data Collection and General Survey Data collection includes obtaining subjective and objective information from clients.

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1 chapter 26 Unit 2 Section Chapter 26 Health promotion Health Assessment data Collection and General Survey Overview Data collection includes obtaining subjective and objective information from clients. The health history provides subjective data and is usually obtained during a client interview. The physical assessment and diagnostic tests provide objective data. Comprehensive health histories are part of the health assessment process. Interviewing Techniques Nurses use a standardized format as a framework for obtaining client information. Therapeutic techniques for health assessment are meant to foster communication and create an environment conducive for an optimal health assessment experience for the client. Therapeutic communication helps nurses develop a rapport with clients. The techniques encourage a trusting relationship, whereby clients feel comfortable telling their stories. Nurses introduce the purpose of the interview, gather information, and then conclude the interview by summarizing the findings. Introduces yourself and the various parts of the assessment to each client. Determine what the client wishes to be called. Allow more time for responses from older adult clients. When possible, start by asking for the health history, performing the general survey, and measuring vital signs to build a rapport with the client prior to moving on to more sensitive parts of the examination. Reduce environmental noises (TV, radio, visitors talking) to enhance communication and eliminate distractions. Ensure understanding by obtaining interpretive services if indicated. 216 fundamentals for nursing

2 Use therapeutic communication techniques including: Active listening Shows clients that they have your undivided attention. Open-ended questions Used initially to encourage clients to tell their story in their own way. Ask questions in a language the client can understand. Clarifying Questioning clients about specific details in greater depth or directing them toward relevant parts of the history. Summarizing Validates the accuracy of the story. Avoid using medical jargon, giving advice, ignoring feelings, and offering false reassurance. Components of the Health History The health history provides subjective data relevant to health status. Health History Demographic information Identifying data includes: Name, address, and phone number Birth date and age Gender Race and ethnic origin Marital status Occupation and working status Insurance Family/significant others living at home Source of history Usually comes from the client, but family members, other medical records, and other providers can provide useful information. Note the reliability of the historian. Chief concern A brief statement in the client s own words of why he is seeking care History of present illness Past health history and current health status A detailed, chronological description of why the client seeks care The description should start at the farthest point in time and work toward the present. Details about the symptom(s), such as location, quality, quantity, setting, timing, alleviating or aggravating factors, and associated phenomena are important aspects to explore with the client. Childhood illnesses, both communicable and chronic Medical, surgical, obstetrical, gynecological, and psychiatric history including time frames, diagnoses, hospitalizations, and treatments Current immunization status and the dates and results of any screening tests Allergies to medication, environmental, and food Current medications including prescription, over-the-counter, vitamins, supplements, and time of last dose(s) taken fundamentals for nursing 217

3 Health History Family history Health information of immediate relatives such as grandparents, parents, siblings, children, and grandchildren Current ages or age-at-death are recorded, as well as disorders that were or are present in family members Social history Information regarding the relationships important to the client, support systems, concerns regarding living or work situations, financial status, ability to perform activities of daily living, and spiritual health Health promotion behaviors Exercise/activity, diet, sun exposure, wearing of safety equipment, substance use, stress, and related coping measures Awareness of risks for heart disease, cancer, diabetes, and stroke Review of Systems Review of systems ascertains information about the functioning of all body systems. Related or other health problems may be discovered at this time. This part of the history is usually extensive and can be incorporated into the physical examination of each body system. System Questions to Be Asked Integumentary Do you have any skin diseases? Do you have any itching, bruising, lumps, hair loss, nail changes, or sores? Do you have any allergies? How do you care for your hair, skin, and nails? Do you use lotions, soaps, and/or sunscreen or wear protective clothing? Head and neck Do you experience headaches? If so, how often? and where are they located? Do you have any other symptoms related to your headaches, such as nausea and vomiting? What do you do to relieve the pain? Have you ever had a head injury? Are you able to move your head and shoulders with ease? Are any of your lymph nodes swollen? Have you noticed any unusual facial movements? Do you have any family history of thyroid disease? 218 fundamentals for nursing

