Health Assessment 2220 Exam 1 Flashcards
What does health assessment include?
encompasses the entire person such as physical, intellectual, spiritual, environmental, sociocultural, and emotional
How to conduct health assessment
gathering information about health status of pt current and past history, health history subjective, and physical assessment objective
types of health assessments
initial/comprehensive, focused/episodic, emergency, and time lapsed
initial/comprehensive assessment
full head to toes exam conducted on admission
focused/episodic assessment
specific to injury/complain of pt and is conducted after comprehensive exam focused on pt chief complaint (ex: ABD pain requires ABD exam)
Emergency Assessment
life threatening problems need to be noted and solved immediately; focused on ABCs then secondary complaints; rapid head to toe exam/trauma assessment conducted (ex: stabbings, anaphylaxis, SOB)
Time lapsed
interval assessment such as taking vital signs every 4 hours or every so many days a pt requires a check up
Types of assessment techniques in order
Inspection, palpation, percussion, and auscultation
Order of assessment for abdominal exam
Inspection, auscultation, percussion, palpation (palpating prior to auscultation can create abnormal bowel sounds)
inspection assessment
what do you see, hear, smell? what size, color, shape, position, symmetrical?
palpation assessment
feeling of the pt body using palmar surface and fingers for sensitivity, ulnar surface for vibration, dorsal surface for temperature; whats the temp., skin turgor, texture, moisture, vibration, shape?
light palpation
1cm (0.5”)
moderate palpation
1cm-2cm (0.5-0.75”)
deep palpation
2cm (1”)
percussion assessment
tapping of pt body listening for different sounds that are produced (hollow vs. dense)
direct percussion
directly tapping on surface of pt
blunt percussion
using the ulnar surface of fist and thumping your own other hand against pt
indirect percussion
tapping finger on own other finger/hand against pt
auscultation assessment
listening to pt organs and bodily systems with stethoscope
use for diaphragm
to hear higher pitched sounds such as lung sounds, bowel sounds, and normal heart sounds
use for bell
listen to lower pitched sounds such as murmurs or bruits
is bell pressed lightly or firmly when auscultating
lightly
diaphragm pressed lightly or firmly when auscultating?
firmly
what are you listening for when auscultating?
quality of sounds such as pitch (high or low), loudness (soft or loud), duration (short,medium, or long), quality (description of sound)
tips for ausculation
examine from the right of pt, warm stethoscope, close eyes for better attention, auscultate on bare skin
general survey importance
begins moment of contact, provides clues to overall health, first impression give cues for what needs attention, establishes pt baseline, includes vitals, H&W
What to observe for in general survey
(11) 1. signs of distress, 2. stature/build, 3. speech patterns, 4. Significant others accompanying, 5. Dressing/grooming, 6. posture/gait/coordination, 7. LOC, 8. Eye contact, 9. vision/hearing problems, 10. nutritional state, 11. affect
example general survey
pt is 56 Y male construction worker appears healthy and stated age
pt AOx4, cooperative and shwoing no signs of distress
HT 6’1” Wt 202lbs
T- 97.6 P-82bpm RR 16/min BP 122/78 R arm sitting
The importance of an interview
establishes trust
Health history
biographical data, reason for seeking care, present health or history of present illness, past health, family history, functional assessment & ADLs/psychosocial
chief complaint
reason pt is seeking care in their own words
present health or HPI
location, character/quality, severity/quantity, timing, setting, aggravating/relieving factors, associated/radiating factors, pt perception; OPQRSTI
Past health
childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, OB history, immunizations, last exam, allergies, current meds
family history
age and health/cause of death of blood relatives; presence of heart disease, cancer, HTN, CVA, diabetes, cancer, blood disorders, obesity, psychiatric
subjective data
symptoms that pt describes; clinician cannot see these and relies on pt word (pain, health history
objective data
what can be seen through a general survey and physical examination
interviewing techniques
(5) validating- validates correctness of what nurse heard, clarifying- using question to decipher the truth or if something is unclear, reflecting- repeating what pt has said or describing feelings to elaborate, sequencing- used to place events in chronological order to identify cause and effect, directing- obtain more information or introduce something new
open ended questions
used to start conversation and obtain information (ex; what concerns do you have about treatment?)
