ATI - Chapter 26 Flashcards
Data collection includes obtaining _______ and _____ data from clients.
subjective and objective
The health history provides _____ data.
subjective
The physical examination and diagnostic tests provide ______ data.
objective
_______ are a framework for obtaining information about clients’ physical, developmental, emotional, intellectual, social and spiritual dimensions.
standardized formats
_______ for health assessment foster communication and create an environment that promotes an optimal health assessment/data collection experience.
therapeutic techniques
Therapeutic communication helps develop rapport with clients. The techniques encourage a _____ relationship, whereby clients feel comfortable telling their story.
trusting
Therapeutic communication begins with the purpose of the interview, gather information, and then conclude the interview by _________
summarizing the findings.
When using therapeutic communication introduce yourself and the various parts of the _____.
assessment
When using therapeutic communication determine what the client wants you to _____.
call him
When using therapeutic communication allow more time for responses from ______.
older adults
When using therapeutic communication make sure the client is ______.
comfortable (temp, chair, bed, etc)
When using therapeutic communication, when possible, start by asking for the health history, performing the general survey, and _______ to build rapport prior to moving on to more sensitive parts of the examination.
measuring vital signs
When using therapeutic communication reduce environmental noises (TV, radio, visitors talking) to enhance communication and eliminate ______.
distractions
When using therapeutic communication ensure understanding by obtaining ______ services for clients who have language or other communication barriers.
interpretive
When using therapeutic communication note the client’s ______ communication (body language, eye contact, tone of voice).
nonverbal
When using therapeutic communication avoid using ______, giving advice, ignoring feelings, and offering false reassurance.
medical/nursing jargon
Health History Components
Demographic info Source of history Chief concern History of Present Illness Past Health History and Current Health Status Family History Pscyhosocial History Health Promotion Behaviors
Demographic Information to Collect
Name, address, contact info Birth date, age Gender Race, ethnicity Relationship status Occupation, employment status Insurance Emergency contact info Family, others living at home Advance directives
Source of history can come from client, family members or close friends, other medical records, ______. The reliability of the historian must be taken into account.
other providers
A brief statement in the client’s own words of why is is seeking care is called the ______.
chief concern
A detailed, chronological description of why the client is seeking care is called the _________. Details about the manifestations, such as location, quality, quantity, setting, timing (onset and duration), precipitating factors, alleviating or ______ factors, associated phenomena (concomitant manifestations)
history of present illness
aggravating
Past health history and current health status include ______ illnesses, both communicable and chronic.
childhood
Past health history and current health status include medical, _____, obstetrical, gynecological, psychiatric history, including time frames, diagnoses, hospitalizations, and ______.
surgical
treatments
Past health history and current health status include ____ to medication, environment, food.
allergies
Past health history and current health status include current medications including prescription, over the counter, vitamins, supplements, ______, time of last dose(s)
herbal remedies
Past health history and current health status include habits and _______ (alcohol, tobacco, caffeine, recreation drugs)
lifestyle patterns
Family history includes health information of grandparents, parents, siblings, children, and _____.
grandchildren
Family history includes family structure, interaction, _____ , and function.
support system
Family history includes current ages or age at death, acute and _____ disorders of family members.
chronic
______ history include relationships, support systems, concerns about living or work situations, financial status, ability to perform activities of daily living and spiritual health.
psychosocial
Health promotion behaviors include exercise/activity, diet, sun exposure, wearing of safety equipment, substance use, environmental exposures, home environment, resources, _____, sleep patterns or coping measures.
stress
Health promotion behaviors include ______ of risks for heart disease, cancer, diabetes, mellitus, and stroke.
awareness
An extensive review of ______ ascertains information about the functioning of all body systems and health problems.
systems
Questions to Ask: Integumentary System
Do you have skin diseases?
Do you have any itching, bruising, lumps, hair loss, nail changes, or sores?
Do you have any allergies?
How do you care for your hair, skin, and nails?
Do you use any lotions, soaps, or sunscreenor wear protective clothing?
Questions to Ask: Head and Neck
Do you get headaches? If so, how often? (ask about and note onset, precipitating factors, duration, character pattern, and concomitant manifestations)
What do you do to relieve the pain?
Have you ever had a head injury?
Can you move your head and shoulders with ease?
Are any of your lymph nodes swollen? (If so, ask about recent colds or viral infections)
Have you noticed any unusual facial movements?
Does anyone in your family have thyroid disease?
Questions to Ask: Eyes
How is your vision?
Have you noticed any changes in your vision?
Do you ever have any fluid draining from your eyes?
Do you wear eyeglasses? Contact lenses?
When was your last eye exam?
Does anyone in your family have any eye disorders?
Do you have diabetes?
Questions to Ask: Ears, nose, mouth, and throat
How well do you hear?