4 System Questions to Be Asked Eyes How is your vision? Have you noticed any changes? Do you ever have discharge from your eyes? Do you wear glasses or contact lenses? When was your last eye examination? Do you have any family history of eye disorders? Do you have diabetes? Ears, nose, mouth, and throat How well do you hear? Have you noticed any changes in your hearing? Have other people commented that you have hearing loss? Do you wear a hearing aid? Do you ever experience tinnitus, discharge, vertigo, or pain? Do you have a history of ear infections? What method do you use to clean your ears? Are you having any pain, stuffiness, or discharge from your nose? Do you ever experience nosebleeds? Have you noticed any change in your sense of smell or taste? How often do you go to the dentist? Do you have dentures? Do you have any problems with your gums? Do you have any difficulty swallowing or problems with hoarseness or a sore throat? Do you have allergies? Do you use nasal sprays? Do you snore? Breasts Do you perform breast self-examinations? What time of month do you perform it? Do you have any tenderness or lumps in your breast(s)? Do you have any discharge from the nipples? Is there any history of breast cancer in your family? Are you aware of breast cancer risks? If over 40, do you get an annual mammogram? fundamentals for nursing 219

5 System Questions to Be Asked Respiratory Do you have any difficulties breathing? Do you need to sit up to breathe? Are you ever short of breath? Have you been around anyone who has a cough, cold, or influenza? Do you receive a yearly influenza vaccine? Have you had the pneumonia vaccine? Do you smoke? If yes, for how long and how much? Are you interested in quitting? Are you exposed to second-hand smoke? Do you experience environmental allergies? Any family history of lung cancer or tuberculosis? Any known exposure to tuberculosis? Cardiovascular Do you have any problems with your heart? Do you ever have pain in your chest? Does it radiate? Do you have high cholesterol or high blood pressure? Do you have any swelling in your feet and ankles? Do you cough frequently? Are you familiar with the risk factors for heart disease? Gastrointestinal Do you have any problems with your stomach, such as nausea, vomiting, or pain? Do you have any problems with your bowels, such as diarrhea or constipation? When was your last bowel movement? Do you ever use laxatives or enemas? Have you had any black or tarry stools? Do you use aspirin or ibuprofen? If so, how often? Do you have any abdominal or lower back pain or tenderness? Have you had any recent weight changes? Do you have any food intolerances? What is your 24-hr food history? Do you have any swallowing difficulties? Do you drink alcohol? If so, how much? If over 50, have you had a colonoscopy? Do you know the signs and symptoms of colon cancer? What is your typical day s intake of food and fluid? Do you have any dietary restrictions or special practices? 220 fundamentals for nursing

6 System Questions to Be Asked Genitourinary Do you have any difficulties voiding, such as burning, incontinence, urgency, frequency, nocturia, or hesitancy? Have you noticed any change in the color of your urine? Have you noticed any changes in your menstrual cycle, such as cramps, discharge, or itching? Have you experienced painful intercourse? Have you experienced any sexual dysfunction? Have you had any pain in your scrotum or testes? Musculoskeletal Have you noticed any pain in your joints or muscles? Have you experienced any weakness or twitching? Have you had any recent falls? Are you able to care for yourself? Do you exercise or participate in sports? For postmenopausal women What is your maximum height? For postmenopausal women Do you take calcium supplements? Neurological Have you noticed any change in your vision, speech, ability to think clearly, or loss of or change in memory? Do you have any problems with dizziness or headaches? Do you ever have seizures? Do you ever have any weakness, tremors, numbness, or tingling anywhere? If so, where? Mental health Is there anything stressful going on at work or at home? Do you feel as though you are having any problems with depression? Have you experienced any recent losses? Are you having any problems concentrating? Endocrine Have you noticed any change in urination patterns? Have you noticed any change in your energy level? Have you noticed any change in your ability to handle stress? Have you experienced any change in weight or appetite? Have you had any visual disturbances? Have you had any palpitations? Allergic/ immunologic Do you have any allergies to medications, foods, or environmental substances? Have you ever received a blood transfusion? If so, did you have any adverse reactions? fundamentals for nursing 221

7 Documentation Tell the client you will take notes. To facilitate note taking during the assessment, summarize information for future clarification. Do not rely on total memory recall. Document descriptive, concise, complete, and relevant data. Ensure confidentiality. Use guidelines for appropriate charting. Physical Assessment Techniques During a physical assessment: Ensure adequate lighting. Maintain a quiet and comfortable environment. Provide privacy, using a gown or draping the client with a sheet and visualizing only one section of the body at a time. Explain the various assessment techniques you will use. Look and observe before touching. Keep nails short, and hands and stethoscope warm. Do not feel or listen through clothing. (Clothing can obscure or create sounds.) Have necessary equipment ready. Use standard precautions when in contact with body fluids, wound drainage, and open lesions. Document any values you might forget later. Additional guidelines for performing a physical assessment of older adult clients include: Allow enough time for position changes. Perform assessments in several shorter segments to avoid overtiring older adult clients. Have sensory aids available for older adult clients to use, such as eyeglasses or hearing aids. Inspect, palpate, percuss, and auscultate in that order. The exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds. 222 fundamentals for nursing

