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Health Assessment - Lecture > Collecting Objective Data > Flashcards

Collecting Objective Data Flashcards

1
Q
  • Reproducible findings
  • True for the patient and for you
  • True for you and others
  • FACT
A

OBJECTIVE DATA

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2
Q

PURPOSE OF PHYSICAL EXAMINATION

A
  • Obtain baseline data about the client’s functional abilities
  • Supplement, confirm, or refute data obtained in the nursing history
  • Obtain data that will establish nursing diagnosis and plan
  • Evaluate the physiological outcomes of healthcare
  • Make clinical judgments about client’s health status
  • Identify areas of health promotion and disease prevention
  • Discover you patient’s strengths
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3
Q

Types of physical assessment

A
  • Complete
  • Focused
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4
Q
  • Body system (cardiovascular system)
  • Body area/ Regional (Lungs)
A

Focused Physical Examination

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5
Q

Establish or monitor health status

A

Complete Physical Examination

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6
Q

Components of Complete Physical Examination

A
  • General survey
  • Vital signs
  • Head
  • Neck
  • Upper extremities
  • Chest and back
  • Abdomen
  • External genitals
  • Anus
  • Lower extremities
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7
Q

Focused Physical Examination
Used when:

A
  • patient is unstable
  • Time constraints exist
  • Episodic follow-up
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8
Q

is used when patient is unstable, time constraints exist and episodic follow-up

A

Focused Physical Examination

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9
Q

Focused Physical Examination
Components:

A
  • General survey
  • Vital signs
  • Assessment of the specific area or system
  • Quick cephalocaudal scan
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10
Q

Situation:
Client complains of abdominal pain

A

inspect, auscultate, percuss and palpate the abdomen; assess vital signs

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11
Q

Situation:
The client’s fluid intake is minimal

A

assess tissue turgor, fluid intake and output, and vital signs

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12
Q

Preparation

A
  • Yourself
  • The environment
  • The patient
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13
Q

Preparing yourself

A
  • Identify yourself
  • Appear calm and organized
  • As a beginner, avoid interpreting your findings
  • Observe standard and universal precaution
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14
Q

Preparing client

A
  • Explain where and when the examination will take place
  • Explain what will happen during the examination
  • Determine contraindicated positions
  • Empty the bladder before the examination
  • If examining a child, start with least invasive/ uncomfortable aspect
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15
Q

Preparing the Environment

A
  • Temperature
  • Lighting
  • Privacy and noise
  • Positioning
  • Draping
  • Instrumentation
  • Methods of Examining
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16
Q

Positioning
Consider

A
  • Client’s ability to assume a position
  • Physical condition
  • Energy level
  • Age
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17
Q

Different Position

A

Sitting
Supine
Dorsal recumbent
Lithotomy
Prone
Sim’s
Knee chest position

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18
Q

A seated position, back unsupported and legs hanging freely

A

Sitting

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19
Q

Back-lying position with legs extended; with or without pillow under the head

A

Supine

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20
Q

Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface

A

Dorsal recumbent

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21
Q

Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table

A

Lithotomy

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22
Q

Lies on abdomen with head turned to the side, with or without a small pillow

A

Prone

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23
Q

Side-lying position with lowermost arm behind the body,
uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow

A

Sim’s

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24
Q

knees and chest with head is turned to one side, arms extended on the bed, and elbows flexed and resting

A

Knee chest position

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25
Q
  • Provide privacy and warmth
  • Expose only the area to be assessed
A

Draping

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26
Q

Ensure equipment are clean, in good working condition, readily accessible

A

Instrumentation

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27
Q

Designate one area for clean/ unused and another area for dirty/ used

A

Instrumentation

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28
Q

Thermometer
Types:

A
  • Glass mercury thermometer
  • Electronic digital thermometer
  • Tympanic thermometer
  • Temporal artery thermometer
  • Disposable paper strips
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29
Q

Used in indirect auscultation

A

Stethoscope

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30
Q

Stethoscope tubing should be ________________ long

A

30 to 35cm

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31
Q

Stethoscope internal diameter of

A

0.3m

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32
Q
  • Fetal heart sounds
  • Locate pulses
A

Doppler

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33
Q

Sphygmomanometer
- Cuff width should be __________ of the arm circumference

A

40%

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34
Q

Sphygmomanometer
Cuff bladder encircle ______________of the arm

A

80%

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35
Q

To assess far and near vision

A

Visual acuity chart

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36
Q

Far vision adult:

