Chapter 25 Flashcards
Purposes of the Health Assessment
- Establish the nurse–patient relationship.
- Gather data about the patient’s general health status.
- Identify patient strengths.
- Identify actual and potential health problems.
- Establish a base for the nursing process.
Types of Health Assessments
Comprehensive
Ongoing partial
Focused
Emergency
Comprehensive Health Assessment
conducted upon admission to health care facility
Ongoing partial Health Assessment
conducted at regular intervals
Focused Health Assessment
conducted to assess a specific problem
Emergency Health Assessment
conducted to determine life-threatening or unstable conditions
Components of a Preventive Health Assessment
- Health history
- Risk for depression
- Functional ability
- Level of safety
- Physical examination
- Patient education and counseling
Considerations When Performing Health Assessment
- Lifespan considerations
- Cultural considerations and sensitivity
- Patient preparation
- Environmental preparations
Factors to Assess During a Health History
- Biographical data
- Reason for seeking health care
- History of present illness
- Past health history
- Family history
- Functional health
- Psychosocial and lifestyle factors
- Review of systems
Preparing the Patient for Physical Assessment
- Consider the physiologic and psychological needs of the patient.
- Explain the process to the patient.
- Explain that physical assessments will not be painful
- Explain each procedure in detail as it is conducted.
- Ask the patient to change into a gown and empty bladder.
- Answer patient questions directly and honestly.
Preparing the Environment for Physical Assessment
-Agree on a time for the assessment.
The time should not interfere with meals, daily routines, or visiting hours.
-Make sure patient is as free of pain as possible.
-Prepare the examination table.
-Provide a gown and drape for the patient.
-Gather the supplies and instruments needed.
-Provide a curtain or screen if the area is open to others
Equipment Used During a Physical Examination
- Thermometer and sphygmomanometer
- Scale
- Flashlight or penlight
- Stethoscope
- Metric tape measure and ruler
- Eye chart
- Tuning fork
Supine position
- lying flat on back
- used to assess head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
- allows relaxation of abdominal muscles
Sims Position
- lying on side with lower arm below the body and upper arm flexed at shoulder and elbow
- used to assess the rectum and vagina
dorsal recumbent position
- lying on back with legs separated and knees flexed
- used for patients having difficulty maintaining supine position
- used to assess head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
Prone position
- lying on stomach with head turned to the side
- assessment of hip joint and posterior thorax
Standing position
assessment of posture, balance, and gait
Sitting position
allows visualization of upper body
Lithotomy position
- assessment of female genitalia and rectum
- giving birth position
Knee–chest position
assessment of anus and rectum
Inspection
- the process of performing deliberate, purposeful observation in a systematic manner
- assessing size, color, shape, position, and symmetry
Palpation
- touch
- assessing temperature, turgor, texture, moisture, vibrations, and shape
Percussion
- is the act of striking one object against another to produce sound
- assessing location, shape, size, and density of tissues
Auscultation
- the act of listening with a stethoscope to sounds produced in the body
- assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration
Characteristics of Masses Determined by Palpation
- Shape
- Size
- Consistency
- Surface
- Mobility
- Tenderness
- Pulsatile
Right Upper Quadrant
- Pylorous
- Duodenum
- Liver
- Right kidney and adrenal gland
- Hepatic flexure of colon
- Head of pancreas
Left Upper Quadrant
- Stomach
- Spleen
- Left kidney and adrenal gland
- Splenic flexure of colon
- Body of pancreas
Right Lower Quadrant
- Cecum
- Appendix
- Right ovary and fallopian tube(female)
- Right ureter and lower kidney pole
- Right spermatic cord(male)
Left Lower Quadrant
- Sigmoid colon
- Left ovary and fallopian tube(female)
- Left ureter and lower kidney pole
- left spermatic cord(male)
Midline
- urinary bladder
- urethra(female)
Characteristics of Sound Heard When Using Auscultation
- Pitch: ranging from high to low
- Loudness: ranging from soft to loud
- Quality: for example, gurgling or swishing
- Duration: short, medium, or long
General Survey
- General appearance
- Vital signs
- Height, weight, waist circumference
- Calculating BMI
Common Thorax and Lung Variations in Older Adults
- Increased anteroposterior chest diameter
- Increase in the dorsal spinal curve (kyphosis)
- Decreased thoracic expansion
- Use of accessory muscles to exhale
Cardiovascular and Peripheral Vascular Variations in Newborns and Children
- Visible cardiac pulsation if the chest wall is thin
- Sinus dysrhythmia (the rate increases with inspiration and decreases with expiration)
- Presence of S3 (in about one-third of all children)
- More rapid heart rate (until about 8 years of age)
Common Cardiovascular and Peripheral Vascular Variations in Older Adults
- Difficult-to-palpate apical pulse
- Difficult-to-palpate distal arteries
- Dilated proximal arteries
- More prominent and tortuous blood vessels; varicosities common
- Increased systolic and diastolic blood pressure
- Widening pulse pressure
Common Abdominal Variations in Newborns
umbilical cord in newborns; dries and falls off within the first few weeks of life
Common Abdominal Variations in Children
a “pot-belly” (under 5 years of age), visible peristaltic waves
Common Abdominal Variations in Older Adults
- Decreased bowel sounds
- Decreased abdominal tone
- Fat accumulation on the abdomen and hips
Common Genitalia Variations in Newborns and Children
- Enlarged labia and clitoris
- Breast enlargement in both boys and girls
- Vaginal discharge in girls, called pseudomenstruation
- Pubic hair and breast development occur at puberty and follow a regular sequence of development.
- Menstruation begins about 2.5 years after puberty begins.
- Irregular menstrual cycle for first 2 years
Risk Factors for Altered Health Assessed in Health History
- History of trauma, arthritis, or neurologic disorder
- History of pain or swelling in the muscles and/or joints
- Frequency and type of usual exercise
- Dietary intake of calcium
- History of any surgery on muscles or joints
- History of smoking (how long, how many packs/day)
- History of alcohol intake
Assessing Level of Awareness
- Time: What is today’s date? What day of the week is it? What season of the year is this? What was the last holiday?
- Place: Where are you now? What is the name of this city? What state are we in?
- Person: What is your name? How old are you? Who came to visit you this morning?
Purposes of Documentation
- Identify actual and potential health problems
- Make nursing diagnoses
- Plan appropriate care
- Evaluate patient’s responses to treatment
Nurse’s Role in Diagnostic Procedures
-Assist before, during, and after diagnostic tests.
-Be responsible for other activities associated with diagnostic tests.
-Witness the patient’s consent.
-Schedule the test.
-Prepare the patient physically and emotionally for the test.
-Provide care and teaching after the test.
-Dispose of used equipment.
Transport specimens.
