 Size, shape, sym, strength
 Alterations, unexpected funds
o Atrophy, hypertrophy
o Hypotonic, hypertonic
o Involuntary movement
 E.g., fasciculations, tremors, tics, mycoclonus, dystonia
Cerebellar Signs

Integration of Systems
 Bp, hr
 Sweating
 Skin temp, colour
Vagus nerve
 Vasovagal response

Numerous tools to assess components of mental status

MoCA (most common across Canada/alberta)



Alterations in Consciousness
Risk and factors
 Alterations in health
o Delirium, dementia, psychosis, dehyd, hypoxemia, acidosis
o Disruptions in place and routine
o Stress, anxiety, pain, sleep deprivation, medications

Parkinson’s disease
Subtle and vague
Early motor signs and symptoms: TRAP
 Tremor at rest, rigidity, akinesia, bradykinesia, postural instability
 Non motor signs

N301- Nursing Research 9/5/2014 7:31:00 PM
First paper due September 29
- APA format
3-4 pages

1. Who are the subjects (quantitative researchers)? OR who are the
participants (qualitative researchers)?
-The students

2. Was any theory building or theory development done (qualitative) OR was
a developed theory or existing model being tested (quantitative)?
Both. Some kids already know how to make their favourite food

3. Was data collected? (quantitative - data that can be summarized or
reported as one or more numbers) OR (qualitative - information gathered for
an improved understanding of the topic or phenomenon of interest)

Yes. Measurements, favourite foods/ recipes/ food types, sweet/salty,
preparation time, ingredient amounts

4. What were the variables (concepts that could have information
counted on each one - quantitative researchers) OR what may be the
key points of understanding gained from reading this booklet with these key
points actually called "codes" which would be grouped together to
form categories and with these categories then grouped into a theory that
would hopefully increase our understanding of the topic or phenomenon of
interest - qualitative researchers)?
Dessert, main meal, side, snack
Ingredient availability

5. What did you find? (qualitative researchers AND quantitative
Measurements were not exact and exact amounts of ingredients and yield
was not provided. Children don’t have a good concept of time.

6. Was this a "good" study (quantitative - random selection of subjects,
objective researcher so no researcher bias, the findings from these children
can be generalized to all children OR qualitative - was this a trustworthy
research process that generated meaningful information that may be used
sometime and/or transferred into practice somewhere)
random selection was not good, objective researcher (biased due to teacher)
bias due to age and preferences, not generalized to all children in the world

7. Which type of study was best at answering the question on page 1 of the
booklet - qualitative or quantitative?
Qualitative- theoretical thinking

Chapter One Review
Overview of Nursing Research

On completing this chapter, you will be able to:
Describe why research is important to nursing and discuss evidence-
based practice
Research is important to nursing because it answers questions, solves
problems and builds upon knowledge.
All this knowledge acquired by the nurse (clinical evidence) helps in the best
course of action for care.
Describe historical trends and future directions in nursing research
Historical trends: Nightingale founded nursing research in 1859 Notes on
Nursing. Focus of paper on environmental factors that influence emotional
and physical well-being.

Describe alternate sources of evidence for nursing practice
Describe the main characteristics of the positivist and naturalistic paradigms,
and discuss similarities and differences between quantitative and qualitative
Identify several purposes of qualitative and quantitative research
Define new terms in the chapter
Research: a systematic inquiry that uses rigorous methods to answer
questions or solve problems. The ultimate goal of research is to develop,
refine, and expand knowledge.
Nursing research: is designed to develop evidence about issues of
importance to various stakeholders
Evidence-based practice (EBP): EBP is broadly defined as the use of the
best clinical evidence in making care decisions.

N303- Nursing Theory 9/5/2014 7:31:00 PM
1. Religious Nursing
2. Florence Nightingale
3. Schools or Nursing
4. Rise of Professional Nursing
5. Public Health Nursing 1920s-1950s
6. Hospital Nursing 1965
7. 1980s

pine needle drink from natives to fight survey

Jeanne Mance
- nurse, not a sister
- considered a founder of Quebec
- founded L’hotel dieu
- Grey Nuns not Cloistered
- Grey means colour and tipsy
 ferry, brewery  money for hospital and for employment for handicapped
 barbers
Grey Nuns in Quebec City, Winnipeg, Edmonton. Followed colonization and
fur trade. Not in Ontario or New England due to English.

First school of nursing in St. Catherines. First school of nursing in Alberta
(Medicine Hat). Properties of hospital. Lectures in evening.

Hospitals owned by mining companies in Alberta.

Nurse groups
- organizations (international)

Victorian Order of Nurses

Yukon- gold rush VONs and sisters

Edith Cavell
- angel glacier
- nurses were “angels of mercy”

Health Insurance
- starts in Saskatchewan

McGill model of nursing
Int council of nursing 1989

Robert Calman
Roberta McAdams

Lpn after WWII


N113- Pathophysiology 9/5/2014 7:31:00 PM
Amy- TA
[email protected]
or post on E-class

For games use the two diagrams for pathogen and pathophys.
N305 lab 9/5/2014 7:31:00 PM
[email protected]
N303 Lab 9/5/2014 7:31:00 PM
[email protected]
[email protected]

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