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Holistic Health Assessment 2 Trauma Informed Care Definitions: Crisis Trauma Violence Trauma Informed Care and Approach

Relationship of Violence and Trauma • Different forms of violence can have interrelated traumatic effects • Examples: o Child maltreatment can increase a person's vulnerability to interpersonal violence in adulthood o Children's exposure to intimate partner violence can result in negative health and social outcomes like those resulting from more direct forms of abuse o Exposure to systemic violence (such as racism) can increase a person's vulnerability to all other forms of violence Types of Crisis:

Phases of Crisis

Signs and Symptoms of Crisis Unique to each person. Examples of signs and symptoms of Crisis • Inability to meet basic needs • Decreased use of social support • Inadequate problem-solving • Inability to attend to information • Isolation • Denial • Exaggerated startle response

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Holistic Health Assessment 2

Practice Recommendations for Trauma Induced Care

Guiding Values (RNAO, 2017) • 1. Avoiding Harm • 2. Intervening in person-centered ways • 3. Shared responsibility • 4. Trauma informed • 5. Establishing feelings of personal safety • 6. Strength based

Health Care Providers’ Responses to IPV • There is inconclusive evidence as to whether routine screening is effective. • Greater detection of abuse did not necessarily lead to meaningful responses. • Women report negative experiences with HCPs who focus on physical consequences, rather than • wider effects and context of IPV.

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7. The whole person 8. The person as a credible source 9. Recovery, resilience, and natural supports 10. Prevention 11. Services are provided in the least restrictive manner 12. Right are reserved.

All care should be informed by knowledge of trauma and violence Listening High index of suspicion for abuse Assessing collaboratively, using a relational approach Physical examination Documentation Women who are victims of IPV will disclose when they feel confident enough to do so.

Listening Listening nonjudgmentally requires health care providers to evaluate social judgements commonly made about abused women Assessing Collaboratively • Following the woman’s lead • Listening for cues of abuse • Self-observation of biases and assumptions • Pattern recognition 2

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Collaboratively developing knowledge Naming and supporting capacity

When Abuse Is Disclosed • Assess level of risk and develop a safety plan. • Identify personal strengths and supports. • Identify appropriate goals with the woman, in collaboration with other health care providers.

HCP’s Responses to Child Abuse • Possible harm related to screening outweighs benefits • Reporting suspicion of child abuse mandatory in most provinces and territories • Approaches similar to IPV but attention to: • greater vulnerability of children. • need for accommodation of developmental stage of child. • Race and class stereotypes • Neglect and emotional abuse most common

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Conduct a thorough assessment. Ensure objective, unbiased documentation. Take photos of injuries. Use verbatim statements in documentation, where possible.

Parents not only possible perpetrators Most allegations are not substantiated Stress of removal of child from parents Influence of dominant stereotypes of good mothering Obligation to provide good care to parents Nursing role as child “rescuer” at expense of relationship with parents or child-parent relationship

Physical Examination • Complete head-to-toe examination • Multiple factors can contribute to bruises in older adults: • Medications and abnormal blood values • Underlying hematological disorders • Accidental bruising (on extremities) • Health evaluation for known or suspected elder abuse and neglect should include baseline • laboratory tests Physical Examination of Children • Significant trauma to children defined as any injury more severe than temporary redness of the skin • Suspicion when there is bruising in infants who are not yet mobile. Bruising in “atypical” places, or bruising that takes the shape of an object

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Canadian Paediatric Society guidelines for head trauma, including “shaken baby syndrome”

History & Documentation • Prior abuse • History of traumatic injuries • Mental health examination • Detailed, objective, unbiased notes: o Use of injury maps o Photographic documentation Photographic Documentation : Characteristics • Patterned, punchlike abrasion to the mid-forehead from an assailant wearing a ring with a stone. • Sutured laceration to the left eyebrow. • Sutured partial-avulsion injury to the nose. • Punchlike contusion to the left eye involving the sclera. • Manual strangulation-related abrasion to the neck. • Bruising ecchymosis on forearm Assessing for Risk of Homicide • In Canada, spousal homicide of women three or four times higher than that of men • Danger assessment: • Map abuse on a calendar. • Note overall score. • Follow-up

