Chapter I Introduction to the Course

Chapter II Collection Techniques

Chapter III Hematology Blood Tests

Chapter IV Special Serology and Blood Chemistry Tests

Chapter VII: STD and HIV Blood Tests

Chapter VIII: Arterial Blood GAS Interpretation

Chapter IX: Select Diagnostic Tests

References

Chapter I     THE NURSING PROCESS AND
GERIATRIC ASSESSMENT CONTINUED

EVALUATION

Evaluation is the purposeful examination and use of measurement data, devices and methods to determine effectiveness of nursing actions and your approach toward achieving short range and long range patient care goals.

Evaluation also includes determination of the problems that have been resolved, that are still unresolved and new ones that have arisen.  Evaluation is the last step in the nursing process.  However, evaluation cannot be separated from assessment, formulating a nursing diagnosis, determining objectives and planning care and intervention.

Evaluation includes predicting outcomes through long term and short term goals.  These outcomes are expressed as behavioral objectives (patient responses) that you expect to see after nursing intervention.  They indicate progress in achievement of stated goals.  The current behaviors of the patient act as a baseline for expected change within a certain limit.

Statements of goals help you not only to determine specific interventions to use, but also the specific patient behaviors that would indicate that these goals have been achieved.  When a behavioral objective (predicted outcome) is reached, a new objective corresponding to progress in status is written (Murray 1980).

Behavioral objectives are based on priorities of care.  They establish the criteria for evaluation.  They must be either observable to the client or to the nurse.  If they are not observable, they must be measurable in some way.  Therefore, the cause of unexpected outcomes can be determined and further negative effects can be avoided.

Nursing can be evaluated for:

EFFORT, EFFECT, EFFICIENCY (Curtis 1975)

Measuring EFFORT involves asking the following questions:

1. What has been done compared to the stated objective of care?
2. Was as much done as could have been done?

Measuring EFFECT involves seeking information about change or lack of change in the patient’s situation:

1. Was the change important?             4.  Was the change safe?
2. Was the change intended?               5.  Was the change necessary?
3. Was the change expected?               6.  Was the change desirable to the patient and the nurse?

Measuring EFFICIENCY involves seeking information on:

1. How actions were performed in terms of time, energy and materials?
2. If the results of nursing care were satisfactory, how many actions were necessary to accomplish the care?

Evaluations should be continuous so that insights gained can be used to reassess the person, modify plans and improve care throughout the nursing process.  Evaluation benefits the senior and the nurse because it provides a final statement about patient progress and is a critical examination of nursing practice (Murray 1979).

Evaluation of care is directly related to accountability.  Accountability is the state of being responsible for your actions and being able to explain, define or measure the results of your decision making.  Accountability involves measuring your effectiveness against a set of criteria.  These criteria might be the unit’s general care standards, the agency’s policies or the patient’s care objectives.  Accountability involves validating intangibles such as attitudes and subtle nuances as well as overt care measures.  You are accountable to the client, the family, the group, the agency, the physician, other health care team members and the community.  Your accountability assures optimum health care delivery.

In summary, your responsibility is to:

1. Assess thoroughly the senior’s health care needs.  This cannot be delegated.  Tools can be utilized, but it is your responsibility to validate any information on a nursing history form collected by someone other than yourself.
2. Determine nursing diagnosis based on your assessment.
3. Plan with the team, supervise others and teach care measures needed by the person or family.  You must assume responsibility for the patient care objectives and the level of care rendered.  Therefore, your responsibility will include supervising, teaching and assigning personnel according to their qualifications and the senior’s needs.
4. Give care when indicated, acting as a role model for other staff members.
5. Evaluate care and determine whether or not goals have been met.  You must take corrective action as indicated. 

Through this process you demonstrate accountability.

As you read the steps of the nursing process, you are no doubt aware that the process is continuous and circular.  Some steps of the process overlap.  For example, while you are doing one intervention, such as bathing the senior, you are simultaneously assessing him or her and mentally making a plan.  That plan might be how you will continue with your intervention of giving skin care and ambulation.  You may think that your mental or verbal plan is sufficient.  However, you will likely find that a written plan is essential to provide for consistency of care.  Other nursing team members cannot read your mind.  Share what you know and plan, both the team and the patient will benefit.

