ch 30 Jess Flashcards
What will your assessment influence
The choice of therapies a patient receives, and an evaluation of the response to those therapies
What is included in a complete health assessment
A nursing history a behavioral exam and a physical exam
What is the purpose of a physical examination (4)
Triage for emergency care
routine screening to promote health and wellness,
to determine eligibility (for health insurance military service new job,)
To admit a patient to hospital or long-term care facility
What do you use physical examination for
- gather baseline data about a patient’s health
- support or refute subjective data obtained in the nursing history
- identify and confirm nursing diagnosis
- make clinical decisions about a patients changing health
- evaluate the outcomes of care
What is cultural sensitivity
Culture influences the patient’s behavior you need to consider health beliefs, using alternative therapies, nutritional habits, relationships with family and personal comfort zone, need to avoid stereotyping and gender bias
Why is it important to be aware of disorders that are more commonly seen in a particular ethnic group?
Because you’re more likely to recognize a rare condition unique to each ethnic group which will lead to higher quality care
If a patient is seriously ill, what should you assess first?
The body system that is most at risk
When should painful procedures be performed
Near the end of the assessment
What do you need to consider in preparation for examination
Infection control,
environment,
equipment,
physical and psychological preparation of the patient assessment of age group
What are the four techniques of physical assessment
Inspection
palpation
percussion
auscultation
What do you need to remember during inspection
- Use adequate lighting
- use penlight to inspect body cavities
- inspect each area for size shape color position and abnormality
- position and expose body parts as needed so all surfaces can be viewed the privacy can be maintained
- validate findings with the patient
What senses should you use during inspection
Look listen and smell to distinguish normal from abnormal
Why is Teeth/gum health/denture fitting important in the elderly?
If they cannot eat due to ill fitting dentures or poor gum health They will not get enough nutrition and will go downhill very quickly
How do you maintain privacy for patients during the physical exam
Take off only what’s needed for that moment example remove one piece of clothing at a time then replace it
Explain palpation during a physical exam
Used to gather information
– use different parts of hands to detect different characteristics
–hands should be warm
- start with light palpation and with deep palpation
When should you palpate sensitive areas
Palpate sensitive areas last
What is percussion
Tapping the body with fingertips to produce a vibration sound determines location size and density of structure
What does auscultation involve?
– Involves listening to sounds
– learn normal sounds first before identifying abnormal sounds or variations
– requires a good stethoscope
– requires concentration practice
What part of the stethoscope is used to hear low pitch versus high pitch sounds
The bell is used to hear low pitch sounds the diaphragm is used for high-pitched sounds
What is the general survey the health assessment
Assesses appearance and behavior assess vital signs assessed height and weight
What does the integumentary system include?
Skin hair scalp and nails
What are some things you can assess just by looking at your patient
Gender and race age signs of distress body type hygiene and grooming body odor speech signs of patient abuse and signs of substance-abuse
Why do you need to obtain a diet history for your patient
Because height and weight reflective person’s overall level of health
What do you need to look for when examining the skin
Integument color moisture temperature texture turgor