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Respiratory Assessment Common Respiratory Conditions • Asthma: Allergic hypersensitivity to allergens that produces • Emphysema: Destruction of pulmonary capillary bed & alveoli creating large air sacs and bullae • Chronic obstructive pulmonary disease (COPD) presents with both bronchitis and emphysema • Pneumonia: Alveoli become congested with bacteria and white blood cells Pneumothorax or hemothorax: Collapsed or blood-filled lung • Heart failure: Fluid overload and pulmonary congestion • Tuberculosis: Slow-growing mycobacterium - form lesions or cavities in the lung Pulmonary embolism: Blood clot in the lungs Diagnostic Tests • Chest X-ray • Sputum for C&S, gram stain examination of sputum to classify as gm.+ve or –ve. • CBC(complete blood count) • MRI(magnetic resonance imaging) • CT scan – for evaluating lung cancer • PET(positron emission tomography) – in early clinical staging, measures differential metabolic activity in normal & diseased tissue • Diagnostic tests • Bronchoscopy – permits visualization of the larynx, trachea and bronchi and allows biopsy of tissue • Thoracentesis – to obtain pleural fluid for analysis • Arterial Blood Gases o pCO2 35-45 mm Hg o HCO3 22-26 meq/litre o pH 7.35-7.45 o p O2 80-100 mm Hg Name the normal breath sounds and their location Bronchial

Bronchovesicular

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Holistic Health Assessment 2 Vesicular

Describe adventitious sounds and their cause Stridor

Crackles- fine and coarse

Wheeze-high and low pitched

Pleural friction rub

Phlegm/sputum • How much? • What colour? • White or clear mucoid: colds, bronchitis, viral infections • Yellow or green: bacterial infections • Rust coloured: tuberculosis, pneumococcal pneumonia • Pink, frothy: pulmonary edema Describe sputum/phlegm • Cough up any blood (hemoptysis)? • Does this look like streaks or frank blood? • Does the sputum have a foul odour? What are the Lifestyle (DADSPIES) that are most important to ask about in regards to respiratory concerns? Give an example • Diet• Alcohol • Drugs- inhaled • Smoking• Physical exam • Immunizations • Exercise• Stress Developmental Considerations Pregnancy • Lower ribs flare • Increased costal angle

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Diaphragm rises (4cm) Respiratory rate same

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↑ tidal volume (volume breath in/out (adult-500ml))

Cultural • Genetic-cystic fibrosis • Antitrypsin deficiency (COPD) Aging Adults • Respiratory strength declines

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↓elasticity ↓ rib flexibility ↓ bone density ↓insp volume (breath) ↑ residual volume (left in lungs after breath) Barrel shaped chest Rigid alveoli (less elastic-stiff

What is the FEV1/FVC ratio of a person with COPD Less than 70% indicates obstruction and possible COPD What conditions would you expect to find hyper-resonance and dull findings during percussion? What technique notes crepitus and what is the cause? • palpation will note crepitus • crepitus- coarse crackling sensation palpable over the skin surface • occurs in subcutaneous emphysema-air escapes from the lung and enters the subcutaneous • tissue • open thoracic injury or surgery What causes decreased & increased tactile fremitus? Decreased fremitus • anything obstructs transmission of vibrations • obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema Increased fremitus • compression or consolidation of lung tissue • lobar pneumonia - only when the bronchus is patent and when the consolidation extends to the lung surface • small areas of early pneumonia do not significantly affect it What conditions may have unequal chest expansion? • marked atelectasis • Pneumonia • thoracic trauma such as fractured ribs • pneumothorax What can cause background noise during auscultation? • examiner's breathing on stethoscope tubing • stethoscope tubing bumping together • patient shivering

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patient's hairy chest-sounds like crackles (rales)-minimize by pressing harder or wetting the hair with a damp cloth rustling of paper gown or paper drapes

