Exam 2 - Chapter 26 (Health Assessment) Flashcards
Types of HEalth Assessnments
Comprehensive
Ongoing Partial
Focused
Emergency
What is a Comprehensive Health Assessment?
This is broad and includes a complete health history and physical assessment
What is a Focused HEalth Assessment
Is conducted to assess a specific problem
What is a Emergency Health Assessment
It is a type of rapid focused assessment conducted when addressing a life-threatening or unstable situation
What is Ongoing Partial Health Assessment
It is one that is conducted at regular intervals during care of the patient
Considerations when performing health assessment
Lifespan Considerations
Cultural Considerations and Sensitivity
Patient Preparation
Environmental Preparations
Factors to Assess During a Health History
Biographical Data Reason for Seeking Health Care History of Present Illness Past Health History Family History Functional Health
Preparing for Physical Assessment (1)
Agree on a time for the assessment
Preparing for Physical Assessment (2)
Make sure patient is as free of pain as possible and empty bladder
Preparing for Physical Assessment (3)
Explain the procedure answers questions directly and honestly
Preparing for Physical Assessment (4)
Provide a gown and drape for the patient
Preparing for Physical Assessment (5)
Gather the supplies and instruments needed
Preparing for Physical Assessment (6)
Provide a curtain or screen if the area is open to others
Techniques used during a Physical Assessment
Inspection
Palpation
Percussion
Auscultation
Inspection
Assessing Size, Color, Shape, Position, And Symmetry
Palpation
Assesssing Temperature, Turgor, Texture, Moisture, Vibrations, And Shape
Percussion
Assessing Location, Shape, Size, And density of tissuese
Auscultation
Assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration
Characteristics of MAsses Determined by Palpation
Shape Size Consisstency Surface Mobility Tenderness Pulsating
Erythema
Redness of the skin, caused by dilation of superficial blood vessels
Cyanosis
Blueish or grayish discoloration of the skin in response to inadequate oxygenation
Jaundice
A yellow color of the skin resulting form elevated amounts of bilirubin in the blood
Pallor
Paleness of the skin
Ecchymosis
Collection of blood in the cubcutaneous tissues
Petechiae
Small hemorrhagic spots caused by capillary bleeding.
Diaphoresis
Exccessive amount of perspiration, such as when the entire skin is mosit
Bronchial Breath Sounds
Heard over the larynx and trachea and are high-outched, harsh blowing sounds with sound of expiration being longer than inspiration
Bronchovesicular Breath Sounds
Heard over the mainstem bronchus and are moderate blowing sounds
Vesicular Breath Sounds
Soft-Low pitched whispering sounds heard over most of lung fields
Adventitious Breaht Sounds
Not normally heard in the lungs and result from air movement through moisture
Assessling Level of Awareness
Time, Place, Person, Situation
Sound Heard: Pitch
Ranging from high to low
Sound Heard: Loudness
Ranging from soft to load
Sound Heard: Quality
For example, gurgling or swishing
Sound Heard: Duration
Short medium or long
Common Thorax and Lung Variations in Older Adults
Increased Anteroposterior Chest Diameter
Increase in the dorsal spinal curve (kyphosis)
Decrease thoracic expansion
Uce of accesory muscles to exhale
Where is the best sound heard in the abdominal quadrants?
Left Lower Quadrant
Common Abdominal Variations in Older Adults
Decreased bowel sounds
Decreased abdominal tone
Fat accumulation on the abdomen and hips
Common Cardiovascular and Peripheral Vascular Variations in Older Adults
Difficult-To-Palpate Distal Arteries Dilated Proximal Arteries More prominent and toruous blood vessels Increased BP Widening Pulse Pressure
