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NUR1112- Nursing > 4: Health assessment > Flashcards

4: Health assessment Flashcards

1
Q

What is the purpose of a health history assessment?

A
  • identify actual, potential and anticipated problems
  • find a purpose for sn issue
    develops goals for care
  • identify and implement interventions by nur/mid
  • provide an opportunity to build a relationship/rapport with patient/client/women
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2
Q

What are some of the guiding principles of a health history interview

A
  • structure and process of HH interview is determined by the condition of the patient.
  • info attained must be documented in retrievable form
  • patients have right to refuse to give info. in interview
  • interview should allow time for the patient to offer any info they like
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3
Q

Guidelines for a patient/women centred interview

A
  • listen attentivley
  • maintain persons identity
  • acknowledge persons strengths and abilities
  • include family where possible
    collaborate w/ healthcare teams
  • identify community-related issues impacting patient
    include assessment of physical, mental, social, cultural and sprintual needs

LOOK AT THE PERSON HOLLISTICALLY

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4
Q

What are the two sources of data

A

1= Primary
- patient

2= Secondary

  • significant other
  • family
  • other health care professionals
  • medical records
  • lab reports/results
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5
Q

What is necessary to prepare for a health history assessment?

A
  • get the equipment ready
  • ensure privacy, quiet and free from distractions
  • consider seating arrangments
  • language/cultural considerations
  • Distance/personal space
  • make sure you are present and attentive
  • convey warm and professional message.
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6
Q

What are the three phases of a health history interview?

A

Preparatory phase
- chat about what happened

Working phase
- ask the questions

Closing phase
- summaries, clarify, tidy up paperwork

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7
Q

Components of a health history interview

A
  1. biographical data
  2. reason for seeking care
  3. perception of present state of health
  4. past health and medical history
  5. family history
  6. general overall health and wellbeing
  7. health and lifestyle management
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8
Q

What is collected under biographical data?

A
  • name, address, contact details
  • age/DOB
  • sex/gender
  • Height/weight
  • culture religion and ethnicity
  • marital/family status
  • occupation
  • primary healthcare provider (GP)
  • emergency contact person
  • nominated medical power of attorney
  • source of data
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9
Q

What is collected under reason for seeking care?

A

“Chief complaint”

  • why have they presented
  • avoid translating into medical terms (if patient says I have a sore tummy right exactly that in “”)
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10
Q

What is collected under perception of present state of health?

A
  • patient’s perceived level of health
  • health promotion activities
  • diet/nutrition
  • immunisations
  • health screening activities
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11
Q

What is collected under perception for current state of health for unwell patients?

A 
PQRSTU
Precipitating factor (started or made them worse)
Quality/quantity 
Region/radiation 
Severity 
Timing/treatment 
Understanding patient perceptions
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12
Q

What is collected under past health and medical history

A

ALLERGIES

  • childhood illness
  • accidents or injuries
  • serious or chronic illnesses ‘
  • Hospitalisations
  • Surgical procedures
  • Obstetric history (if applicable)
  • immuisations
  • health screening and there results
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13
Q

What is collected under family history?

A

of parents blood relatives, spouse and children- identify genetic or environmental issues.

Focus on relevant conditions only

  • Diabetes
  • Hypertension
  • Cancer
  • Dementia
  • Hypercholesterolemia
  • Heart attack and stroke
  • Obesity

A genome may be useful to draw when figuring out genetic inheritance of a gene.

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14
Q

What is collected in a general overall health and wellbeing?

A
  • interpersonal relationships/resources
  • values and beliefs/spritual resources
  • coping and stress management
  • self concept
  • sleep/rest
  • Diet nutrition
  • functional ability
  • mental health
  • personal habits
  • health promotion activities
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15
Q

What is collected in health and lifestyle management?

A
  • current health screenings
  • current medications
  • smoking and tobacco history
  • alch=ohol and recreation drug use
  • environmental hazards
  • occupational health
  • sexual health
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16
Q

What are communication techniques that can enhance data collection?

A
  • good questions
  • active listening
  • being proactive about message
  • clarifying
  • paraphrasing/summarising
  • focusing/refocusing
  • confrontation
  • providing support
  • managing awkward moments
17
Q

What are communication techniques that can be diminishing data collection?

