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
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
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
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
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.
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
7
Q
Components of a health history interview
A
- biographical data
- reason for seeking care
- perception of present state of health
- past health and medical history
- family history
- general overall health and wellbeing
- health and lifestyle management
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
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 “”)
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
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
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
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.
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
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
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
Explain the physical examination technique= inspection
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
What can you inspect for during a physical examination?
- sounds
- movements
- colour
- effort of breathing
- overall appearance
- interaction
- Distress
- Secretions
- muscles
27
Explain the physical examination technique=
| Auscultation
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
The stethoscope
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
Auscultation sounds
```
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
Explain the physical examination technique= percussion/palpation
- 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
Describe percussion
- 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
Describe direct percussion
- 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
Indirect percussion
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
Describe some percussion sounds and what they mean
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
What characteristics can be observed from palpitation?
- texture (rouch/smooth)
- temp (warm/hot/cold)
- moisture (dry/wet/moist)
- Consistency (solid/fluid filled)
- Distension (swelling)
do not palpitate pulsing mass
36
Describe what parts of the hand are used for what palpation
finger tips= fine discrimination and pulsations
Palmar/ulnar surface= vibrations
Dorsal (back surface)= temperature
37
Explain deep palpitation
- should only be done by advanced practitioners
- 2-4cm with firm deep pressure
- used to feel internal organs (size, shape, tenderness, symmetry, mobility)
38
Define bimanual palpation
- only be done by advanced practitioners
- access deep abdominal organs
- two hands are used on each side of body.
