Chapter 47 Data Collection in Client Care

1. Chapter 47Data Collection in Client Care

2. Collecting Data and Physical Examination • Identifies and clarifies a client’s health status • Medical diagnosis • Primary healthcare provider • *Emphasizes disease process • *Identifies the disease or disorder • Estimates disease’s • Course • Outcome (prognosis)

3. Collecting Data and Physical Examination, cont. • Nursing diagnosis • Concise problem-centered description of actual or potential health problems • Based on nursing process • For unusual problems that may arise, provide needed care measures within nurses scope of practice • Stated in terms of NANDA groupings

4. Data Collection to Assist in Diagnosis • Nursing history or interview • Physical findings • Observation/assessment findings • Documented in language all members of healthcare team understand

5. Data Collection • **COLDSPA • Character • Onset • Location • Duration • Severity • Pattern • Associated Factors

6. Nursing Care Plan and Data Collection • Nursing care plan • All members of the healthcare team participate in carrying out the plan. • Factors that influence data collection • Risk factors for disease and illness • Course of the disease, body’s response to the disease • Laboratory tests and special diagnostic procedures

7. Data Collection • Risk factors for disease • Diet, immobility, lack of exercise, age, obesity, smoking and use of smokeless tobacco, excessive use of alcohol and other drugs, heredity, and race • Course of the disease • Acute disease • Chronic disease • Primary disease • Secondary disease

8. Factors That Influence the Course of the Disease or Disorder • Acutedisease • Develops suddenly and runs its course in days or weeks • Chronicdisease • Continues for months, years, or life • Acuity • Level of severity

9. Factors That Influence the Course of the Disease or Disorder, cont. • Complication • Unexpected event in the disease’s course that often delays recovery • Primarydisease • Occurs independently by itself • Secondarydisease • Direct result of or dependent on another disorder

10. Body’s Response to Disease • Signs • Objective evidence (data) of disease that can be seen or measured • Symptoms • Subjective evidence (data) of disease; sensations that only the client knows and can report

11. Body’s Response to Disease, cont. • Inflammation • Body’s response to some type of injury • Infection • Invasion of cells, tissues, or organs by pathogens • Malaise • Overall feeling of illness

12. Body’s Response to Disease, cont. • Exudate • Excess of fluid and cells usually present in or oozing from tissues • Purulent • Contains pus • D/t presence of bacteria • Suppuration • Formation of pus

13. Body’s Response to Disease, cont. • Abscess • Collection of pus in a localized area • Necrosis • Tissue death • Granulation tissue • New tissue • Ulcer • Local unhealed area of epithelial tissue • Healed area-scar or keloid

14. Body’s Response to Disease, cont. • Wound sinus • Canal or passage leading to an abscess • Fistula • Abnormal tube like passage that connects two internal organs, or connects an internal organ to the surface of the body • Chronic inflammation • Persists over a long period of time • Does not follow the usual healing process

15. Body’s Response to Disease, cont. • Subacute inflammation • Midway in severity between acute and chronic • Acute inflammation • Heals and leaves no aftermath or other related disorders (sequelae)

16. Urinalysis (UA) *Complete blood count (CBC) *Urine drug/alcohol screen (UTox) *Urine pregnancy test (UPT) *Culture and sensitivity (C&S) *Type and crossmatch (T&X) Stool examinations *Blood (guaiac or Hemoccult) Ova and parasites (O&P) Blood tests *Metabolic panel baseline data, differentiate mental illness from other disorders, evaluate clients with total body situations (ETOH, drug toxicity, assess # of organs at once) Blood chemistries Examples of Laboratory Tests

17. *Selected Diagnostic Tests • Skin tests • Patch/scratch • Musculoskeletal tests • Neurologic tests • Cardiovascular tests • Stress test • Echocardiogram • Cardiac catheterization

18. *Selected Diagnostic Tests • Respiratory tests • Chest radiograph • Pulse oximeter • Bronchoscopy • ABG • Gastrointestinal tests • Oral endoscopy • Barium enema • Urologic tests • Urinalysis (UA) • Gynecologic tests

19. Xrays and other exams • Spirometry • Pulmonary function tests • Help determine respiratory status

20. Special Types of Diagnostic Procedures • Determine abnormalities or disorders of various body systems • *Endoscopy (endoscope) • Long, slender, flexible tube with a fiberoptic scope (similar to a TV camera) on the end • Passed through body orifice to examine internal body areas • Esophagoscopy • Sigmoidoscopy

21. Lumbar Puncture (LP), Spinal Tap • Indicates some disorders and conditions of nervous system • Determines intracranial pressure (ICP) • Indicates presence of abnormal components • Used to administer drugs or spinal anesthesia

22. Preparing the Client for Diagnostic Procedures • **Informed consent is required for most procedures. • Explain the procedure and the need for the procedure. • Nursing responsibilities • Assist the client to maintain NPO status, special diet, or medications before examination. • Transport the client. • Update client record. • Position and drape the client. • Frequent vital sign monitoring.