close-ended questions
helpful for seeking specific information or clarification (ex: how many times do you take this medication?)
communicating with children
be responsive to nonverbal communication, get at eye level, be gentle and calm, use understandable language, use structured play
communicating with critically ill
assume they can hear you, explain what you are doing and provide cues about day/night, call bell within reach
sources for assessment
reviewing medical records, patient interview, family interview, other providers
phases of interview
introduction-purpose of interview, how long it will take, expectations, ensure confidentiality, working- open-ended questions for obtaining info and close-ended for direct questions, closing- summary of the interview
functional assessment
self esteem/self-concept: personal identity, body image, role-performance, activity: are they active or sedentary, sleep/rest: adequate sleep, nutrition/elim.: good diet and bowels, stress/adaptations: stressors in life d/t job or family and what coping skills, intimate partner violence: safe at home or stating domestic violence
older adult assessment tool
SPICES: sleep disorders, problems with eating, incontinence, confusion, evidence of falls, skin breakdown
non-verbal communication
physical appearance and facial expressions (how you present to the pt), posture (get at eye level), gestures, tone of voice and touch (be careful with touch)
equipment used for assessments
opthalmoscope for eyes, odoscope for ears, stethothscope for lungs, hear, BP, heart sounds, bowel sounds, pulse ox for sat
when are vital signs taken?
admissions, discharge, change in status, every 1-4-8 hours (depending on floor)
normal ranges
BP- 120/80, HR-60-100, RR- 12-20, Sat. 95-100 , Core temp. 35.9-38 C or 96.7-100.4F
What can affect vitals
pain
most accurate temp.
rectal (98.7-100.5)
least accurate temp.
axillary
ways to measure core temp
tympanic and rectal (rectal usually 1 degree F higher than oral)
how to take BP
using sphygmomanometer and stethescope, aneroid (calibrated 2mmHg), needle at 0
incorrect BP readings
too small of cuff = higher reading and too large cuff= lower reading; pt has not rester (5 min), consumption of caffeine, smoked, arm not at heart level, pt not quiet
factors affecting temperature
circadian rhythm (lowest temp in AM and peak around 4-8PM), age (older = lower core temp.), sex progesterone during ovulation increases temp. (~0.5-1F), environmental temp or consuming warm drink (wait 15 min), increase in metabolic rate (exercise, stress, illness)
oral route temp
most common; blue one for mouth; wait 15-30 minutes after iced or hot drink
contraindications to oral temp
kids <5 years, confused/unconscious pt, comatose pt, pt with seizure disorders, pt after oral/nasal surgery, pt receiving O2
tympanic membrane route
measures core temp (usually 1F higher than oral), good for young, confused/unconscious pt
contraindication for tympanic membrane temp.
pt with ear drainage, external ear infection (middle ear infect. is fine), or scars on tympanic membrane
temporal
non-inasive, quick, reliable
contraindications to temporal artery route temp.
do not measure over scar tissue, open lesions, or abrasions
axillary route
used when both oral and rectal are contraindicated, not used when accuracy required, usually 1 F lower than oral
core temp measurements
tympanic membrane and rectal
rectal temp. route
measures core temp., the most accurate, 1 degree higher than oral, use lubricant, insert in direction of umbilicus 1.5 inch
contraindication of rectal temp
pt with diarrhea, bowel surgery, rectal diseases, heart disease or after cardiac surgery, neutropenic pt, pt with spinal cord injury, throbocytopenia
factors that afect respirations
(12 factors) age (d/t lung capacity), sex (males lower RR d/t capacity), altitude (increased elevation = increased RR), stree/anxiety (stimulates SNS increasing R), exercise (increase O2 demand increasing RR), medications (narcs depress Resp. drive and stimulants increase), acid-base balance (hyperventilate to release CO2), brain lesions (cheyne stokes), respiratory disease (can affect rate, depth, pattern), pain (incease RR but decreases depth), anemia (decreased O2 carrying which increases RR), fever (increases metabolic rate which increases RR)