exam 2/ assessing health Flashcards
The purpose of a health assessment is to:
1) To establish the clien-nurse relationship, 2) to obtain into about he client’s health using the 5 variables of the nsm, 3) to identify client strengths, 4) To identify actual and potential health problems.
Nursing assessment has 2 components, they are:
A. Health history elicits subjective data (what the patient tells you)
B. Nursing examination elicits objective data (what the nurse sees)
With inspection the nurse uses visual, auditory and olfactory senses. We inspect each area for:
size, color, shape, position, and symmetry
When the nurse palpates, he/she should provide a warm, comfortable and relaxed environment. Nurses hands should be:
warm, nails short, palpate areas of tenderness last.
Some things you can identify through palpation are:
Texture- hair, psoriases temperature-skinwarmth, thrombophlebitis vibration-pneumonia position-size, consistency and mobility of organs or masses. distention-urinary bladder presence and rate of peripheral pulses tenderness or pain turgor-dehydration moisture-diaphoresis Shape-enlarged liver
Striking finger against finger creating sounds generated by body tissue. It is used to assess location, shape, size and density of underlying tissues. What is this called?
percussion
Some percussion sounds are:
Tympany- a loud drumlikesound (percussion of stomach, or puffed out cheek)
resonance- moderate to loud, lower pitched, hollow sound percussed over lung tissue
Hyperresonance- very loud, low pitched sound with booming quality. (percussion of emphysema lung)
Dullness- soft to moderate, hish-pitched sound with thud-like quality (over liver with ascites_
Flatness- soft, high piched sound that is flat (over muscle or bone)
Auscultated sounds are described according to their:
pitch, intensity, and duration
When using the stethoscope, the diaphragm best transmits:
high pitched sounds (example: bronchial)
when using the stethoscope, the bell transmits
low pitched sounds
Blood pressure is a good measure of the patients:
oxygenation of the brain
orthostatic bp checks are usually ordered whenever:
the patient is light headed or dizzy
indirect percussion is performed by:
using the finger of one hand, (plexor) to tap the finger of the other hand, (pleximeter).
percussion is used to determine:
the size and shape of an internal organ by establishing their borders. It indicates whether tissue is fluid filled, air filled, or solid.
flatness is an extremely dull sound produced by:
very dense tissue, such as muscle or bone.