23. Responsibilities Relating to Diagnostic Examinations/Procedures • Client responsibilities • Maintain nothing by mouth (NPO) status • Eat a special meal before the examination • Take specific medications prior to the examination • Nursing responsibilities • Reassure client • Teach and answer questions • Use therapeutic listening skills

24. Physical Examination • The goals of data gathering and physical assessment performed by nurses are to: • Distinguish between normal and abnormal. • Identify potential problems. • Promptly report changes, unusual or abnormal findings to the appropriate person. • Deliver client care within the prescribed scope of practice.

25. Examination Techniques • Inspection • Careful, close, and detailed visual examination of a body part • Palpation • Feeling body tissues or parts with hands or fingers • Auscultation • Listening with stethoscope or ultrasound blood-flow detector (Doppler) • Percussion • Tapping or striking the fingers against body; resulting sounds indicate the place and density of body tissues or organs

26. Examination Tools

27. Tools Used in an Examination • Ophthalmoscope • Instrument to look at retinas of eyes through pupils • *Otoscope • Instrument to examine ear canals and eardrum • Tuning fork • Checking hearing • Reflex hammer • Test reflexes

28. Tools Used in an Examination, cont. • Speculum • Vaginal speculum • Nasal speculum • Neurological testing • Devices to test the tactile senses of sharp, soft, hot, or cold, eg, pin, ice, hot pack, cotton swab, etc. • Test for ability to smell and taste substances

29. Examination • Preparing for the physical examination • Performing the physical examination • Head-to-toe method • Body systems • Focused physical examination • One body system is thoroughly examined* • Caring for the client following any examination or testing.

31. General Examination • Emaciation • Physical wasting • Skin assessment • Turgor • Skin resiliency and plumpness • Erythema • Redness • Pallor • Edema • Temp • Ecchymosis • Bleeding into the tissues under the skin, leaving small bruises

32. Skin Color Variations

33. Normal and Abnormal Fingernails

34. General Examination, cont. • Skin assessment, cont. • Anasarca • Serous • Containing clear fluid • Purulent • Consisting of or secreting pus • Serosanguineous • Fluid composed of serum and blood

35. Primary Skin Lesions

36. Head and Neck Assessment • Cognitive function • Ability to think and reason • Baseline mental status • *Glascow Coma Scale • Dysphasia • Difficulty in understanding or expressing language • Conjunctivitis • Commonly called pink eye; inflammation of the conjunctiva

37. Head and Neck Assessment, cont. • Accommodation • Adjustment, as the accommodation of the lens of the eye • Strabismus • Deviation of the eye; squint • Diplopia • Double vision • Rinne and Weber test • Snellen Chart • 20/20 vision

38. Musculoskeletal Assessment • Homans’ sign • Test for thrombophlebitis in which pain occurs behind the knee when the foot is flexed upward (dorsiflexion) • Thrombophlebitis • Formation of a blood clot in a vein, with inflammation Abduction Adduction

39. Curvatures of the Spine • Lordosis • Abnormal increase in the lumbar curvature of the spine • Also known as “swayback” • Kyphosis • Abnormal increase in the thoracic curvature of the spine • Hunchback appearance, commonly R/T osteoporosis • Scoliosis • Lateral curvature of the spine • Sometimes is S-shaped

40. Cardiovascular Assessment • Heart Sounds • Pulse • Rate • equality

41. Types of Lung Sounds (Adventitious Sounds) • Crackles (also known as “rales”) • Small airway obstruction, may be local or generalized • Rhonchi: larger airway obstruction heard by auscultation, deep sound, may be local or generalized • Wheezes (may be inspiratory and/or expiratory) • Whistling respiratory sound, typical of asthma • Stridor: shrill and harsh sound heard on expiration

42. Abnormal (Adventitious) Lung Sounds

43. Abdominal Assessment • Stool Guaic • Striae • Stretch marks • Herniation • Condition in which there is an abnormal protrusion of an organ or tissue through the structure usually containing it