CLASS 1 - COMPREHENSIVE HEALTH ASSESSMENT Flashcards
NONVERBAL COMMUNICATION
- Listening w/ the eyes
- Tells if the patient is upset, agitated, maintaining eye contact
VERBAL COMMUNICATION
- Asking open-ended or close-ended questions
OPEN-ENDED QUESTIONS
- “Tell me about why you’re here today”
CLOSE-ENDED QUESTIONS
- “Tell me where you’re hurting”
SUBJECTIVE DATA
- What the patient tells you through open-ended and close-ended questions
EXAMPLES OF SUBJECTIVE DATA
- Health History
- Symptoms (pain, nausea)
- Feelings (happy, sad, nervous)
- Perceptions (beliefs, desires)
OBJECTIVE DATA
- What the nurse assesses
EXAMPLES OF OBJECTIVE DATA
- Observations
- Vital signs (blood pressure, pulse, respirations)
- Physical exam findings
ANTHROPOMETRIC MEASURES
- Height/Weight
- BMI
UNDERWEIGHT BMI VALUE
- < 18.5
NORMAL BMI VALUE
- 18.5 - 24.9
OVERWEIGHT BMI VALUE
- 25.0 - 29.9
OBESE BMI VALUE
- > 30.0
VITAL SIGNS
- Temperature
- Pulse
- Respiration
- Blood Pressure
- Pulse Oximetry
- Pain
AVERAGE ORAL TEMPERATURE
- 37 degrees C or 98.6 degrees F
AVERAGE RECTAL TEMPERATURE
- 0.5 degrees C or 1 degrees F > oral temperature
AVERAGE AXILLARY TEMPERATURE
- 0.5 degrees C or 1 degrees F < oral temperature
AVERAGE TYMPANIC TEMPERATURE
- 0.8 degrees C or 1.4 degrees F > oral temperature
AVERAGE TEMPORAL TEMPERATURE
- Close to core body temperature
PLACEMENT FOR ORAL TEMPERATURE
- Posterior sublingual pockets (hot spots)
FACTORS OF INACCURATE ORAL TEMPERATURE
- Hot and cold foods
- Unable to close mouth
- Smoking cigarettes
PLACEMENT FOR TYMPANIC TEMPERATURE
- Beginning of the ear canal and aim the infrared beam at the tympanic membrane
FACTORS OF INACCURATE TYMPANIC TEMPERATURE
- Cerumen
- Hearing aides
PLACEMENT FOR TEMPORAL TEMPERATURE
- Sliding probe across the forehead and down behind the ear
DOCUMENTING TEMPERATURE
- Example: 98.2 degrees F oral/rectal/temporal
PULSE LOCATIONS
- Radial (wrist)
- Brachial (inside elbow)
- Carotid (side of neck)
- Pedal (top of foot)
- Apical (chest)
MOST ACCURATE PULSE LOCATION
- Apical because you’re listening to the actual beat of the heart
NORMAL PULSE RANGE
- 60 - 100 beats/minute
PULSE EXAM TECHNIQUE
- Palpate for pulse
- Count beats for 30 seconds, multiple x 2
BRADYCARDIA
- Less than 50 beats/minute
TACHYCARDIA
- Greater than 95 - 100 beats/minute
PULSE INTENSITY CATEGORIES
- 3+ - Full, bounding
- 2+ - Normal
- +1 - Weak, thready
- 0 - Absent
DOCUMENTING PULSE
- Example: 80 BPM apical/radial/carotid
T/F : IF BREATHING OR PULSE IS IRREGULAR YOU HAVE TO DO THE TEST FOR 60 SECONDS?
- True
NORMAL RESPIRATORY RATE
- 14 - 20 breaths/minute
RESPIRATORY RATE EXAM TECHNIQUE
- NEVER tell a patient you are counting respirations
- After 30 seconds of counting normal pulse, continue with 30 seconds of watching respirations (as if you were still counting the pulse)
RESPIRATORY RHYTHM CATEGORIES
- Regular
- Labored
RESPIRATORY DEPTH CATEGORIES
- Shallow
- Gasping
OXYGEN SATURATION DEFINITION
- Using a pulse oximeter to assess arterial oxygen saturation
- Measures the % of hemoglobin attached to oxygen
NORMAL OXYGEN SATURATION
- SpO2 of 97 - 99%
- SpO2 of > 93% is clinically acceptable
FACTORS OF INACCURATE OXYGEN SATURATION
- Nail polish
- Cold hands
- If SpO2 is on the low side, have the patient take a couple deep breaths
DOCUMENTING OXYGEN SATURATION
- Example: 92% room air
- Example: 92% on 4 L of oxygen nasal cannula (if on oxygen need to report how much)
PAIN RATING SCALE
- Pain is subjective
- 0 - 10 rating scale
- Pain score > 3 means the patient needs intervention and re-assessment
DOCUMENTING PAIN RATING SCALE
- Example: Pain scale 3/10 on left ankle
BLOOD PRESSURE EXAMINATION TECHNIQUE
- Palpation for brachial artery
- Rest patient arm with your own at mid-chest level
- Center at brachial artery 2.5 cm above antecubital crease
- Inflate cuff
- Palpate radial pulse and inflators until pulse disappears
- Inflate 20-30 mmHg further
- Place stethoscope over brachial artery
- Deflate cuff by 2-3 mmHg/second
- First sound = systolic
- Second sound = diastolic
FACTORS OF INACCURATE BLOOD PRESSURE
- Too large of a cuff doesn’t put enough pressure on the artery –> low BP
- Too small of a cuff puts too much pressure on the artery –> high BP
- Releasing the bladder too slowly causes venous congestion –> high diastolic
NORMAL BLOOD PRESSURE VALUE
- < 120 / < 80 mmHg
PREHYPERTENSION BLOOD PRESSURE VALUE
- 120 - 139 / 80 - 89 mmHg
HYPERTENSION (STAGE 1) BLOOD PRESSURE VALUE
- 140 - 150 / 90 - 99 mmHg
HYPERTENSION (STAGE 2) BLOOD PRESSURE VALUE
- > 160 / > 100 mmHg
HYPERTENSION CRISIS BLOOD PRESSURE VALUE
- > 180 / > 110 mmHg
- Emergency care needed!
