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HEALTH ASSESSMENT LEC > Collecting Objective Data > Flashcards

Collecting Objective Data Flashcards

1
Q

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

A

SUBJECTIVE DATA

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2
Q

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

A

OBJECTIVE DATA

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

▪ Focused

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6
Q

▪ Establish or monitor health status
▪ Components:
✓ General survey
✓ Vital signs
✓ Head
✓ Neck
✓ Upper extremities
✓ Chest and back
✓ Abdomen
✓ External genitals
✓ Anus
✓ Lower extremities

A

Complete Physical Examination

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7
Q

Used when:
▪ patient is unstable
▪ Time constraints exist
▪ Episodic follow-up
Components:
▪ General survey
▪ Vital signs
▪ Assessment of the specific area or
system
▪ Quick cephalocaudal scan

A

Focused Physical Examination

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8
Q

Preparation

A

▪ Yourself
▪ The environment
▪ The patient

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9
Q

What is the striking finger in percussion called?

A

the plexor

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10
Q

▪ Identify yourself
▪ Appear calm and organized
▪ As a beginner, avoid interpreting your
findings
▪ Observe standard and universal precaution

A

Preparing yourself

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11
Q

▪ 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

A

Preparing client

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12
Q

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

A

Preparing the Environment

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13
Q

Positioning Considerations

A

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

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14
Q

A seated position, back
unsupported and legs hanging freely.

A

Sitting

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15
Q

Back-lying position with legs
extended, with or without a pillow under the head.

A

Supine

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16
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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17
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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18
Q

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

A

Prone

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19
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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20
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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21
Q

▪ Provide privacy and warmth
▪ Expose only the area to be assessed

A

Draping

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22
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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23
Q

Thermometer
Types:

A

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

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24
Q

▪ 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

A

Stethoscope

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25
Q

▪ Fetal heart sounds
▪ Locate pulses

A

Doppler

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26
Q

▪ Cuff width should be 40% of the arm
circumference
▪ Cuff bladder encircle 80% of the arm

A

Sphygmomanometer

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27
Q

▪ To assess far and near vision
▪ Far vision adult: 20 feet
▪ Far vision children: 10 feet
▪ vision: 14 inches
▪ 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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28
Q

Visual acuity charts

A

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

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29
Q

▪ Eyes
▪ Hard-to-see places

A

Penlight

30
Q

▪ Assess the internal structures of the eyes
▪ Always use in dark room
▪ Right- to- right
▪ Left- to- left

A

Ophthalmoscope

31
Q

▪ Always palpate the tragus, helix, mastoid
process for tenderness before inserting an
otoscope, if tender proceed carefully
▪ Adult: pull the helix up
▪ For preschool child, pull the earlobe down

A

Otoscope/Nasoscope

32
Q

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

A

Tuning fork

33
Q

▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height

A

Tape measure/ pocket ruler.

34
Q

▪ To assess range of motion exercises

A

Goniometer

35
Q

▪ Used to measure body fat

A

Triceps skin fold calipers

36
Q

▪ Used to measure weight
▪ If obtaining daily weights, weigh the patient
at the same time with the same scale

A

Scale

37
Q

▪ Better visualization of the pharynx
▪ Assessing gag reflex
▪ Break tongue depressors after use

A

Wooden tongue depressor

38
Q

▪ Used during neurological examination:
▪ Light touch
▪ Corneal reflex

A

Cotton balls

39
Q

Assess hot and cold sensation

A

Test tubes

40
Q

Assess the sense of smell.

A

Coffee

41
Q

Assess sense of taste

A

Sugar and lemon

42
Q

Swallowing ability and thyroid

A

Cup of water

43
Q

Assess for stereognosis

A

Paper clip

44
Q

▪ Assess light touch and pain
▪ Discard after use

A

Safety Pin

45
Q

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

A

Gloves

46
Q

Techniques of Physical Examination

A

▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation

47
Q

General guidelines

A

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

48
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

49
Q

Types of Inspection

A

▪ Direct inspection
▪ Indirect inspection

50
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

51
Q

Temperature

A

Dorsal aspect of the hand

52
Q

Vibration

A

Ball of the hand and ulnar surface

53
Q

Fine sensations [pulsations]

A

finger pads

54
Q

Types of palpation

A

Light Palpation
Deep Palpation

55
Q

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

A

Percussion

56
Q

In percussion, we assess the:

A
  • Density of underlying structure
  • Areas of tenderness
  • Deep tendon reflexes
57
Q

Types of percussion

A

Direct Percussion [Immediate Percussion]
Indirect percussion
Fist or Blunt Percussions

58
Q

Percussion Sounds

A

Sound
Intensity
Pitch
Duration
Quality
Source

59
Q

Quality of Sound of Normal Lung

A

Hollow

60
Q

Quality of Sound of Gastric Air Bubble or intestinal Air

A

Drumlike

61
Q

Quality of Sound of Liver, full bladder, pregnant uterus

A

Thudlike

62
Q

Hyperinflated lung [emphysema]

A

Booming

63
Q

Quality of Sound of Muscle

A

Flat

64
Q

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

A

Auscultation

65
Q

Types of auscultation

A

Direct Auscultation = Without Stethoscope

Indirect Auscultation = With Stethoscope

66
Q

Patients with special needs

A

▪ Children
▪ Pregnant patients
▪ Elderly
▪ Disabled patients

67
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

68
Q

▪ 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

A

Pregnant Patients

69
Q

▪ Do not rush
▪ Look for developmental changes
▪ Conserve your patient’s energy
▪ Allow enough time to respond

A

Elderly patients

70
Q

▪ Identify the disability
▪ Focus on the patient’s functional ability and mental capacity
▪ Modify as necessary

A

Disabled patients

HEALTH ASSESSMENT LEC (8 decks)

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