A

20 feet

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37
Q

Far vision children:

A

10 feet

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38
Q

vision:

A

14 inches

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39
Q
  • Test each eye separately then both eyes together
  • Test with and without correction glasses
  • No more than 2 mistakes
A

Visual acuity chart

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40
Q

Visual acuity charts (types)

A
  • Snellen eye chart
  • E chart
  • STYCAR test cards
  • Pocket vision screener
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41
Q
  • Eyes
  • Hard-to-see places
A

Penlight

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42
Q
  • Assess the internal structures of the eyes
  • Always use in dark room
  • Right- to- right
  • Left- to- lef
A

Ophthalmoscope

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43
Q

Always palpate the _____________________________ for tenderness before inserting an otoscope, if tender proceed carefully

A

tragus, helix, mastoid process

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44
Q

Using Otoscope/Nasoscope on adults:

A

pull the helix up

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45
Q

Using Otoscope/Nasoscope for preschool child

A

pull the earlobe down

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46
Q
  • Assess hearing and vibratory sensation
A

Tuning fork

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47
Q

testing vibratory sensation

A

Low frequency fork (256Hz)

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48
Q

assessing hearing

A

High frequency fork (512Hz)

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49
Q
  • Lengths and circumferences
  • Abdominal girth
  • Fundal height
A

Tape measure/ pocket ruler

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50
Q

To assess range of motion exercises

A

Goniometer

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51
Q

Used to measure body fat

A

Triceps skin fold calipers

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52
Q

Used to measure weight

A

scale

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53
Q
  • Better visualization of the pharynx
  • Assessing gag reflex
A

Wooden tongue depressor

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54
Q
  • Used during neurological examination:
  • Light touch
  • Corneal reflex
A

Cotton balls

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55
Q

Assess hot and cold sensation

A

Test tubes

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56
Q

Assess the sense of smell:

A

Coffee

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57
Q

Assess sense of taste

A

Sugar and lemon

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58
Q

Swallowing ability and thyroid

A

Cup of water

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59
Q

Assess for stereognosis

A

Paper clip

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60
Q
  • Assess light touch and pain
  • Discard after use
A

Safety Pin

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61
Q

Use when there is risk for exposure to blood or body fluids

A

Gloves

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62
Q

Techniques of Physical Examination

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
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63
Q

General guidelines

A
  • Be systematic
  • Use you patient as a comparative
  • Always consider your patient’s growth and developmental stage
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64
Q

Inspection

A
  • Visual examination
  • Assessing using sense of sight
  • Moisture
  • Color
  • Texture of the body surface
  • Shape, size, position, color and symmetry of the body
  • Also use sense of hearing and smell
  • Use your patient as a comparative
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65
Q
  • Visual examination
  • Assessing using sense of sight
  • Moisture
  • Color
  • Texture of the body surface
  • Shape, size, position, color and symmetry of the body
  • Also use sense of hearing and smell
  • Use your patient as a comparative
A

Inspection

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66
Q

Types of Inspection

A
  • Direct inspection
  • Indirect inspection
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67
Q
  • Use of sense of touch
  • Surface characteristics, texture, consistency, temperature
  • Masses, organs, pulsation, muscle rigidity, chest excursion
  • Able to differentiate areas of tenderness from pain
A

Palpation

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68
Q

Temperature

A

dorsal aspect of the hand

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69
Q

vibration

A

ball of the hand on palm and ulnar surface

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70
Q

fine sensation (pulsations)

A

finger pads

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71
Q

types of palpation

A
  • light palpation
  • deep palpation
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72
Q

Light palpation

A
  • Temperature, texture, mobility, shape, size
  • Pulses
  • Areas of edema
  • Tenderness
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73
Q

Deep palpation

A
  • Organ size, masses
  • Rebound tenderness
  • Voluntary guarding
  • Ballottement
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74
Q

Striking a body surface with quick, light blows and eliciting vibrations and sounds

A

Percussion

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75
Q

Percussion
Assess:

A
  • Density of underlying structure
  • Areas of tenderness
  • Deep tendon reflexes
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76
Q

Types of percussion:

A
  • Direct/Immediate Percussion
  • Indirect Percussion
  • Fist or Blunt Percussion
77
Q