ORDER OF EXAMINATION
- Inspection (includes impression and all subcategories)
- Palpation
- Percussion
- Auscultation
INSPECTION ASSESSMENT
- Process of observation
- Careful scrutiny of the individual as a whole then of each body system
- Good lighting
- Adequate exposure
ORDER OF IMPRESSION
- Overall state of health
- Physical appearance
- Body structure
- Behavior
- Distress
OVERALL STATE OF HEALTH ASSESSMENT
- Does the person stand promptly to meet you?
- Does the person look sick?
- Does the person fully extend their arm to shake your hand?
- Are the palms dry or clammy?
FACTORS OF PHYSICAL APPEARANCE ASSESSMENT
- Stated vs. apparent age
- Body fat, stature
- Level of consciousness
- Motor activity
- Body and breath odors
- Facial expressions
STATED VS. APPARENT AGE ASSESSMENT
- The person appears his or her stated age?
BODY FAT, STATURE ASSESSMENT
- The height appears within normal range for age, genetic heritage
- The weight appears within the normal range for height and body build
- Body fat distribution is even
LEVEL OF CONSCIOUSNESS ASSESSMENT
- The person is alert and oriented to person, place, time, and situation
- Responds appropriately to your questions
- A & O x 3
MOTOR ACTIVITY ASSESSMENT
- The person has smoothness of motion, no tremors, coordinated gait
BODY AND BREATH ODOR ASSESSMENT
- The person appears clean and groomed appropriately (if culturally appropriate) for his/her age or occupation, and socioeconomic group
FACIAL EXPRESSION ASSESSMENT
- The person maintains eye contact (if culturally appropriate)
- Expressions are appropriate to the situation (thoughtful, serious, smiling)
FACTORS OF BODY STRUCTURE ASSESSMENT
- Posture/Position
- Range of Motion
- Gait
- Stature/Symmetry
- Nutrition
POSTURE/POSITION ASSESSMENT
- The person stands comfortably erect as appropriate for age
RANGE OF MOTION ASSESSMENT
- Full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated.
GAIT ASSESSMENT
- Feet approximately shoulder width apart
- Foot placement accurate
- Walk is smooth and even
- Person can maintain balance without assistance
- Symmetric arm swing present
STATURE/SYMMETRY ASSESSMENT
- The height appears within normal range for age, genetic heritage
- Body parts look equal bilaterally and are irrelative proportion to each other
NUTRITION ASSESSMENT
- The weight appears within normal range for height and body build
- Body fat distribution is even
FACTORS OF BEHAVIOR ASSESSMENT
- Dress/grooming
- Mood/manner
- Speech
- Facial expressions
DRESS/GROOMING ASSESSMENT
- Clothing is appropriate for the climate
- Looks clean and fits the body
- Appropriate to the person’s culture and age-group
- Culturally determined dress should not be labeled as inappropriate by Western standards
MOOD/MANNER ASSESSMENT
- The person is comfortable and cooperative with the examiner and interacts pleasantly
SPEECH ASSESSMENT
- Articulation is clear and understandable
- Stream of talking is fluent, with even pace
- Conveys ideas clearly
FACIAL EXPRESSION ASSESSMENT
- The person maintains eye contact (if culturally appropriate)
- Expressions are appropriate to the situation (thoughtful, serious, smiling)
FACTORS OF DISTRESS ASSESSMENT
- Physiological
- Pain
- Emotional
PHYSIOLOGICAL ASSESSMENT
- The person has no apparent distress
PAIN ASSESSMENT
- Is the person short of breath, grimacing, guarding a certain area of the body?
EMOTIONAL ASSESSMENT
- What kind of emotions is the person showing? Pleasant, relaxed, angry, distressed
- Flat affect: no smiling, monotone - can be hard to read
FACTORS OF PALPATION ASSESSMENT
- Fingertips
- Ball of hand
- Dorsa of hands and fingers
- Base of fingers
FINGERTIP PALPATION ASSESSMENT
- Best for fine tactile discrimination
- Skin texture
- Swelling
- Pulsation
- Determining lumps
- Crepitation
- Organ size
BALL OF HAND PALPATION ASSESSMENT
- Vibration
- Can also be felt with ulnar surface of hand
DORSA OF HANDS AND FINGERS ASSESSMENT
- Best for determining temperature
PERCUSSION ASSESSMENT
- Tapping the person’s skin with short, sharp strokes to assess underlying structures
- Produces vibration and subsequent sound waves in body
- Determine location and size of organ
- Signaling density (air, fluid, or solid)
AUSCULTATION ASSESSMENT
- Listening to sounds produced by the body (heart, blood vessels, bowels)
- Stethoscope used to block out sounds and concentrate on the sound