THE GERIATRIC ASSESSMENT
BASIC CONSIDERATIONS

Approaching an elderly patient for a health history and conducting the interview need not be difficult if you anticipate his/her special needs.  If possible, plan to talk with the elderly client early in the day when he/she is likely to be most alert.  Many elderly experience the so-called “sundown syndrome”.  This means their capacity for clear thinking diminishes by late afternoon or early evening.  Some of these patients may even become disoriented or confused late in the day.

Have a comfortable chair available for your elderly patient, (if not on bed-rest) especially if the interview will be lengthy.  If the patient is on bed-rest, then have a comfortable chair for yourself.  Be sure to encourage your patient to move around in bed or change position often because some orthopedic disabilities may make being in one position for a long time uncomfortable.

The elderly may have mild hearing and vision loss.  Sit close and face him/her.  Speak slowly in a low-pitched voice.  Do not shout at the patient who has a hearing problem.  Shouting raises the pitch of your voice and may make understanding more difficult, not easier.  Hearing loss from aging affects perception of high-pitched tones first.

Try to evaluate your patient’s ability to communicate, and his reliability as a historian, early in the interview.  If you have doubts about these matters before the interview begins, ask if a family member or close friend can be present to verify facts.

Do not be surprised if your elderly patient requests that someone accompany him/her during the interview.  The patient may have concerns about getting through the interview alone.  Having another familiar person present during the interview gives the nurse an opportunity to observe the patient’s interaction with this person and provides more data for the history.  However, this might also prevent the patient from speaking freely about certain subjects.  Therefore, plan to have some private time with the patient as well as time with the other person present.

GERAITRIC ASSESSMENT TOOL
A  SOCIOCULTURAL ASSESSMENT
(For use on admission to the hospital, nursing home or residence for senior citizens.)

I. Identifying data

II. Environment

1.  Describe neighborhood and geographical area in which you reside
   What about it was important to you?
   
   
2.  Describe your current or previous home and arrangement of space:
   What health hazards are or were present?
   
   
3. What transportation facilities do or did you use?
   
   
4. What leisure activities or recreation do you pursue?
   Where?  With whom?
   
   
5.  What was or is the environment at work?
    What health hazards were or are present?

III: Socioeconomic Level and Life-Style

1.  How would you describe your socioeconomic level and life-style?
   How do you think these have affected your health?
   
   
2.  How has your health status affected your life-style?
   
   
3. What changes do you expect in your life-style as a result of growing older? Illness, hospitalization, admission to hospital?
   
   
4.  What special practices or foods do you consider essential?

IV: FAMILY PATTERNS

1.  Marital status.
2. Children.
3. Other important members of the family.
4. Who resides in the home with you?
5. What is the usual daily living pattern in your family?
6. What family events are important?
7. What rituals are important in your family?
8. How do daily living pattern and rituals affect your health?

Family Functions and Interactions:

1. What is your role in the family?
2. How are decisions made in the family?
3. Who helps provide for the family?
4. Who has the responsibility for the various family tasks?
5. What are your special concerns in your family?

V: RELIGIOUS PRACTICES

1.  What church or religious denomination do you belong to as a member?
2. Are you active in that church?
3. Are there special beliefs that you adhere to?
   How do these beliefs affect your health?
4.  How do you see your relationship to God during this time period?
   What affect does God have on your health or illness?
5.  If you do not prescribe to a particular religion, what are your basic beliefs and values?
6. How do these beliefs and values affect your health or illness?
7. What can the nurse do to assist you in practicing your religion or beliefs during your stay at this center?

VI: MEMBERSHIPS

1. What groups/organizations in the community to you belong to?
2. What is your role in these groups?
3. How much satisfaction do you get from group activities?

VII: PERSONAL VALUES  (consider expressed ideal vs. real)

a. What are your ideas about the following:

Man and the environment relationship?

Privacy vs. group interaction (being with others)?