Directly tapping your hand over a body surface

A

Direct/Immediate Percussion

78
Q
  • Plexor, pleximeter technique
  • Percussion hammer
A

Indirect Percussion

79
Q
  • Assess organ tenderness
  • Can be direct or indirect
A

Fist or Blunt Percussion

80
Q

▪ Use of sense of hearing
▪ Assess heart sounds, lung sounds, bowel sounds, vascular sounds
▪ Pitch (medium, high or low) oIntensity (soft or loud)
▪ Duration (short or long)
▪ Quality

A

Auscultation

81
Q

Types of Auscultation:

A
  • Direct Auscultation
  • Indirect Auscultation
82
Q
  • Without stethoscope
  • Respiratory congestion
A

Direct Auscultation

83
Q

With stethoscope

A

Indirect Auscultation

84
Q

Patients with special needs

A
  • Children
  • Pregnant patients
  • Elderly
  • Disabled patients
85
Q

Adopt an age appropriate approach:
- Infants
- Children 1 to 2 years old
- Children 2 to 3 years old
- Children 4 to 5 years old
- School- age children
- Adolescent
- Look for normal growth and developmental changes

A

Children

86
Q

Pregnant Patients

A
  • Assess both mother and fetus
  • Include fundal heights and fetal heart tones
  • Assess for physiologic changes
  • Include nutritional assessment
  • Remember that patients may have difficulty changing positions
  • Patients may have mood swings
87
Q

Elderly patients

A
  • Do not rush
  • Look for developmental changes
  • Conserve your patient’s energy
  • Allow enough time to respond
88
Q

Disabled patients

A
  • Identify the disability
  • Focus on patient’s functional ability and mental capacity
  • Modify as necessary
89
Q

is a systematic study of right and wrong conduct in situations that involve issues of values and morals

A

Ethics

90
Q

consider in a broad, general manner what is good or bad, right or wrong

A

Morals

91
Q

are set of enforceable principle and rules established to protect society.

A

Laws

92
Q

is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including benefits and risks of treatment, alternatives to treatment and prognosis if not treated by a health care provider.

A

Informed Consent

93
Q

2 Types of Consent

A
  • Express Consent
  • Implied Consent
94
Q
  • Either oral or written agreement
  • The more invasive procedure or the greater potential for risk to the client, the greater the need for written permission.
A

Express Consent

95
Q

Exists when the individual’s nonverbal behavior indicates agreement

A

Implied Consent

96
Q

reponsible for obtaining informed consent for specific medical and surgical treatment.

A

Primary care provider, usually the physician

97
Q

may obtain informed consent for procedures that he/she will perform as a dependent nursing intervention (e.g. NGT insertion, drug administration).

A

Nurse

98
Q

ELEMENTS OF AN INFORMED CONSENT

A
  • Completeness (Disclosure)
  • Comprehension
  • Voluntariness
  • Competence
99
Q

Patients need a great deal of information to make educated decision.

A

Completeness (Disclosure)

100
Q

The patient (or his surrogate decision maker) must understand the explanation.

A

Comprehension

101
Q

The patient must be free to accept or reject the treatment.

A

Voluntariness

102
Q

The person must have the capacity to understand the information and make a choice about his situation.

A

Competence

103
Q

3 groups of people who cannot provide consent

A
  • Minors
  • Unconscious/injured
  • Mentally Ill
104
Q

Be sure to make a record of all interaction with clients, as well as the patient’s refusal or noncompliance with treatment.

A

Charting

105
Q

Charting should always be:

A

F – Factual
A – Accurate
C – Complete
T – Timely

106
Q

Done if a standard care is breached or an unusual incident occurs (e.g. a visitor or patient falls or is somehow injured)

A

Incident Report

107
Q

is a law that seeks to protect all forms of information, be it private, personal, or sensitive. It meant to cover both natural and juridical persons involved in the processing of personal information.

A

RA No. 10173 or Data Privacy Act

108
Q

Any information whether recorded in a material form or not, from which the identity of an individual is apparent or can reasonably and directly ascertained by the entity holding the information, or when put together with other information would directly and certainly identify an individual.

A

Personal information

109
Q

SENSITIVE PERSONAL INFORMATION

A
  1. race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations;
  2. health, education, genetic or sexual life of a person;
  3. civil, criminal or administrative proceedings
  4. unique identifiers issued by government agencies peculiar to an individual;
  5. specifically established by law as classified
110
Q

Any operation or any set of operations performed upon personal information including, but not limited to, the collection, recording, organization, storage, updating or modification, retrieval, consultation, use, consolidation, blocking, erasure or destruction of data.

