Health Assessment Flashcards
What type of data do you collect, validate and analyze during health assessment?
- Subjective
- Objective
Subjective Data
Information based on patient experiences and perceptions
Objective
Measurable and directly observed
Health assessment includes two components:
- Health History
- Physical Assessment
Health history
collection of subjective information about the patient’s health status
Physical assessment
collection of objective data about changes in the patient’s body systems
Types of Health Assessments- 4 types
- Comprehensive
- Ongoing Partial
- Focused
- Emergency
Comprehensive Health Assessment
Conducted upon admission to health care facility
Ongoing Partial Health Assessment
Conducted at regular intervals
Focused Health Assessment
Conducted to assess a specific problem
Emergency Health Assessment
Conducted to determine life threatening or unstable conditions
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 health concern
- Past Health History
- Family Health History
- Functional Health
Preparing the Environment for Physical Assessment:
- Hand Hygiene
- Prepare the Examination Table
- Provide a gown and drape for the patient
- Are there any precautions beside standard
- Gather the supplies and instruments needed
- Provide a curtain or screen if the area is open to others
- Provide a comfortable room temp.
Equipment Used During a Physical Examination:
- Thermometer
- Sphygmomanometer
- Scale
- Flashlight or penlight
- Stethoscope
- Metric tape measure and ruler
- Eye chart
- Watch with a second hand
Positions used during Physical Assessment: There are eight
- Standing
- Sitting
- Supine
- Dorsal Recumbent
- Sim’s
- Prone
- Lithotomy
- Knee-chest
Techniques used during a Physical Assessment (say in order)
- Inspection
- Palpation
- Percussion
- Ausculation
Inspection Assesses
size
color
shape
position
symmetry
Palpation Assesses:
temperature
turgor
texture
moisture
vibrations
shape
Percussion assesses
location
shape
size
density of tissues
Auscultation assesses
the four characteristics of sound:
pitch
loudness
quality
duration
General survey includes
General appearance
vital signs
height, weight, waist circumference
calculating BMI
Physical Assessment includes: 10 things
- Integument
- Head and Neck
- Thorax and lungs
- Cardiovascular and peripheral vascular systems
- Breasts and axillae
- Abdomen
- Female and male genitalia
- Anus, rectum, prostate
- Musculoskeletal system
- Neurologic system
Integument (Skin) Assessment Subjective data includes:
History of rashes, lesions, bruising, allergies
Exposures to sun, chemicals
Piercings or tattoos
Degree of mobility
Nutritional status
Skin Language Terminology
Erythema
Ecchymosis
Petechaie
Cyanosis
Jaundice
Pallor
Diaphoresis
Turgor
Edema
Erythema
redness (pertaining to skin)
Ecchymosis
Collection of blood in
subcutaneous tissue (pertaining to skin)
Medical term for a bruise
Petechiae
Hemorrhagic spots/capillary
bleeding (pertaining to skin)
Cyanosis
bluish or grayish color (pertaining to skin)
Jaundice
yellow color (pertaining to skin)
Pallor
Paleness (pertaining to skin)
Diaphoresis
Excessive perspiration (pertaining to skin)
Turgor
Elasticity (pertaining to skin)
Edema
excess fluid (pertaining to skin)
Two types of skin lesions
- Primary Lesions
- Secondary Lesions
Primary Lesions - 9 types
- Macule
- Papule
- Vesicle
- Pustule
- Bulla
- Cyst
- Nodule
- Plaque
- Wheal
Macule
a flat, circumscribed area; can be brown, red, white, tan
Is a primary lesion
Papule
An elevated, palpable, firm, circumscribed area generally less than 5 mm in diameter
Is a primary lesion
Vesicle
an elevated, circumscribed, superficial, fluid-
filled blister less than 5 mm in diameter
Is a primary lesion
Pustule
An elevated, superficial area that is similar to a
vesicle but filled with pus
Is a primary lesion
Bulla
A vesicle greater than 5
mm in diameter
Is a primary lesion
Cyst
An elevated, circumscribed area of the skin filled
with liquid or semisolid fluid
Is a primary lesion
Nodule
An elevated, firm, circumscribed, and palpable
area greater than 5 mm in diameter; can involve all skin layer
Is a primary lesion
Plaque
An elevated, flat-topped, firm, rough, superficial papule greater than 2 cm in diameter; papules can coalesce to form plaques
Is a primary lesion
Wheal
An elevated, irregularly shaped area of cutaneous edema; wheals are solid, transient, and changeable, with a variable diameter; can be red, pale pink, or white
Is a primary lesion
Secondary Lesions include- 4 things
- Crust
- Excoriation
- Lichenification
- Scale
Crust
a slightly elevated area of variable size; consists of dried
serum, blood, or purulent exudate
Is a secondary lesion
Excoriation
Linear scratches that may or may not be denuded
Is a secondary lesion
Lichenification
Rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching (eg, chronic eczema and lichen simplex)
Is a secondary lesion
Scale
Heaped-up keratinized cells; flakey exfoliation; irregular;
thick or thin; dry or oily; variable size; can be white or tan
Is a secondary lesion
Skin, Hair and Nails Objective Assessment: when INSPECTING look for
Color, shape
Lesions (use descriptive terms)
Bruising, lacerations, wounds
Distributions
Clubbing
ABCDE for skin cancer screening
Skin, Hair and Nails Assessment Objective: When PALPATING FEEL for
Temperature
Texture, moisture
Turgor
Edema
Palpable lesions
Capillary lesions
Capillary refill (Normal is <3 seconds)
ABCDE for Skin Cancer Screening
Asymmetry
Border
Color
Diameter
Evolving
Assessing for Melanoma: Assymetry
If a line is drawn through a mole, the two halves will not match
Assessing for Melanoma: Border
The borders of an early melanoma tend to be uneven
The edges may be scalloped or notched
Assessing for Melanoma: Color
A number of different shades of brown, tan, or black could appear
A melanoma may also become red, white or blue
Assessing for Melanoma: Diameter
Melanomas usually are larger in diameter than the size of the eraser on your pencil, but may sometimes be smaller when first detected
What does HEENT stand for?
Head
Ears
Eyes
Nose
Throat
What is SUBJECTIVE data having to do with HEENT
Changes in vision or hearing
History of allergies, chronic illnesses
Exposure to harmful substances or smoking
History of infection or trauma
Pain
Dental care practices
What is OBJECTIVE data having to do with HEENT.
Only Head, Face and Nose for now
Inspection
Shape of head
Size of head
Symmetric and Proportionate
Nasal turbinates
Cranial Nerve I: Olfactory
Terms to document NORMAL findings of head (size and shape)
Normocephalic, symmetric
Terms to document NORMAL findings of nose
Nares moist and darker red than oral mucosa
No evidence of swelling, bleeding, or discharge
reports sense of smell
What is OBJECTIVE data having to do with HEENT.
Only Head, Face and Nose for now
Palpation
Masses, symmetry of head
Frontal and maxillary sinuses
Nasal patency
Cranial Nerve V: Trigeminal nerve
Cranial Nerve VII: Facial