Possessions (personal vs. shared)?

b.  Time orientation:

Do you like to have things done promptly?

Do you rely on past experiences primarily?

Do you like to plan ahead into the future?

How do you feel if you know that you or someone else is going to be late to an event?

 c. Work or Activity – Leisure Orientation:

How much time do you spend in work tasks daily?

Do you prefer to be busy?  Sitting and thinking; Reading or relaxing?

What do you do to relax?

How much time do you spend in leisure daily?

 d. Attitude toward change:

How do you feel when you hear the word change?

How often do you make/have you made changes in your life?

What changes would you like to make in yourself?  In others?  In the environment?

e. Education:

 Level of school achievement?

How important is education to you?

What do you consider necessary for achievement?

f. Health-Illness Value or Definitions:

When do you consider yourself or members of your family healthy?

When do you consider them ill?

What do you do when you or members of your family become ill?

What customs, special practices or rituals do you and your family engage in to keep healthy?

Do you and your family have any specific beliefs or observe any specific traditions concerning health?

NOTE:  This tool could be adapted by the nurse who is working in the home health care agency and in other settings.

PHYSICAL ASSESSMENT
(For use on admission to the hospital, nursing home or residence for senior citizens.)

The Health history Includes the Following Data:

I. Identifying Data:

Name:	Sex:
Address:	Race/Ethnicity:
Age:
Marital Status:	If widowed, when?
Occupation:	If retired, date?
Reason for contacting health agency:

II. A concise statement of the Chief Complaint and its Duration

III. Concise chronological description:  Present health status and present illness

IV.Past Medical History

(Beginning as far back as the person can remember and continuing up to the time when he considered himself to be in good health.)

1. Childhood:
   
   
2. Medical:
   
   
3. Surgical, including accidents:
   
   
4. Psychiatric:
   
   
5. Obstetrical:
   
   Number/outcomes of pregnancies, abnormalities or complications.
   
   
6. Hospitalizations:
   
   Include names of hospitals, dates, attending physicians and problems.
   
   
7. Previous routine or periodic examinations.
   
   
8. Exposure to known cause of illness:
   
   Travel in foreign countries, exposure to toxic substances.
   
   
9. Allergies – to what and what reactions:

V. Personal and Social History

1. Childhood:
   Birth (when & where), family group, education, environment, problems:
   
   
2. Adulthood – employment history, military service:
   
   
3. Sexual & marital history – marital status, sexual activity, children:
   
   
4. Present life-style:
   Descriptions of home, occupation, family life, affiliations, habits:
   
   Tobacco:  Type – cigarettes, cigars, pipe, chewing, snuff.
   Age at which began use.
   Current level of usage.
   
   Beverages:  Coffee, tea, cola.
   Alcohol:  Average daily use or weekly consumption.
   
   Drugs:  Drug use – including legal and illegal drugs, prescription drugs,
   over-the-counter drugs.
   
   Present schedule and dosage – Sleeping pills, aspirin, weight-control drugs,
   antihistamines, folk remedies, laxatives, enemas, vitamins.
   
   Personal Habits:  Sleep, working hours, travel, vacation, hobby or leisure activities
   

 Nutrition and hydration (sample one day’s diet and fluid intake).

 Special diet needs.

Family history:

Health status of close relatives:

Presence of specific diseases:  Diabetes, tuberculosis, cancer, mental illness, illness similar to the patient’s present illness:

Family tree:  Include grandparents, parents, siblings, children

Religious practices:  Denomination, church location, pastor, usual attendance.

Do you anticipate any specific spiritual/religious needs?  If so, what?