What can cause decreased or absent breath sounds? • obstruction of the bronchial tree- secretions, mucus plug, or foreign body • emphysema- inhaled air does not make as much noise (loss of elasticity, decreased force inspired air, hyperinflated lungs) • obstruction of the transmission- pleurisy or pleural thickening or by air (pneumothorax) or fluid • (pleural effusion) in the pleural space • silent chest means no air is moving in or out, which is an ominous What can cause increased breath sounds? • sounds are louder than they should be (e.g., bronchial sounds heard over an abnormal location, • the peripheral lung fields, are abnormal) • high-pitched, prolonged expiratory distinct pause between inspiration and expirationsound very close to your stethoscope • occur when consolidation (e.g., pneumonia) or compression (e.g., fluid in the intrapleural space) • increases the density in a lung area- enhances transmission of sound from bronchi • inspired air reaches the alveoli, it hits solid lung tissue conducts sound more efficiently to the surface Why is a forced expiratory time pulmonary function test done? • identify early pulmonary disease • test FVC before discharge from hospital • Monitor chronic respiratory disease What would you expect to be the associated symptoms for pneumonia on a respiratory exam? Why? • Sputum that is yellow/green (infectious) or rust coloured • Cough –hacking (mycoplasma pneumonia) or congested • May be dry with dry non-productive (pneumocystis) • Chest pain- thoracic muscle soreness from cough or inflammation of pleura (pleuritic pain) • overlying pneumonia • Shortness of breath, dyspnea, anxiety What would you expect to be the objective findings for pneumonia on a respiratory exam? Why? • Intercostal retractions/nasal flaring- increased inspiratory effort (seen in children) • Unequal chest expansion- with marked pneumonia- decrease in diaphragm movement on side with pneumonia (lag)- make have guarding 8

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Increased tactile fremitus- consolidation of lung tissue with lobar (one lobe involved) pneumonia small areas of pneumonia with not alter fremitus decreased if bronchus obstructed Dull percussion- abnormal density in lungs Vital signs- rapid shallow breathing and fever (infection)

What would you expect to be the objective findings for pneumonia on a respiratory exam? Why? • Increased breath sounds- consolidation with pneumonia increases lung density and increases • sound transmission (with patent bronchus) • May be decreased (pneumocystis) • Crackles- in area of pneumonia (may be fine or coarse) • Voice sounds- in area of pneumonia • Bronchophony-clearly hear “ninety-nine” • Egophony- “eeee” sounds like “aaaa” • Whispered Pectoriloquy- hear “one-two-three” If you suspected your patient had early pneumonia which one voice sounds would you use? Why? • Whispered Pectoriloquy • whispered voice is transmitted with only small amounts of consolidation • whispered voice is transmitted very clearly and distinctly Describe objective findings on a patient who has COPD • Sit in tripod position • Pursed lip breathing • Barrel chest • Use of accessory muscles • A-P diameter 2:2-wide costal angle • Hypertrophied neck muscles • O2 sats 88-92% • Clubbing • Percussion- hyper resonance • Inspiratory crackles, wheeze

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Cardiac Assessment Assessment of the Cardiovascular System Subjective data • •Past health history • •Past and current medications • •Surgery or other treatments • •Cues to cardiovascular problems • •Fatigue, abdominal obesity, fluid retention, irregular heart rate, dyspnea, pain, calf tenderness, dizziness, altered neurological function, leg pain Objective data • Physical examination • Vital signs • Peripheral vascular system • Inspection: Colour, hair distribution, venous blood flow, edema, jugular veins • Palpation: Neck and extremity pulses, pressure of pulse wave, rigidity of vessel • Auscultation: Major arteries, bruit assessment Factors to consider when doing a Cardiac Assessment. Nursing Management: Hypertension, Coronary artery disease, Left ventricular hypertrophy, Heart failure, Cerebrovascular disease, Peripheral vascular disease, Nephrosclerosis, Retinal damage Hypertension (HTN) • Sustained elevation of systemic arterial blood pressure (BP) • Leading cause for visits to primary care physicians • High BP is the most significant modifiable risk factor for cardiovascular disease and • mortality in Canada • 1 in 5 adult Canadians has high blood pressure • Persistent elevation of • Systolic blood pressure ≥140 mm Hg or • Diastolic blood pressure ≥90 mm Hg or • Current use of antihypertensive medication(s) Normal Regulation of Blood Pressure • Cardiac output (CO) is the total blood flow through the systemic or pulmonary • circulation per minute. • CO can be described as stroke volume (SV, or the amount of blood pumped out of • the left ventricle per beat [~70 mL]) multiplied by the heart rate (HR) for 1 minute. • Systemic vascular resistance (SVR) is the force opposing the movement of blood within 10

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the blood vessels.

