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Health Assessment Lec > Collecting Objective Data > Flashcards

Collecting Objective Data Flashcards

1
Q

SUBJECTIVE DATA

A

▪ Perception
▪ Opinion
▪ True for the patient
▪ May or may not be true to you

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2
Q

OBJECTIVE DATA

A

▪ Reproducible findings
▪ True for the patient and for you
▪ True for you and others
▪ FACT

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3
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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4
Q

Types of physical assessment

A

▪ Complete
▪ Focused

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5
Q

Types of Focused

A
  • Body system (cardiovascular
    system)
  • Body area/ Regional (Lungs
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6
Q

Establish or monitor health status

A

Complete Physical Examination

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7
Q

Components of Complete Physical Examination

A

✓ General survey
✓ Vital signs
✓ Head
✓ Neck
✓ Upper extremities
✓ Chest and back
✓ Abdomen
✓ External genitals

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8
Q

Focused Physical Examination
Used when:

A

▪ patient is unstable
▪ Time constraints exist
▪ Episodic follow-up

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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

PA Preparation

A

▪ Yourself
▪ The environment
▪ The patient

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11
Q

PA 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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12
Q

PA 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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13
Q

PA Preparing the Environment

A

▪ Temperature
▪ Lighting
▪ Privacy and noise
▪ Positioning
▪ Draping
▪ Instrumentation
▪ Methods of Examining

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14
Q

Positioning Consider

A

▪ Client’s ability to assume a position
▪ Physical condition
▪ Energy level
▪ Age

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15
Q

Different Position

A

Sitting
Supine
Dorsal Recumbent
Lithotomy
Prone
Sim’s
Knee Chest Position

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16
Q

A seated position, back
unsupported and legs hanging freely.

A

Sitting

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17
Q

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

A

Supine

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18
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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19
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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20
Q

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

A

Prone

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21
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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22
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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23
Q

Provide privacy and warmth, expose only the area to be assessed.

A

Draping

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24
Q

▪ Ensure equipment are clean, in good
working condition, readily accessible
▪ Designate one area for clean/ unused and
another area for dirty/ used

A

Instrumentation

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25
Q

Thermometer Types:

A

▪ Glass mercury thermometer
▪ Electronic digital thermometer
▪ Tympanic thermometer
▪ Temporal artery thermometer
▪ Disposable paper strips

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26
Q

Used in indirect auscultation.

A

Stethoscope

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27
Q

Stethoscope parts

A

▪ Used in indirect auscultation
▪ Tubing should be 30 to 35cm long
▪ Internal diameter of 0.3cm
▪ Has a diaphragm and amplifier (bell)
▪ Have the earpieces pointing forward

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28
Q

▪ Fetal heart sounds
▪ Locate pulses

A

Doppler

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29
Q

an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff

A

Sphygmomanometer

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30
Q

Sphygmomanometer
▪ Cuff width should be _____ .

A

40% of the arm circumference

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31
Q

Sphygmomanometer Cuff bladder encircle ____.

A

80% of the arm.

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32
Q

To assess far and near vision

A

Visual acuity chart

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33
Q

▪ Far vision adult: __ feet
▪ Far vision children: __ feet

A

20 feet
10 feet

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34
Q

Visual acuity charts

A

▪ Snellen eye chart
▪ E chart
▪ STYCAR test cards
▪ Pocket vision screener

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35
Q

uses for
▪ Eyes
▪ Hard-to-see places

A

Penlight

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36
Q

Assess the internal structures of the eyes and Always use in dark room

A

Ophthalmoscope

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37
Q

Always palpate the tragus, helix, mastoid
process for tenderness before inserting an
otoscope, if tender proceed carefully

A

Otoscope/Nasoscope

38
Q

Assess hearing and vibratory sensation

A

Tuning Fork

39
Q

Tuning Fork frequencies

A

▪ Low frequency fork (256Hz): testing
vibratory sensation
▪ High frequency fork (512Hz): assessing hearing

40
Q

Tape measure/ pocket ruler uses.