A

Processing

111
Q

a person or organization who controls the collection, holding, processing or use of personal information, including a person or organization who instructs another person or organization to collect, hold, process, use, transfer or disclose personal information on his or her behalf.

A

Personal Information Controller

112
Q

An individual whose personal information is processed

A

Data subject

113
Q

DATA PRIVACY PRINCIPLES

A
  • Transparency
  • Legitimate purpose
  • Proportionality
114
Q

A data subject must be aware of the nature, purpose, and extent of the processing of his or her personal data, including the risks and safeguards involved, the identity of
personal information controller, his or her rights as a data subject, and how these can be exercised.

A

Transparency

115
Q

The processing of information shall be compatible with a declared and specified purpose, which must not be contrary to law, morals, or public policy.

A

Legitimate purpose

116
Q

The processing of information shall be adequate, relevant, suitable, necessary, and not excessive in relation to a declared and specified purpose.

A

Proportionality

117
Q

begins with the opening moments of the patient encounter

A

GENERAL SURVEY/STATUS

118
Q

“First impression” of your patient
- Use your senses and observation skills

A

GENERAL SURVEY/STATUS

119
Q
  • Is the patient acutely or chronically ill?
  • Is the patient frail?
  • Is the patient fit or robust?
  • Is the patient overweight or underweight?
A

Apparent State of Health

120
Q
  • Is the patient awake, alert, and responsive to you and others in the environment?
  • Is the patient drowsy, lethargic or stuporous?
  • Is the patient unconscious?
A

LEVEL OF CONSCIOUSNESS

121
Q
  • Is there clutching of the chest?
  • Is there pallor? Cyanosis? Diaphoresis?
  • Is there labored breathing, wheezing, or coughing?
A

SIGNS OF DISTRESS

122
Q

Is there wincing, diaphoresis, protectiveness of a painful area, grimacing, or unusual posture favoring one limb or region of the body?

A

Pain

123
Q

Are there any anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat affect, poor eye contact, or psychomotor slowing?

A

Anxiety or Depression

124
Q
  • Observe facial expression at rest, during conversation and social interactions, and during the physical examination
  • Ask yourself what is the patient’s face telling me?
  • Do you see pain, fear, or anxiety?
  • Does the patient maintain eye contact?
  • Is his/her facial expression happy or sad?
  • Look at the facial features. Are they symmetrical?
A

Facial Characteristics

125
Q

Drooping of the eyelid

A

Ptosis

126
Q

May indicate a transient ischemic attack or stroke.

A

Drooping on one side of the face

127
Q
  • Bulging or protruding eyeballs
  • May suggest hyperthyroidism
A

Exopthalmos

128
Q

Pale complexion or unusual lightness of skin color, may indicate anemia, malnutrition, vitamin deficiency

A

Pallor

129
Q

Bluish discoloration of the skin or mucous membrane, may indicate poor oxygenation.

A

Cyanosis

130
Q

Yellowish discoloration of the skin or mucous membranes; may suggest an underlying hepatobiliary tract disease.

A

Jaundice

131
Q

Medical term for a mole, a common benign skin lesion but some may be malignant.

A

Nevus

132
Q

may reflect cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences

A

Excess Clothing

133
Q

suggest gout, bunions, edema, or other painful foot conditions

A

Holes or slippers

134
Q

can contribute to foot and back pain, calluses, falls, and infection

A

Run-down shoes

135
Q

suggest joint pain; studies show that wearing copper jewelry may ease arthritic pain

A

Copper bracelets

136
Q

can be associated with alcohol and drug use

A

Jewelries, tattooes, and body piercings

137
Q

They may be clues to the patient’s personality, mood,
lifestyle, and self-regard

A

Hair, finger nails, and use of make up

138
Q

suggest the length of a possible illness

A

“Grown-out” hair and nail polish

139
Q

may suggest high levels of ketones

A

fruity odor/acetone breath

140
Q

a complication of Type 1 diabetes

A

diabetic ketoacidosis

141
Q

A disorder where your body makes too much cortisol

A

Cushing’s syndrome

142
Q

excessive abdominal fat

A

Truncal obesity

143
Q

collection of excess fat behind the neck

A

Buffalo hump

144
Q

May reflect a cardiopulmonary problem

A

Nail clubbing and edema

145
Q

May reflect arthritic changes

A

Deformities

146
Q

sitting upright

A

Left-sided heart failure

147
Q

leaning forward with arms braced

A

COPD (Chronic obstructive pulmonary disease)