Hypertension: Etiology • Primary hypertension o 90–95% of patients o Focus on primary related to prevalence in clinical practice • Secondary hypertension o 5–10% in adults; >80% in children o Many causes; treatment aimed at eliminating the underlying cause Clinical Manifestations • HTN is a lanthanic or silent disease. • Frequently it is asymptomatic until it becomes severe and target-organ disease has • occurred. • Secondary symptoms with severe HTN include fatigue, reduced activity tolerance, dizziness, palpitations, angina, and dyspnea. Cardiovascular Assessment • Subjective Data • Objective Data • Inspection: Look at the patient • Palpation: Feel the patient • Auscultation: listen to the patient’s heart Subjective Data, Chest Pain • Where? • When? • Intensity? • Type? • Duration? • Radiates? • With or without excursion? • What alleviates or aggravates? • Associated Symptoms: • Any shortness of breath? Objective Data, Inspection • What do you see? • Is the patient thin or obese? • LOC= anxious, drowsy, oriented? • Skin color, turgor, texture, temperature? • Is the patient hydrated, mucous membranes? • Any clubbing of the fingers? • Symmetry of chest wall:

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Sweating Nausea or vomiting? Palpitations or anxiety? If so What type of palpitations? Racing, fluttering, pounding SOB or dyspnea? Lying down, sitting up? When you bend over or cough? Swelling or edema?

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Any pulsations or retractions? Extremities: Any arterial or venous disorders? Symmetry Edema Weeping of skin Turgor Wounds

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Jugular Venous Distention(JVD) • Position the patient on their back elevating the head of bed to 45 degrees. • Turn the patient’s head away from you. • Look at the pulsations in the neck that occurs in several waves with each cardiac cycle. • Note: Normally the jugular veins are not distended when head of bed is at a 45-degree angle. • If you are unsure- check the radial pulse while watching the neck. Pulses should coincide. Palpation • When Palpating you should be noting turgor, temperature, edema and pulses. • When palpating pulses note: o Size o Location o Intensity o Amplitude o Duration

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Noting: equal in strength, regular in rhythm. Pulses to palpate: o Temporal o Carotid o Brachial o Radial o Femoral popliteal o Posterior tibial o Dorsalis pedis

Cap refill and Edema • Capillary refill: press the nail beds on fingers and toes, refill time should be 3 seconds or less. • Edema is measured and documented as: • +1 = trace edema: slight indentation when pressed • +2 = mild edema • +3 = moderate edema • +4 = severe edema: finger press leaves an indent that is deep and returns very slowly. Auscultation of the heart • Auscultate the heart in more than one position: • Patient is sitting up • Patient is lying on back with head of bed at 30-45-degree angle. • Lying on left side if possible, for the patient. • With your stethoscope on bare skin (clothing muffles sound), use the diaphragm to hear high pitched

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sounds and use the bell to hear low pitched sounds. Auscultate starting at the base of the heart in a zig zag pattern down to the apex. Can you hear S1, (LUB)? Can you hear S2, (DUB)? S1 is shorter and louder at the apex S2 is longer and louder at the base of the heart.

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5 areas to listen to the heart (use diaphragm) • Aortic valve= Right 2nd intercostal space (ICS) • Pulmonic valve= Left 2nd intercostal space • ERB’s point= Left 3rd intercostal space • •Tricuspid valve= Left 4th intercostal space • Mitral valve = Left 5th intercostal space, midclavicular line. What if there are extra heart sounds? • S3 and S4 are sometimes present with conditions like CHF(S3) and HTN, CAD, MI (S4) • These are low pitched heart sounds and better heard with the bell of your stethoscope • Murmurs: Swooshing or wooshing sounds can sometime be heard when a valve doesn’t close tightly, and regurgitation happens. • A scratchy sound like sandpaper rubbing together indicates a pericardial friction rub. • This is where the membrane surrounding the heart becomes inflamed.

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Ear, Nose, Sinuses, Mouth & Throat Assessment Ears Structure and Function • External ear – sound through air – Helix, antihelix, tragus, antitragus & lobule – External auditory canal – Tympanic membrane • Middle ear – sound through air & bone – Malleus, incus, and stapes – Eustachian tube • Inner ear – sound through fluid & nerve fibres – Vestibule and semicircular canals – Cochlea Middle Ear • Tiny air filled cavity inside the temporal bone. It contains tiny ear bones or auditory ossicles called the Malleus, Incus, Stapes! • Several openings into middle ear are present. Opening to outer or external ear is covered by the Tympanic membrane! • Opening to the inner ear are at the end of the stapes in the oval window and the round window. • Another opening is the Eustachian Tube which connects the middle ear with the

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nasopharynx and allows passage of air. This tube open during swallowing and yawning -normally it’s closed. • Middle ear has three functions: o Conducts sound vibrations o Protects the inner ear by reducing amplitude of loud sounds o The eustachian tube allows equaliza...