Have you noticed any changes in your hearing?
Have other people commented that you aren’t hearing what they say?
Do you wear hearing aids?
Do you have ringing or buzzing in your ears, drainage, dizziness, or pain?
Have you had ear infections?
How do you clean your ears?
Are you having any pain, stuffiness, or fluid draining from nose?
Do you have nosebleeds?
DO you have any difficulty breathing through your nose?
Have you noticed any change in your sense of smell or taste?
How often do you go the the dentist?
Do you have dentures or retainers?
Do you have any problems with your gums, like bleeding or soreness?
Do you have any difficulty swallowing or problems with hoarseness or a sore throat?
Do you have allergies?
Do you use nasal sprays?
Do you know if you snore?
Questions to Ask: Breasts
Do you perform breast self-examinations? For women: What time of the month do you perform them?
Do you have any tenderness, lumps, thickening, pain, drainage, distortion, or change in breast size, or any retraction or scaling of the nipples?
Has anyone in your family had breast cancer?
Are you aware of breast cancer risks?
For clients over 40: How often do you get a mammogram
Questions to Ask: Respiratory system
Do you have any difficulties breathing?
Do you breathe easier in any particular position?
Are you ever short of breath?
Have you recently been around anyone who has a cough, cold, or influenza?
Do you receive and influenza vaccine every year?
Have you had the pneumonia vaccine?
Do you smoke? If yes, for how long and how much? Are you interested in quitting?
Are you around second hand smoke?
Do you have environmental allergies?
Has anyone in your family had lung cancer or tb?
Have you ever been around anyone who has tb?
Have you had a tb test?
Questions to Ask: Cardiovascular system
Do you have any problems with your heart?
Do you take any medications for your heart?
Do you ever have pain in your chest? Do you also feel it in your arms, neck or jaw?
Do you know if you have high cholesterol or high bp?
Do you have any swelling in your feet and ankles?
Do you cough frequently?
Are you familiar with the risk factors for heart disease?
Questions to Ask: Gastrointestinal system
Do you have any problems with your stomach, such as nausea, vomiting, heartburn, or pain?
Do you have any problems with your bowels, such as diarrhea or constipation?
When was your last bowel movement?
Do you ever use laxatives or enemas?
Have you had any black or tarry stools?
Do you take aspirin or ibuprofen? If so, how often?
Do you have any abdominal or lower back pain or tenderness?
Have you had any recent weight changes?
Do you have any swallowing difficulties? Do you drink alcohol? If so, how much?
For clients over 50: Have you had a colonoscopy? If so, when was your last one?
Do you know the signs and symptoms of colon cancer?
What is your typical day’s intake of food and fluid?
Do you have any dietary restrictions, food intolerances, or special practices?
Questions to Ask: Genitourinary system
Do you have any difficulties with urination, such as burning, leakage or loss of urine, urgency, frequency, waking up at night to urinate, or hesitancy?
Have you noticed any change in the color of your urine? For women: Have you noticed any changes in your menstrual cycle?
Have you had pain during intercourse?
Have you had any sexual problems?
For men: Have you had any pain in your scrotum or testes?
Questions to Ask: Musculoskeletal system
Have you noticed any pain in your joints or muscles?
Do you have any weakness or twitching?
Have you had any recent falls?
Are you able to care for yourself?
Do you exercise or participate in sports?
For postmenopausal women: What was your max height?
For postmenopausal women: Do you take calcium supplements?
Questions to Ask: Neurological system
Have you noticed any change in your vision, speech, ability to think clearly, or loss of or change in memory?
Do you have any dizziness or headaches?
Do you ever have seizures? If so, what triggers them?
Do you ever have any weakness, tremors, numbness, or tingling anywhere? If so, where?
Questions to Ask: Mental Health
Is there anything stressful going on at work or at home?
Are you having any problems with depression or changes in mood?
Have you had any recent losses?
Are you having any problems concentrating?
Questions to Ask: Endocrine system
Have you noticed any change in urination patterns?
Have you noticed any change in your energy level?
Have you noticed any change in your ability to handle stress?
Have you noticed any change in in weight or appetite?
Have you had any visual disturbances?
Have you had any palpitations?
Questions to Ask: Allergic / Immunologic system
Do you have any allergies to medications, foods, or environmental substances?
Have you ever received a blood transfusion? If so, did you have any adverse reactions.
During a physical examination make sure there is ______ lighting.
adequate
During a physical examination maintain a quiet and ______ environment.
comfortable
During a physical examination provide ____, using a gown or draping the client with a sheet and visualizing only one section of the body at a time.
privacy
During a physical examination ____ the various assessment/data collection techniques you will use.
explain
During a physical examination look and ______ before touching.
observe
During a physical examination keep _____ short, and hands and stethoscope warm.
nails
During a physical examination do not feel or listen through _____ (it can obscure or create sounds).
clothing
During a physical examination have necessary _____ ready.
equipment
During a physical examination use standard precautions when in contact with body fluids, wound drainage, and _______.
open lesions
During a physical examination with older adult clients allow enough time for ______ change.
position
During a physical examination with older adult clients perform assessments/data collection in several shorter segments to avoid overtiring older adults. Organize the examination, finishing all techniques requiring the same position before moving on to the _____.
next position.