8 Inspection Inspection, which is the first step in an assessment, begins with the first interaction with the client and continues throughout the examination. A penlight, an otoscope, an ophthalmoscope, or another lighted instrument may enhance the process. Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. Inspect areas for size, shape, color, symmetry, and position. Palpation is touching to determine the size, consistency, texture, temperature, location, and tenderness of an organ or body part. Palpate tender areas last. Light palpation (less than 1 cm) is required for most body surfaces. Deeper palpation is used to assess abdominal organs or masses. Various parts of the hands are used to detect different sensations. The dorsal surface is the most sensitive to temperature. The ulnar surface and base of the fingers are sensitive to vibration. Fingertips are sensitive to pulsation, position, texture, size, and consistency. The fingers and thumb are used to grab an organ or mass. Starting with light palpation, be systematic, calm, and gentle. Proceed to deep palpation if indicated. Percussion involves tapping body parts with fingers, fists, or small instruments to evaluate size, location, tenderness, and presence or absence of fluid or air in body organs, and to detect any abnormalities. Techniques for percussion include: Direct percussion, which involves striking the body to elicit sounds. Indirect percussion, which involves placing a hand flatly on the body, as the striking surface, for sound production. Fist percussion, which is used to assess for tenderness over the kidneys, liver, and gallbladder. fundamentals for nursing 223

9 Auscultation is the technique used to listen to sounds produced by the body. Some sounds are loud enough to be heard unaided, but most sounds require a stethoscope or a Doppler technique (heart sounds, air moving through the respiratory tract, blood moving through blood vessels). The examiner must learn to isolate the various sounds produced by the body to make accurate assessments. The sounds produced are evaluated for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and quality (what it sounds like). The diaphragm of the stethoscope is used to listen to high-pitched sounds (normal heart sounds, bowel sounds, breath sounds). The diaphragm should be placed firmly on the body part being examined. The bell of the stethoscope is used to listen to low-pitched sounds (abnormal heart sounds, bruits). The bell should be placed lightly on the body part being examined. Equipment Equipment needed for a screening examination includes: Gown Drapes Scale with height measurement Thermometer Stethoscope with diaphragm and bell Sphygmomanometer Reading/eye chart Otoscope, ophthalmoscope, and nasal speculum Penlight (or ophthalmoscope) Cotton balls Sharp and dull objects Tuning fork Glass of water Items to test smell and taste Clean gloves Tongue depressor 224 fundamentals for nursing

10 Reflex hammer Marking pen Measuring tape and clear, flexible ruler with measurements in centimeters Watch or clock to measure time in seconds General Survey The general survey is a written summary of the impressions of the client s overall health. The nurse gathers this information from the first encounter with the client and continues to make observations throughout the assessment process. The nurse will assess: Physical appearance Age Gender and race Level of consciousness Color of skin Facial features Signs of distress (pallor, labored breathing, guarding, anxiety) Signs of possible physical abuse or neglect Signs of substance abuse Body structure Body build, stature, height, and weight Nutritional status Symmetry of body parts Posture and usual position Gross abnormalities (skin lesions, amputations) Mobility Gait Range of motion Motor activity Behavior Facial expression and mannerisms Mood and affect Speech Dress, hygiene, grooming, and odors (body and breath) fundamentals for nursing 225

11 Vital signs Temperature Pulse Respiration Sample Documentation Blood pressure Client 16-year-old male, alert and oriented x 3. No distress noted. Personal hygiene and grooming slightly unkept but appropriate for age. Weight appropriate for height, good posture, and steady gait. Full range of motion. Does not maintain good eye contact. Volunteers no information but answers questions appropriately when asked. No gross abnormalities noted. 226 fundamentals for nursing

12 Chapter 26: Data Collection and General Survey Application Exercises 1. Which of the following is an effective technique to use when interviewing a client? A. Start the interview with nonthreatening topics. B. Use only nondirective questions. C. Have the client fill out a printed history form. D. Ask questions word for word from the history form. 2. A client presents with severe headache pain. Identify what questions to ask to obtain information regarding a symptom analysis. Location Quality Quantity Timing Setting Alleviating or aggravating factors Associated phenomena 3. A client expresses concern over the confidentiality of the information she is providing during her health history. The nurse should respond by telling the client A. exactly with whom the information will be shared. B. that it is required for her to give any information that is requested. C. a confidential piece of information about herself. D. her family members will be informed of necessary information. 4. Which of the following therapeutic techniques is used to provide a comfortable environment for performing a health assessment? (Select all that apply.) Provide privacy. Examine sensitive areas first. Reduce environmental noises. Explain various techniques before performing them. Use medical terminology to save time. fundamentals for nursing 227