148
Q

is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing

A

Review of Systems

149
Q

Estimated Due of Confinement or Estimated Due Date Last Menstrual Period

A

Nagele’s Rule

150
Q

Obstetric / Gynecologic History

A

GTPAL
Gravida (# of Pregnancy)
Term
Preterm
Abortion
Children Living

151
Q

woman who is or has been pregnant

A

Gravida

152
Q

woman who has never has been pregnant

A

Nulligravida

153
Q

first time pregnant

A

Primigravida

154
Q

pregnant more than once

A

Multigravida

155
Q

past pregnancies that have reached viability (24 AOG)

A

Para

156
Q

has never completed to period of viability

A

Nullipara

157
Q

completed one pregnancy regardless the result

A

Primipara

158
Q

completed two or more pregnancies

A

Multipara

159
Q

USE specific RULES, THEORIES, principles, and PERSPECTIVES TO inquire into THE justification of ah individual’s action in a PARTICULAR situation

A

ETHICS

160
Q

They should be told everything they would
consider important in making a treatment
decision

A

Completeness (disclosure)

161
Q

Ask the patient to describe in his own words
the procedure to which he is consenting

A

Comprehension

162
Q
  • He must not be pressured or coerced to give consent
  • There must be no actual or implied threat
A

Voluntariness

163
Q

REPORTING AND DOCUMENTING
REMEMBER:

A

If it isn’t documented, it wasn’t done

164
Q

When you first see a patient…

A

OBSERVE and ASSESS!!!

165
Q

May suggest an underlying neurological disorder

A

Ptosis

166
Q

Ptosis may suggest an underlying neurological disorder. Example?

A

Bell’s Palsy, Myasthenia gravis

167
Q

Manner of walking

A

Gait

168
Q

are rhythmic oscillatory movements

A

Tremors

169
Q

Three Groups of Tremors

A
  • Resting (or Static) Tremors
  • Postural Tremors
  • Intention Tremors
170
Q

may present with changes in voice quality

A

Cranial nerve IX lesion

171
Q

are most prominent at rest and may decrease or diappear with voluntary movement.

A

Resting (or Static) Tremors

172
Q

appear when the affected part is actively maintaing a posture

A

Postural Tremors

173
Q

are rhythmic, repetative, bizzare movements hat chiefly involve the face, mouth, jaw and tongue grimacing, pursinf of the li[s, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw

A

Oral-Facial Dyskinesias

174
Q

are brief, repetitive, coordinated movements occuring at irregular intervals

A

Tics

175
Q

are similar to athetoid movements, but often involve larger parts of the body, including the trunk

A

Dystonia

176
Q

are slower and more twisting and writhing than choreiform movements,a nd ahve a larger amplitude

A

Athetosis

177
Q

are brief, rapid, jerky, irregular and unpredictable. they occur at rest or interrupt normal coordinated movements

A

Chorea

178
Q

Level of Consciousness (Arousal): Techniques

A

Alertness
Lethargy
Obtundation
Stupor
Coma

179
Q

speak to the patient in a normal tone voice

A

alertness

180
Q

speak to the patient in a loud voice

A

lethargy

181
Q

shake the patient gently as if awakening a sleeper

A

obtundation

182
Q

apply a painful stimulus

A

stupor

183
Q

apply repeated painful stimuli

A

coma

184
Q
  • Is there clutching of the chest?
  • Is there pallor? Cyanosis? Diaphoresis?
  • Is there labored breathing, wheezing, or coughing?
A

Cardiac or Respiratory Distress

185
Q
  • How is the patient dressed? * Is the clothing suitable for the temperature and weather? Is it clean and appropriate to the setting?
  • Excess clothing may reflect cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences
A

Clothing

186
Q
  • View your patient’s body size and build with respect to his or her age and gender
  • Is he/she stocky, slender, or of average build? Obese or
    cachectic? Proportional?
  • Does you patint have abnormal fat distribution?
  • Take a close look at the patient’s hand. Do you see clubbing, edema or deformities?
A

Body Type

187
Q

may reflect a cardiopulmonary problem

A

Nail clubbing and edema

188
Q

are rhythmic oscillatory movements

A

tremors

189
Q

3 groups of tremors

A

resting (static) tremors
postural tremors
intention tremors

Health Assessment - Lecture (17 decks)

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