During a physical examination with older adult clients make sure older adults who use sensory aids (glasses, hearing aids) have them _____.
available for use
During a physical examination with older adult clients invite the client to use the ______ before beginning the physical examination. Collect urine or fecal specimens at this time.
bathroom
Inspect, palpate, ____, ausculate in that order. The exception is the abdomen in which you inspect, ausculate, ______ and the palpate to avoid altering bowel sounds.
percuss
percuss
_______ begins with the first interaction and continues throughout the exam.
inspection
During inspection a ______, an otoscope, and ophthalmoscope, or another lighted instrument can enhance the process.
penlight
Inspection involves using the senses of vision, smell (olfaction), and _____ to observe and detect any expected or unexpected findings. Inspect for size, shape, ___, symmetry (comparing both sides of the body), and position
hearing
color
During inspection validate finding with the _____.
client
_____ is the use of touch to determine the size, consistency, texture, temperature, location and ____ of the skin, underlying tissues, an organ or a body part. Palpate ____ areas last.
palpation
tender
tender
Use light palpation (less than 1 cm for most body surfaces. Use deeper palpation (4 cm) to evaluate the ______ organs or masses.
abdominal
Various part of your hands detect different _____ when using palpation.
sensations
The ____ surface is the most sensitive to temperature.
dorsal
The ____ surface and base of the fingers are sensitive to vibration
palmar
_____ are sensitive to pulsation, position, texture, turgor, ______ and consistency.
fingertips
size
Starting with light palpation, be _____, calm, and gentle. Proceed to deep palpation if necessary.
systematic
______ involves tapping body parts with fingers, fists, or small instruments to vibrate underlying tissues and evaluate size, location, tenderness, and presence or absence of fluid or air in body organs, and to detect any _______.
percussion
abnormalities
The denser the tissue, the quieter the _____.
sound
An understanding of the effect of various densities on sound can help you locate organs or masses, find their ____, and estimate their size.
edges
Techniques for percussion include _____, indirect, and fist.
direct
____ percussion, which involves striking the body to elicit sounds.
direct
_____ percussion, which involves placing your hand flatly on the body, as the striking surface, for sound production.
indirect
_____ percussion, which helps identify tenderness over the kidneys, liver, and gallbladder.
fist
_______ is the process of listening to sounds the body produces to identify unexpected findings. Some sounds are loud enough to hear unaided (speech and coughing), but most sounds require a ____ or a doppler technique (heart sounds, air moving through the respiratory tract, blood moving through blood vessels). Learn to isolate the various sound to collect data accurately.
auscultation
stethescope
Evaluate sounds for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and ___ (what it sounds like).
quality
Use the diaphragm of the stethosocpe to listen to high-pitched sounds (heart sounds, _____, lung sounds).
bowel sounds
Place the ____ firmly on the body part.
diaphragm
Place the ____ lightly on the body part.
bell
Use the bell of the stethoscope to listen to ______ sounds (unexpected heart sounds, bruits).
low pitched
Equipment for Screening Examination
Gown Drapes Scale with height measurment Thermometer Stethoscope with diaphragm and bell Sphygomomanometer Reading/eye chart Otoscope, opthalmoscope, nasal speculum Penlight Cotton balls Sharp and dull objects Tuning fork Glassor water Items to test smell and taste Clean gloves Tongue depressor Reflex hammer Pulse oximeter Marking pen Measuring tape and clear, flexible ruler with measurements in centimeters Watch or clock to measure time in seconds
The _____ is a written summary or appraisal of overall health. Gather is info form the first encounter with the client and continue to make observations throughout the assessment process.
general survey
General Survey: Physical appearance
Age Gender Race and/or Ethinicity Level of consciousness Color of skin Facial features Signs of distress (pallor, labored breathing, guarding, anxiety) Signs of possible physical abuse or neglect Signs of substance use disorders
General Survey: Body Structure
Body build, stature, height, and weight Nutritional status Symmetry of body parts Posture and usual position Gross abnormalities (skin lesions, amputations)
General Survey: Mobility
Gait
Movements (purposeful, temulous)
ROM
Motor activity
General Survey: Behavior
Facial expression and mannerisms
Mood and affect
Speech
Dress, hygiene, grooming, and odors (body, breath)
General Survey: Vital Signs
Temperature Pulse Respirations Blood pressure Oxygen saturation
