1.1 Introduction to Health Assesment

Question 1

Purpose of Health Assessment

Answer 1

Establish relationship between patient and nurse

Gather as much information about health status, strengths (diet, exercise) and potential health problems.

Potential - Can try to prevent from happening, or identify them early.

Baseline for nursing process.

Question 2

Types of Health Assessments

Answer 2

1. Comprehensive - Upon admission to health care facility. Personal, social, medicinal, family history information.
2. Ongoing - Preformed at regular intervals and follow up appointments
3. Focused - Assess specific problem
4. Emergency - Determines fatal conditions. Begins with airway, breathing and circulation (ABC).

Question 3

Components of assessment

Answer 3

Health History, review of systems, physical assessment.

Question 4

Health History

Answer 4

Subjective Data. Cannot be measured, is what your patient tells you is wrong.

6 basic Facets

1. Biographical Data - Name, Age, Gender, DOB, Address
2. Reason for seeking care (why are they admitted)
3. History of present illness (HPI) - Story behind reasoning for coming in
4. Medical History - Past illness, surgeries, pregnancies, medications, allergies, vaccinations, immunizations, hospitalizations.
5. Family History - Goes back 3 generations with major chronic disease / mental illness
6. Lifestyle/social history - Sexual practices, tattoos, diet and exercise, occupation, family life, home environment.

Question 5

Review of systems

Answer 5

Subjective data for each body part
HEENT - Head, Eyes, Ears, Nose, Throat

Conducted before, sometimes during, physical assessment.

Examples
Cardiovascular system - chest pain, palpitations
Respiratory system - Shortness of breath, cough

Question 6

Physical Assessment

Answer 6

Objective data (measurable)

Vital signs, head to toe sequence assessing one at a time.

Before you start patient should disrobe and empty bladder.

Question 7

Equipment for physical assessment

Answer 7

Ophthalmoscope - Visualize interior of eye

Otoscope - Examines inner ear canal and tympanic membrane

Snellen Chart - Screens for distant vision

Nasal Speculum - Examine lower and middle turbinate’s of the nose.

Vaginal Speculum - Examines vaginal canal/cervix

Tuning Fork - Tests auditory function, air/bone conduction.

Percussion Hammer - Tests deep tendon reflex and tissue density.

Question 8

Positions during physical examination

Answer 8

Supine - Lying down face up
Prone - Lying face down
Lateral - On side
Lithotomy - lying face up with legs up 
Knee chest position - lying face down with knees lowered

Question 9

Physical Assessment Techniques

Answer 9

Preformed in order for all systems except abdomen

1) Inspection - Assess size, color, shape, symmetry
2) Palpation - First light than deep, temperature, turgor, texture, moisture, vibrations, shape. Used to locate masses.

Question 10

Percussion

Answer 10

Assess location, shape, size, and density of tissues/organs. (Tapping the body)

Sounds

Flat - Soft sound heard over fatty tissue. (Thigh area/bones)
Dull - Medium sound heard over masses and dense orders (Liver)
Resonance - Loud sound over air filled sacs (Lungs)
Hyperresonance - Very loud (air trapping in lungs field like with emphysema)
Tympani - Loud sound over abdominal area, over intestines. (Like hollow watermelon)

Question 11

Order of Physical Assessment

Answer 11

1. Integument (Skin)
2. Head/Neck
3. Thorax/Lungs
4. Cardiovascular/Peripheral Vascular Systems
5. Breast/Axillae
6. Abdomen
7. Female/Male Genitalia
8. Anus, Rectum, Prostate
9. Musculoskeletal System
10. Neurological System

Question 12

Assessment Developmental Considerations

Answer 12

Infants - Least to most invasive techniques. Assessed in parents arms if comfortable there.

Preschoolers - Use simple terms and allow to touch devices if they want.

School-Age - Realistic thinkers. Involve them in history taking and ask recreational activities

Adolescents - Privacy is most important (ask parents to step aside if willing

Older Adults - Threat of losing independence and death is highest concern.