Health Assessment braden scale

Braden Scale
A scale which evaluates a person for pressure ulcer risk; Range of pts from 6-23. Lower score means increase risk for pressure ulcer development
Symptom Analysis
Systematic way to collect data about the history and status of symptoms. Uses the acronym PQRSTUA
What does P stand for in PQRSTUA?
Provocative/Palliative.
What cause the symptom?
What make it better or worse?
What does Q stand for in PQRSTUA?
Quality.
How would you describe the symptom?
What does R stand for in PQRSTUA?
Region/Radiation.
Where is the symptom located?
How does it radiate?
What does S stand for in PQRSTUA?
Severity.
How does the symptom rate on a scale of 0-10 with 10 being the most extreme?
What does T stand for in PQRSTUA?
Timing.
When did the symptom begin?
Is it sudden or graduate onset?
How often does it occur?
What does U stand for in PQRSTUA?
Understanding.
What do you think it means?
What does A stand for in PQRSTUA?
Associated symptoms.
Are there any associated symptoms? For example, like fever, headache, nausea, fatigue, etc.
What is health assessment defined as?
Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgements about nursing interventions based on the findings and evaluating patient care outcomes.
What are the 3 basic types of assessments?
1. Emergency Assessment
2. Focused Assessment
3. Comprehensive Assessment
Emergency Assessment
Utilized in a life threatening or unstable situation in an emergency department.
Triage is ulilized to determin acuity based on:
A-Airway
B-Breathing
C-Circulation
D-Disability
Focused Assessment
Based on specific issues identified by the client or abnormal findings discerned in the comprehensive assessment.
Usually limited to 1 or 2 body systems.
Focuses on the symptoms associated with the clients chief complaint.
Comprehensive Assessment
Includes complete history and physical exam.
Consists of 4 components:
1. Interview
2. Physical Assessment
3. Interpretation/Analysis of findings-critical thinking
4. Documentation
Subjective data
What the patient say about self.
Objective data
Info that is measurable and that the health pro gathers during the assessment of the client
Components of lifesyyle
Activities of Daily Living (ADL’s)-Self care activities-grooming, eating, dressing, home maintenance-meal prep, laundry, shopping, driving, management of finances; Mobility- balance, walking, stairs, use of walking aids.
-Exercise
-Nutrition
-Sleep
-Personal habits-tobacco use, ETOH consumption, drug use
Basic techniques to obtain objective data during health assessment
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Inspection
General observation of the client including hygiene, level of anxiety or discomfort, level of alertness, skin, musculoskeletal structures, lesions, scars, etc.
Note: Color, size, shape, contour, location, movement, behavior, SYMMETRY, odors, and sounds.
Palpation
Texture-rough or smooth.
Temp-warm, hot or cold.
Moisture-dry, wet or moist.
Motion or mobility-fixed, moveable, still, vibrating.
Consistency of structures-soft, hard, fluid filled.
Size-small, medium, large.
Shape-well defined, irregular.
Degree of tenderness.
Edema (swelling).
Palpation-purpose and technique
1. Light palpation (finger tips)-depth 1 cm, assess for surface characteristics.
2. Moderate to deep palpation (palmer surface of fingers)-approx 1-2 cm, assess underlying organs
Percussion
Direct-direct contact of fingertips to pts skin eg.sinuses.
Indirect-non-dominant hand on clients skin and tap with your dominant hand.
Blunt (or fist)-to percuss organs below the surface such as kidneys, liver or gallbladder.
Percussion sounds
Resonance.
Hyper-resonance.
Tympany.
Dullness.
Flatness.
Resonance
Intensity-Loud.
Pitch-Low.
Quality/duration-clear; hollow/long.
Location-Normal lungs
Hyper-resonance
Intensity-Very loud.
Pitch-Very low.
Quality/duration-booming, longer than resonance.
Location-Hyper inflated lungs (COPD).
Tympany
Intensity-Loud.
Pitch-High.
Quality/duration-drumlike/medium.
Location-Gastric bubble in stomach.
Flatness
Intensity-Very soft.
Pitch-High.
Quality/duration-Flat/very soft.
Location-Muscle.
Dullness
Intensity-Soft.
Pitch-High.
Quality/duration-Thudlike/short.
Location-solid, dense organs/bones (liver).
Pulse Range
60-100 beats per minute
Pulse Description
Rate + Range, Regular, Force 2+, Smooth, straight and resilient
Breathing Range for Adult <65
12-20 breaths/minute
Breathing Range for Adult >65
12-24 breaths/minute
Systolic Blood Pressure Range
100-139 mm/Hg
Diastolic Blood Pressure Range
60-89 mm/Hg
Description of Breaths
Eupnea OR relaxed, regular, symmetrical, no distress noted, no shortness of breath, no accessory muscles used
Temperature Range (oral)
36.5 – 37.5 degrees Celsius
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