26 Health Assessment Flashcards
5 types of Health Assessment
1 comprehensive/initial
2 ongoing/partial
3focused
4 emergency
primary source of info is from…
the patient.
preparing patient for physical assessment
- consider physiologic/psychologic needs
- explain process
- explain physical assessment will not be painful
- explain procedure
- ask patient to change into gown + empty bladder
- answer patient questions directly + honestly
Sim’s Position
laying on left side w right leg and right arm raised
Supine
laying on back
Prone
laying on belly
Lithotomy
laying on back with legs open and raised
Dorsal Recumbent
laying on back with legs bent and open
Low Fowlers, Fowlers, High Fowlers
Low Fowlers 30 degree
Fowlers 45 degree
High Fowlers sitting, leaning forward
what is high fowler position for
breathing problems, feeding issues
General Survey
- general appearance
- vital signs
- height, weight, waist measurement
auscultation sound types
pitch, loudness, quality, duration
3 places we carry our fluids
cells, bloodstream, inbetween
Pitting Edema
when an indentation remains after palpation
-may be measured by mm
objective vs subjective data
objective = signs subjective = symptoms
Health Assessment
health history + physical assessment
health history vs physical assessment
both make up a HEALTH ASSESSMENT
health hx is collection of subjective info
phys assessment is collection of objective data
Comprehensive Health Assessment
broad; incl. complete health hx + physical assessment
-conducted when patient first enters a health care setting
why is a comprehensive health assessment important?
makes up the patient’s baseline for comparing later assessments
Ongoing Partial Health Assessment
aka follow-up assmt
- conducted at reg intervals (beginning of each patient visit)
- focuses on ID’d health problems, to monitor +/- changes, + evaluate intervention effectiveness
Focused Health Assessment
- conducted to assess a specific problem
- may also address most immediate/highest priority concern for patient
ex) woman w ab pain:focus will be on urinary, bowel, allergies, or menstrual history
Emergency Health Assessment
type of rapid focused assessment
-conducted while addressing life-threatening/unstable situation
Physical Assessment
sequence
1 inspection
2 palpation
3 percussion
4 auscultation
**bilateral body parts are inspected for symetry
ecchymosis
collection of blood in subcutaneous tissue, causes purplish discoloration
lesions
diseased or injured tissue
ex) bruise, cut, burn, scratch
Abdomen Assessment
sequence
1 inspection
2 auscultation
3 percussion
4 palpation
why is percussion + palpation sequenced towards the end?
they can stimulate bowel sounds
Abdomen Auscultation
sequence
1 R lower Q
2 R upper Q
3 L upper Q
4 L lower Q
PERRLA
pupils are Equal Round Reactive to Light + Accommodations
supine is best for…
VS, head, neck, lung,s heart, breasts, abdomen, extremities
never check a patient’s pulse in these positions
standing or sitting can alter the patient’s pulse
Prone is best for…
hip joint, posterior thorax
Knee to chest is best for…
anus/rectum… but sim’s is usually more common
sitting is best for…
lung expansion
6 Cardinal Gaze
- checks for 6 extraocular eye muscles are working along with cranial nerves III, IV, VI
- wagon wheel or H technique
Accommodation
+++LENS CHANGING ITS SHAPE++
act of physiologically adjusting crystalline lens elements to alter the refractive power and bring objects that are closer to the eye into sharp focus
how to check for accommodation
have the patient focus on a n object close to the face and move away
-check for pupil constrict/dilate
normal bowel sounds
gurgles and clicks every 5 - 34 seconds
-can be heard w diaphragm
HYPOactive bowel sounds may indicate…
post-abdomen surgery or
late bowel obstruction
HYPERactive bowel sounds may indicate…
diarrhea or early bowel obstruction
absent bowel sounds may indicate…
peritonitis or paralytic ileus
high pitched tinkling of rushes of high pitched sounds may indicate…
bowel obstruction
diaphragm vs bell for pitch
high pitch = diaphragm
low = bell
Pitting Edema
grading
1+ 2mm 2+ 4mm 3+ 6mm 4+ 8mm Brawny fluid can no longer be displaced, no more pitting, tissue palpates as hard + firm
Snellen Chart reading
someone with 20/60 vision can read at 20 feet away what a person with normal vision could read at 60 feet away
percussion checks for…
location, shape, size, density of tissues
Tonsil Grading
0 removed tonsils 1 hidden w/in pillars 2 extending to pillars 3 beyond pillars 4 extend to midline
Orthostatic Hypertension
increase in the blood pressure upon assuming an upright posture
Otoscope
medical device which is used to look into the ears
Ophthalmoscope
an instrument for inspecting the retina and other parts of the eye.
conditions that can lead to Systolic Hypertension
1+ gradual stiffening of large arteries 2 anemia 3 overactive thyroid or adrenal gland 4 malfunctioning aortic valve 5 kidney disease 6 obstructive sleep apnea
bell of stethoscope is used for
low pitch, hrt murmurs,
