EXAM 3- Health Hx Flashcards
why do we perform a pt health hx
- gather baseline data
- supplement, confirm, or refute previous data
- confirm/identify nursing diagnosis
- make clinical judgements r/t changes in data
- evaluate physiological outcomes of care
what should you consider when completing a pt hx?
- cultural sensitivity- match the pt’s culture, use professional translators
- infection control- clean equip., PPE, hygiene
- environment- privacy (visitors/door)
- equipment- be prepared
primary source of data
comes from pt
secondary source of data
comes from family/friends, EMR, healthcare professionals
diagnostic tests
- laboratory- ABg, CBC, sputum
- radiologic studies- X-Ray, CT, V/Q Scan, PET scan
- skin tests
- pulmonary function tests
- endoscopy exam
interview method of data collection
- orientation phase
- working phase
- termination phase
methods of data collection
- interview
- nursing health hx
- physical examination
- diagnostic & laboratory results
types of physical assessment
- comprehensive
- focused- focused on the cc/problem
- system specific- focused on a system
- ongoing- same routine assessment, looking for changes
- all assessments are considered head to toe
all include assessing & asking questions
elements of an assessment
- history- baseline & problem-based
- examination- vitals, inspection, auscultation, palpation
assessment process & physical
- assessment- interview, physical assessment
- nursing diagnosis- identiy the risk
- planning- based on assessment data, plan care to prevent problems/ avoid the risk
- evaluation- establishes nursing accountability, evaluate, take responsibility
in what stage of the nursing process does the nurse establish accountability & responsibility?
evaluation
techniques for assessment
- inspection
- palpation
- percussion
- auscultation
- olfaction
included all senses except taste
inspection process
visual
- good lighting, use additional lighting/devices if needed
- expose all of the body part to be examined, respect privacy
- observe for: color (sclera, skin), shape/symmetry, movement (gait), position (anatomically, midline)
palpation process
tactile
- bimanual/manual technique
- dorsum of hand- assess temp
- palm/ulnar surface of hand- shape, texture
- palmar surface/ finger pads- radial pulse
- assess for: texture, resisitance (ROM), resilience (duration), mobility, temp, thickness (skin integrity), shape (breast), moisture (clammy)
- light palpation: 1/2 in depth (radial pulse)
- deep palpation: 2 in depth (abd. assessment)
percussion process
auditory & tactile
- direct- applied directly to body
- indirect- applied through another surface
auscultation process
auditory
characteristics of sounds:
* frequency
- # of oscillations per second generated by vibrating object
- loudness- amplitude of a sound wave
- quality- descriptive (rumbling, trill, dialysis pts)
- duration- length of time that sounds lasts
using a stethoscope for auscultation
- always place directly on skin
- bell is best for low pitch sounds (vascular & heart sounds)
- diaphragm is best for high pitch sounds (bowel & abnormal lung sounds)
olfactory process
smell
used to detect abnormal vs normal
* alcohol on breath
* foul smelling odor from wound (C-Diff)
* sweet smelling odor from mouth (diabetes)
usually descriptive in nature
special considerations for aged pts
recognize physical/sensory limitation
* adjust position
* allow more time (fatigue)
* allow more space
* recognize normal changes of aging vs abnormal
beginning of pt hx assessment
begin with general survey:
* race/ gender
* age
* body type
* posture
* signs of distress (rapid breathing)
* substance abuse (pinpoint eyes)
* speech (slurred)
* movement/ gait
* hygiene/grooming
* dress (appropriate for weather?)
* affect/mood
* pt abuse
signs of abuse
- inconsistency b/w injury & statement
- bruises, lacs, burns, bites
- x-ray shows fx in various stages of healing/ unreported fx or injuries
- behavior issues, insomnia, anxiety, isolation
is the RN a mandatory reporter of abuse if it is suspected?
yes
what is the dorsum of hand used to palpate?
assessing temp
what is the palmar/ulnar of hand used to palpate?
assess shape & texture
ex: examining breast for lumps