A

▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height

41
Q

Goniometer

A

To assess range of motion exercisers

42
Q

Used to measure body fat

A

Triceps skin fold calipers

43
Q

Scale

A

▪ Used to measure weight

44
Q

this is for:
▪ Better visualization of the pharynx
▪ Assessing gag reflex
▪ Break tongue depressors after use

A

Wooden tongue depressor

45
Q

▪ Used during neurological examination

A

Cotton balls

46
Q

Cotton, used during neurological examination:

A

▪ Light touch
▪ Corneal reflex

47
Q

Assess hot and cold sensation.

A

Test Tubes

48
Q

Coffee

A

Assess the sense of smell.

49
Q

Sugar and lemon

A

Assess sense of taste

50
Q

Cup of water

A

Swallowing ability and thyroid

51
Q

Paper clip

A

Assess for stereognosis.

52
Q

Safety Pin

A

▪ Assess light touch and pain
▪ Discard after use

53
Q

Gloves

A

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

54
Q

Techniques of Physical Examination

A

▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation

55
Q

General guidelines

A

▪ Be systematic
▪ Use you patient as a comparative
▪ Always consider your patient’s growth and
developmental stage

56
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

57
Q

Types of Inspection

A

▪ Direct inspection
▪ Indirect inspection

58
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

59
Q

Dorsal aspect of the Hand

A

for temperature

60
Q

Ball of the hand on palm and ulnar surface

A

Vibration

61
Q

Finger Pads

A

Fine sensation (pulsations)

62
Q

Types of Palpation

A

Light Palpation
Deep Palpation

63
Q

type of palpation with
temperature, texture, mobility, shape, size
pulses
areas of edema
tenderness

A

Light Palpation

64
Q

Type of palpation with:
organ size, masses
rebound tenderness.
voluntary guarding
ballottement

A

Deep Palpation

65
Q

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

A

Percussion

66
Q

Percussion Assess:

A

Assess:
* Density of underlying structure
* Areas of tenderness
* Deep tendon reflexes

67
Q

Types of percussion

A

Direct/ Immediately percussion
Indirect Percussion
Fist or Blunt Percussion

68
Q

Direct tapping your hand over a body surface

A

Direct/ Immediately percussion

69
Q

Assess organ tenderness
can be direct or indirect

A

Fist or Blunt Percussion

69
Q

Percussion Sounds

A

Resonance
Tympany
Dullness
Hyperresonance
Flatness

69
Q

Plexor, pleximeter technique
percussion hammer

A

Indirect Percussion

69
Q

▪ Use of sense of hearing

A

Auscultation

69
Q

Auscultation, Assesses

A

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

69
Q

Patients with special needs

A

▪ Children
▪ Pregnant patients
▪ Elderly
▪ Disabled patients

70
Q

Types of Auscultation:

A

Direct auscultation
Indirect auscultation

71
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

72
Q

Nagele’s Rule →

A

Estimated Due of
Confinement or Estimated Due Date
Last Menstrual Period
Subtract 3 months
Add 7 days
Add 1 year

73
Q

woman who is or has been
pregnant

A

Gravida

74
Q

woman who has never has
been pregnant

A

Nulligravida

75
Q

first time pregnant

A

Primigravida

76
Q

pregnant more than once

A

Multigravida

77
Q

past pregnancies that have reached viability (24 AOG)

A

Para

78
Q

has never completed to period of
viability

A

Nullipara

79
Q

completed one pregnancy
regardless the result

A

Primipara

80
Q

completed two or more pregnancies

A

Multipara

81
Q

Obstetric / Gynecologic History

A

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

82
Q

This refers to the total number of times a woman has been pregnant, regardless of the outcome

A

Gravida

83
Q

This indicates the number of full-term pregnancies a woman has had. A full-term pregnancy is one that lasts at least 37 weeks.

A

Term

84
Q

This represents the number of preterm pregnancies a woman has experienced. pregnancy is one that ends before 37 weeks of gestation.

A

Preterm

85
Q

In the context of GTPAL, refers to the number of pregnancies that were terminated before 20 weeks of gestation. It includes both spontaneous abortions (miscarriages) and induced abortions.

A

Abortion

86
Q

This denotes the number of living children a woman currently has. It does not include the current pregnancy.

A

Living

Health Assessment Lec (11 decks)

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