CH 27/26 Health Assessment Flashcards
Data Collection includes obtaining
subjective and objective data
Subjective Data
Things only the client can tell
Objective Data
Things the nurse can observe
The health history
provides subjective data
The physical exam and diagnostic test
provide objective data
Interviewing techniques
standardized formats and therapeutic techniques
Standardized formats
framework for obtaining information about clients, physical, developmental, emotional, intellectual, social, and spiritual demensions
Therapeutic technique
foster communication and create an environment that promotes an optimal health assessment/data collection experience
Health history components
demographic, history, chief concern, history of present illness, past history, family history, psychosocial history, health promotion behaviors
Demographic Info
name, age, race, family, relationship status, insurance, etc
Source of history
client, family member, friend, record
chief concern
reason for client seeking care
history of present illness
location, timing, onset, duration, predicating factos, things that make better or worse
past and current health history
childhood illnesses, medical, surgical, ob, immunizations status, medications, habits, substance use
Family history includes
grandparents, parents, siblings, children and grandchildren , chronic disorders, ages, ages at death,
Psycho social history
relationships, support systems, living and work situations, financial status, all spitural wellness
Health promotion beahviors of client
excerisce activity, diet, stress prevention, risk of heart diseases or other chronic disease, prevention of substances, sunlight
Review of systems
An extensive review of systems ascertains info about the functions of all body systems and health problems
integumentary system
skin disease? itching? hair loss? nail changes? allergies? sunscreen? etc
head and neck?
headaches? how often? relieve of pain? can you move? facial movements? thyroid disease? etc
eyes?
vision? eyeglasses? diabetes? etc
Ear nose throat and mouth
hearing? changes? hearing aids? buzzing? ear infections? dizziness? nose bleeds? difficulty breathing though nose? changes in smell or taste? dentures? dentist?? etc
breast
self exams? Family hx of breast cancer? over 40? mammogram?
respiratory system
breathing problems? flu vaccine? void vaccine? allergies? hx o flung cancer? etc?
cardiovascular system
heart problems? heart med? chest or jaw pain? cough? etc?
gastrointestinal system?
stomach? heartburn? last bowel movement? laxatives? weight changes? difficulty swallowing? drink alcohol?? food intolerances? etc
genitourinary system?
diff urinating? color of urine? pain during sex? scrotum pain? etc
Musculoskeletal system
pain in joint or muscles? vitamin d or calcium supplements? exercise? sports? falls? etc
Neurologic system
vision changes or speech? dizziness or headaches? weakness? seizures? tremors? etc
Mental health
recent losses? stress? depression? concentration? etc?
Endocrine system
urination patters? every level? weight or appetite change? visual disturbances? palpitations?
Allergic/immunologic system?
allergies to meds or foods? blood transfusion? reactions?
physical exam
look and observe before touching
Do not feel or listen
through clothing
use standard precautions
when in contact with body fluids wound drainage or open lesions
For most body systems follow the sequence of (except abdomen)
1.inspect
2.palpate
3.percussion
4.ausculate
except abdomen
For abdomen follow the sequence
1.inspect
2.ausculate
3.percuss
4.palpate
Use light palpation for most body surfaces
0.4 in less than
Use deeper palpation to evaluate abdominal organs or masses
1.6 in
dorsal surface of hands
detect temperature
palmar surface of hand or finger base
sensitive to vibration
fingertips
sensitive to pulsation, position,texture, turgor, sizefi
fingers and thumb
useful for grasping an organ or mass
Use the diagram of the stethoscope to listen to
high pitched sounds such as hear sounds bowel sounds or lung sounds
use the bell of the stethoscope to listen to
low pitched sounds such as unexpected heart sound so bruits