A
  • using medical jargon
  • expressing value judgments
  • interrupting the patient
  • being authoritarian
  • using leading questions
  • to much talking
    providing false reassurance
18
Q

What are some of the requirements for quality documentation requirements

A
  • info recorded= based on facts
  • info should be timely and occur asap after event
  • should be relevant, accurate, organised, complete yet be concise
  • should include; date, time, signature and title

The integrity of document should be maintained;

  • care should be used when abbreviating
  • legible with accepted terminology, correct spelling and readable handwriting.
  • error should not be obliterated in full
19
Q

What is the purpose of a physical examination

A
  • supplements data from health history
  • enable objective validation of subjective data.
  • provides basis for nur/mid care
20
Q

Preparing the environment for a physical assessment

A
  • find time and place
  • ensure privacy and comfort
  • ensure adequate liting and space
  • minimise external noise and interruptions
  • have bed/examination table at working height
21
Q

Preparing the equipment for a physical assessment

A
  • perform hand hygiene (infection control)
  • gather supplies + instruments needed
  • have equipment in reach and arranged in order of use
  • check equipment is functioning properly
  • warm equipment that will touch the patient’s skin
22
Q

Preparing patient for physical examination

A
  • explain purpose and procedure
  • ensure the patient is comfortable
  • ask the patient to change into a gown and empty bladder/bowel
  • dress drape appropriately
  • sequence exam to minimise position changes
  • monitor patient responses throughout the examination
  • pace the examination according to patient tolerance
  • answer patient questions directly and honestly.
  • position patient correctly
23
Q

Describe the lithotomy position

A

on back with legs on styrips (labor pushing position)

24
Q

4 physical assessment techniques

A
  • inspection (smell, look)
  • Auscultation (listen)
  • Percussion (listen)
  • Palpitation (feel)
25
Q

Explain the physical examination technique= inspection

A

uses vision, smell, hearing to observe the patient condition.

  • most frequently used technique when performed correctly
  • only parts of patient being observed should be exposed
  • Ensure appropriate room temp
26
Q

What can you inspect for during a physical examination?

A
  • sounds
  • movements
  • colour
  • effort of breathing
  • overall appearance
  • interaction
  • Distress
  • Secretions
  • muscles
27
Q

Explain the physical examination technique=

Auscultation

A

involves listening to sounds produced in the body such;

  • breath
  • heart
  • blood
  • bowel sounds

Hear direct sounds= wheeze
Hear indirect sounds= gas/fluid as a result

28
Q

The stethoscope

A

Diaphram= big flat side

  • press firmly on skin
  • high pressure sounds
    e. g. breathing and bowel sounds

Bell= curved small side

  • Press lightly over body part, just enough to seal
  • used for low pitched sounds
    e. g. heart sounds, vascular sounds
29
Q

Auscultation sounds

A 
pitch= frequency of the vibrations 
Intensity= amplitude, described as loud or soft 
Duration= length of time the sound lasts 
Quality= types of sounds e.g. blowing, gurgling, wheezing
30
Q

Explain the physical examination technique= percussion/palpation

A
  • gloves must be worn
  • deep palpitation only to be performed by experienced physician
  • tender areas are palpated last
  • technique should be slow and systematic
31
Q

Describe percussion

A
  • tapping of a portion of the body to elicit tenderness, or sounds that carry with density of underlying structures.
  • allows for location or organ shape, position and consistency.
  • requires skilled touch and a trained ear
32
Q

Describe direct percussion

A
  • body part is tapped with 1-2 fingers or ulnar side of fist
  • strike is rapid from wrist
  • used to detect tenderness through vibration
33
Q

Indirect percussion

A

striking with an object held against the body being examined.
- interphalangeal joint is struck with the tip of the middle finger of the dominant hand.

34
Q

Describe some percussion sounds and what they mean

A

Flat= dull sound from dense tissue (muscle or bone)
Dull= thud like/muffled sound produced by dense tissue (liver, spleen and heart)
Resonance= clear, hollow sound produced by air (normal lung sound)
Hyper-resonance= booming sound (children’s lungs, emphysema)
Tympany: drum-like sound from air-filled spaced (stomach, intestines)

35
Q

What characteristics can be observed from palpitation?

A
  • texture (rouch/smooth)
  • temp (warm/hot/cold)
  • moisture (dry/wet/moist)
  • Consistency (solid/fluid filled)
  • Distension (swelling)

do not palpitate pulsing mass

36
Q

Describe what parts of the hand are used for what palpation

A

finger tips= fine discrimination and pulsations

Palmar/ulnar surface= vibrations

Dorsal (back surface)= temperature

37
Q

Explain deep palpitation

A
  • should only be done by advanced practitioners
  • 2-4cm with firm deep pressure
  • used to feel internal organs (size, shape, tenderness, symmetry, mobility)
38
Q

Define bimanual palpation

A
  • only be done by advanced practitioners
  • access deep abdominal organs
  • two hands are used on each side of body.

NUR1112- Nursing (11 decks)

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