THE REVIEW OF SYSTEMS AND THE PHYSICAL EXAMINATION
INCLUDES THE FOLLOWING DATA:

 I. MEASUREMENT OF VITAL SIGNS

Weight:                 Height:                           Pulse:  (rate, rhythm)
Temp:                    Resp:  (rate, rhythm)    BP:  (arm & position)

II. GENERAL APPEARANCE

Opening statement describing muscular development, posture, position of body, body movements, nutritional status, appearance of acute or chronic illness, whether he/she appears his/her age, personal hygiene.)

a. HISTORY OF ANY WEAKNESS: Fatigue, malaise, fever, chills, weight gain or weight loss.

b. SKIN: Color, temperature, turgor, moisture, pigment changes, bruises, pressure areas, decubitus, lesions, rashes and scars (location), dryness, texture, appearance of nails, size and shape of fingers (clubbing), use of hair dyes or other agents.

c. HEAD: History of headache, head injury, dizziness, syncope.

d. EXAM:

1.  Skull – deformities
2. Scalp – scaling
3. Hair – color, baldness, parasites
4. Face – expression, edema, muscle tics, paralysis

e. EYES: History of pain, use of glasses, last change in refraction, diplopia, infection, glaucoma, cataract.

1. Vision – near, distant and peripheral
2. Pupils – reaction to light and accommodation, equality of size
3. Condition of lids, conjunctiva and sclera – movements, the expression, presence of discharge

f. EARS:

History of earaches, hearing loss, use of hearing aid, presence of tinnitus, vertigo, discharge, infection, pain.

1. External – auditory meatus, tympanic membrane, general appearance
2. Hearing – distance whispered word heard

g. NOSE:

History of sinus pain, epistaxis, obstruction, discharge, postnasal drip, colds, sneezing.

1. External – size, shape, smell, difficulty in breathing, discharge
2. Internal – patency, polyps, septal deviation, others.

h. MOUTH:

History of toothache, recent extractions, soreness or bleeding of lips, gums, mouth, tongue or throat, disturbance of taste, thirst, hoarseness, tonsillectomy.

1. Lips – pallor, cyanosis, lesions, dryness
2. Teeth – natural, state of repair, dentures.
3. Gums – bleeding, retracted, color, hypertrophic.
4. Tongue – color, size, deviation, hydration, lesions, tremors, paralysis.
5. Pharynx – motion of palate, uvula, tonsils, gag reflex, posterior pharynx-hoarseness, difficulty speaking or swallowing, ulcerations, inflammation.

i. NECK:

History of pain, limitation of motion, thyroid enlargement.

1. General – stiffness, R.O.M., tenderness, veins, pulses, bruits.
2. Thyroid – enlargement, nodules, tenderness.
3. Lymph glands – size, consistency, tenderness.

j. THORAX:

History of pain, breast lumps, discharge or operations.

1.  Chest – size, shape and movements.
2. Breasts – nipple discharge, areola, contour, symmetry, masses (size, location, shape, consistency, fixation), skin ulceration, axillary nodes.

k. HEART:

History of pain or distress, palpitations, dyspnea (relate to effort), orthophea, paroxysmal nocturnal dyspnea, edema, nocturia, cyanosis, heart murmur, rheumatic fever, hypertension, coronary artery disease, anemia, last EKG.

1. Inspection:
   1. Apex beat, relation to midclavicular or midsternal line.
   2. Other pulsations.
2. Palpation:
   1. Size, vigor of apex beat.
   2. Left sterna lift, epigastric palpation, thrills.
3. Percussion:
   1. Distance of dullness from midsternal line in left second to sixth or seventh interspace.
4. Auscultation:
   1. Quality and intensity of S1 and S2 in each valve area.
   2. Splitting.
   3. Extra sounds – S3 and S4.
   4. Murmur – location ,radiation, systolic or diastolic, intensity, frequency, character-crescendo, decrescendo, holosystolic.

l. LUNGS:

History of pain, cough, sputum (character, amount), hemoptysis, wheezing, asthma, shortness of breath, bronchitis, pneumonia, TB, or contact with, date of last x-ray or skin test and the results of these.

