chapter 30 Melissa Flashcards
What type of data do you collect through the health history interview?
Subjective data about a patient’s condition
A complete health assessment involves what?
A nursing history and behavioral and physical examination
When performing a health assessment how would you collect objective data?
By observing a patient’s behavior and overall presentation. Also through a head-to-toe body system review during the physical examination.
Why is a physical examination conducted?
As an initial evaluation in triage for emergency care; for routine screening to promote wellness behaviors and preventative health care measures; to determine eligibility for health insurance, military service, or a new job; or to admit a patient to a hospital or long-term care facility.
A physical examination is used to do what?
- Gather baseline data about the patient’s health status.
- Support or refuse subjective data obtained in the nursing history.
- Identifying confirm nursing diagnoses.
- Make clinical decisions about a patient’s changing health status and management.
- Evaluate the outcomes of care.
Five important things to consider when performing an examination and history on a patient?
- The patient’s health beliefs
- The use of alternative therapies
- Nutrition habits
- Relationship with family
- Comfort with physical closeness
When preparing for an examination a nurse should consider what 6 things?
- Infection control
- Environment
- Equipment
- Physical preparation of the patient
- Psychological preparation of the patient
- Assessment of age groups
When considering infection control a nurse should do what?
- Wear gloves on all patients and if a patient has excessive drainage or there is a risk of splattering from a wound, additional personal protective equipment such as isolation gowns or eye shield should be used.
- Identify any latex allergies in the patients and use equipment items that are latex free if such allergies exist.
What environmental factors should a nurse consider when preparing for an examination?
- Privacy such as an examination room with the door shut or patient’s room with the curtain pulled shut.
- Adequate lighting to illuminate body parts
- Eliminate extra noise
- Take precautions to prevent interruptions from others
- Room must be warm
- An examination table with head elevated 30 degrees
- A small pillow to help with head and neck comfort
When preparing for an examination, what are some things a nurse can do to prepare the equipment that will be used?
- Arrange any necessary equipment so that it is readily available and easy to use
- Warm the diaphragm of the stethoscope between the hands before applying to the skin
- Be sure that equipment functions properly before using it
Physical preparation of the patient includes what?
-Physical comfort needs are met: empty their bladder and/or bowels before examination
~ collection of urine or fecal specimens occur at this time
- Provide a proper dress or draping to the patient to provide privacy and allow proper time for them to change
- Provide extra blankets or eliminate drafts in the room so the patient can stay warm
- Help position patient so body parts are accessible but make sure the patient remains comfortable
How would a nurse psychologically prepare a patient for an examination?
- Thoroughly explain the purpose and the steps of each assessment
- Encourage the patient to ask questions
- During the examination, watch the patient’s emotional responses and body movements
-Postpone the examination if the patient is unwilling to cooperate
~ results are more accurate when the patient can cooperate and relax
When preparing for an examination, why is assessment of age group so important?
Your approach will vary with each age group
- Children: Show sensitivity and anticipate the child’s anticipation of the examination as a strange and unfamiliar experience
- Older adults: Do not always exhibit the expected signs and symptoms. Some take longer to be interviewed and examined due to sensory and physical limitations. Provide adequate space for walkers/wheelchairs. Be aware of closets restroom.
8 positions for examination?
1) Sitting
2) Supine
3) Dorsal recumbent
4) Lithotomy
5) Sims’
6) Prone
7) Lateral recumbent
8) Knee-chest
What areas are assessed in the sitting position?
- Head
- Neck
- Back
- Posterior thorax and lungs
- Anterior thorax and lungs
- Breast
- Axillae
- Heart
- Vital signs
- Upper extremities
What areas are assessed in the supine position?
- Head and neck
- Anterior thorax and lungs
- Breast
- Axillae
- Heart
- Abdomen
- Extremities
- Pulses
What areas are accessed in the dorsal recumbent position?
- Head and neck
- Anterior thorax and lungs
- Breasts
- Axillae
- Heart
- Abdomen
What areas are accessed in the lithotomy position?
- Female genitalia
- Genital tract
What areas are accessed in the sims’ position?
- Rectum
- Vagina
What areas are assessed in the prone position?
- Musculoskeletal system
What areas are assessed in the lateral recumbent position?
- Heart
What areas are assessed in the knee-chest position?
- Rectum
During an inspection what are three things you should do to distinguish normal from abnormal findings?
- Carefully look
- Listen
- Smell
During an inspection, what are three things you should do to distinguish normal from abnormal findings?
- Carefully look
- Listen
- Smell
Palpation allows a nurse to do what?
Make judgments about expected and unexpected findings of the skin or underlying tissue, muscle, and bones.
What are the two types of palpations?
- Light : Place the hand on the body part being examined pressing inward about 1cm ( 1/2 inch ). It allows the patient the chance to identify areas of tenderness.
- Deep: Depress the area under examination approximately 4 cm ( 2 inches ), using one or both hands. It is used to examine the condition of organs such as those in the abdomen.