13 5. Identify the location where the following percussion sounds are normally produced in the body. Tympany Resonance Dull Flat Percussion Sound Expected Location to be Heard 6. Put an X in the box for the appropriate technique(s) used to assess each of the following. (Select all that apply.) Assessment Inspection Palpation Percussion Auscultation Pupil size Ankle edema Skin temperature Bowel sounds Loose teeth Liver size External ear Kidney tenderness 7. The nurse should use which part of the hand to assess for vibration? A. Ulnar surface B. Finger pads C. Dorsal surface D. Palmar surface 8. The correct order for performing abdominal assessment techniques is A. inspection, palpation, percussion, and auscultation. B. inspection, auscultation, percussion, and palpation. C. auscultation, inspection, percussion, and palpation. D. auscultation, palpation, percussion, and inspection. 228 fundamentals for nursing

14 Chapter 26: Data Collection and General Survey Application Exercises Answer Key 1. Which of the following is an effective technique to use when interviewing a client? A. Start the interview with nonthreatening topics. B. Use only nondirective questions. C. Have the client fill out a printed history form. D. Ask questions word for word from the history form. Starting the interview with nonthreatening topics will facilitate establishing rapport and trust between the client and nurse. Using nondirective questions may make the client feel comfortable, but may allow the client to avoid discussing important details. Having the client fill out a history form and asking questions word for word may discourage the establishment of a therapeutic relationship with the client. NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment 2. A client presents with severe headache pain. Identify what questions to ask to obtain information regarding a symptom analysis. Location Quality Quantity Timing Setting Alleviating or aggravating factors Associated phenomena Where is your headache? Point to where it hurts. What does the pain feel like? Is it dull, stabbing, throbbing, and/or achy? On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you have ever experienced, how would you rate the pain? When did the pain start? How long have you had it? Is it constant or intermittent? Where are you when you experience the pain? Does it happen at work? At home? What makes the pain better or worse? Have you taken any medications for the pain? Do you have any nausea? Are you dizzy? NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment fundamentals for nursing 229

15 3. A client expresses concern over the confidentiality of the information she is providing during her health history. The nurse should respond by telling the client A. exactly with whom the information will be shared. B. that it is required for her to give any information that is requested. C. a confidential piece of information about herself. D. her family members will be informed of necessary information. The client has a right to confidentiality and the right to know with whom her information will be shared. The client has the right to refuse to reveal information if she chooses. The nurse telling the client confidential information about herself is not professional. Giving information to family members is a violation of confidentiality. NCLEX Connection: Management of Care, Confidentiality/Information Security 4. Which of the following therapeutic techniques is used to provide a comfortable environment for performing a health assessment? (Select all that apply.) X X X Provide privacy. Examine sensitive areas first. Reduce environmental noises. Explain various techniques before performing them. Use medical terminology to save time. Providing for privacy, reducing environmental noises, and explaining techniques to be used will facilitate establishing a trusting relationship and performing a health assessment. Sensitive areas should be examined after the client has developed some trust and feels more comfortable. Medical terminology may confuse the client and lead to misunderstanding of the intended message. NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment 5. Identify the location where the following percussion sounds are normally produced in the body. Tympany Resonance Dull Flat Percussion Sound Expected Location Gastric bubble Lungs Liver Muscles NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment 230 fundamentals for nursing

16 6. Put an X in the box for the appropriate technique(s) used to assess each of the following. (Select all that apply.) Assessment Inspection Palpation Percussion Auscultation Pupil size Ankle edema X X Skin temperature Bowel sounds Loose teeth X X X Liver size X X External ear X X Kidney tenderness NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment 7. The nurse should use which part of the hand to assess for vibration? A. Ulnar surface B. Finger pads C. Dorsal surface D. Palmar surface The ulnar surface of the hand is the most sensitive to vibration. NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment 8. The correct order for performing abdominal assessment techniques is A. inspection, palpation, percussion, and auscultation. B. inspection, auscultation, percussion, and palpation. C. auscultation, inspection, percussion, and palpation. D. auscultation, palpation, percussion, and inspection. X The abdomen is examined using inspection, auscultation, percussion, and palpation. Percussion and palpation are delayed to avoid changing normally occurring bowel sounds. NCLEX Connection: Health Promotion and Maintenance, Techniques of Physical Assessment X X fundamentals for nursing 231