1. Inspection:
   1. Breathing pattern.
   2. Symmetry.
   3. Venous pattern.
2. Palpation:
   1. Vocal fremitus.
   2. Use of accessory muscles.
3. Percussion:
   1. Location by inter-space dullness, flatness, hyperresonance, or tympany.
4. Auscultation:
   1. Type of breath sounds – vesicular, bronchial, or bronchovesicular.
   2. Adventitious sounds – rales, cavernous breathing, asthmatic breathing, friction rub.
   3. Vocal resonance – bronchophony.

m. ABDOMEN:

History of appetite, food intolerance, dysphagia, heartburn, pain or distress after eating, colic, jaundice, belching, nausea, vomiting, hematemesis, flatulence, character and color of stools, any change in bowel habits, rectal conditions, ulcer, gallbladder disease, colitis, hepatitis, appendicitis, parasites, hernia.

1.  Inspection:
   1. Distention.
   2. Masses.
   3. Peristalsis (visible).
2. Palpation:
   1. Tenderness of light or deep palpation.
   2. Masses (location, consistency, mobility, nodularity).
   3. Rigidity.
   4. Organ outlines (liver, spleen).
3. Percussion:
   1. Abdominal distension (air or ascites).
   2. Bladder distension.
4. Auscultation:
   1. Bowel sounds.
   2. Bruits.

n. EXTREMITIES AND BACK:

History of intermittent claudication, varicose veins, thrombophlebitis, joint pain, stiffness, swelling, arthritis, gout, bursitis, flat feet, infection, fracture, muscle pain, cramps; assistance devices utilized (prostheses, cane, crutches, walker, wheelchair).

1. Blood vessels – pulse veins.
2. Joints – tenderness, deformities, crepitation, range of motion.
3. Edema – location, pitting, discoloration.
4. Reflexes.
5. Sensation – pain and temperature, vibration position.
6. Muscular function – standing on toes, strength of movement.
7. Gait and stance – walking, standing with eyes closed.
8. Back – pain (location and radiation, especially to extremities), stiffness, limitation of movement.

o. GENITOURINARY:

History of urinary tract – renal colic, frequency, nocturia, polyuria, oliguria, hesitancy, urgency, dysuria, narrowing of stream, dribbling, incontinence, hematuria, albuminuria, pyuria, kidney disease, facial edema, renal stone, cystoscopy; genital (male) – testicular pain, scrotal change, nodules in scrotum; genital (female) – menstrual history, vaginal bleeding or discharge, menopause and associated symptoms, date of last PAP smear, venereal disease – gonorrhea or syphilis (note date, treatment, complications); sexual – drive, activity, pleasure, discomfort, impotence.

Examination of the male genito – Urinary System:

1. Penis
2. Scrotum – size, symmetry, consistency, tenderness, masses, atrophy.
3. Inguinal region – pulses, lymph glands, hernia, parasites.
4. Character of urine – presence of indwelling catheter, date changed.

Examination of the female reproductive system:

1. External genitalia.
2. Vulva – ulceration.
3. Urethra – discharge
4. Pelvic relaxation – cystocele, rectocele, prolapse uterus (degree).
5. Internal genitalia.
6. Speculum exam of vagina (discharge, ulcerations, irregularities).
7. Cervix (ulceration, irregularity), PAP smear.

Examination of the rectum:

1. External inspection - hemorrhoids, perianal skin, pilonidal cyst.
2. Internal palpation – sphincter tonicity, abscess, prostate enlargement, rectal masses, impaction.

p.       CENTRAL NERVOUS SYSTEM:

General history – syncope, loss of consciousness, convulsions, meningitis, 
encephalitis, stroke.

Mentative – aphasia (describe), emotional status, mood, orientation, memory,
change in sleep pattern, psychiatric illness.

Motor – tremor, weakness, paralysis (describe involvement), clumsiness of
movement.

Sensory – neurological pain, reduced sensation, paresthesia.   

q.  HEMATOPOIETIC:

Bleeding tendencies; of skin or mucous membranes; anemia and treatments, blood type,
transfusions, any reactions; blood dyscrasias, exposure to toxic agents or radiation.

r.    ENDOCRINE:

History of nutrition and growth; thyroid function – (changes in skin, relationship of
appetite to weight, nervousness, tremors, thyroid medications), diabetes or its
symptoms, hirsutism, secondary sex characteristics, hormone therapy.

Activities of Daily Living Survey

Next: Chapter II: PSYCHOLOGICAL ASSESSMENT