Health Assessment Flashcards
The health history of a patient provides what type of data?
subjective data
The physical examination and diagnostic tests provide what type of data?
objective data
What are the nurses preliminary actions ?
- introduce yourself
- identify patients (name and DOB, look at arm band)
- gather your supplies
- explain the procedure
- wash your hands
- provide privacy
What are the vital signs?
Temperature Pulse Respiration Blood Pressure O2 Saturation (95 - 100 %)
In what order are you suppose to assess a a patient?
Inspect Palpate Percuss Auscultate *(the exception if the abdomen; inspect, auscultate, percuss, and palpate in that order in order to avoid altering bowel sounds)
Begins with the first interaction and continues throughout the examination.
- validation of findings with the client is necessary
- a use of vision, smell (olfacation), and hearing to observe and detect any expected or unexpected findings.
Inspection
The use of tough to determine the size, consistency, texture, temperature, location and tenderness of skin , underlying tissues, an organ, or a body part. Save tender areas for last
Palpation
Involves tapping body parts with fingers, fists, or small instruments to vibrate underlying tissues and evaluate size, location, tenderness, and presence or absence of fluid or air in body organs, and to detect any abnormalities. An understanding of the effect of various densities on sound can help you locate organs or masses, find their edges, and estimate their size
Percussion
The process of listening to sounds the body produces to identify unexpected findings.
Auscultation
The written summary of appraisal of overall health. This information is gathered from the first encounter with the client and continues through observation throughout the assessment process.
General Survey
What kind of data should be collected in regards to a clients physical appearance during the general survey?
Age Gender Race/ethnicity Level of consciousness Color of skin Facial features signs of distress signs of possible physical abuse of neglect signs of substance use disorders
What kind of data should be collected in regards to a clients body structure during the general survey?
Body build, stature, height, and weight Nutritional status, symmetry of body parts posture and usual position gross abnormalities (skin lesions, amputations)
What kind of data should be collected in regards to a clients mobility during the general survey?
gait
movements (purposeful, tremulous)
range of motion
motor activity
What kind of data should be collected in regards to a clients behavior during the general survey?
facial expression and mannerisms
mood and affect
speech
dress, hygiene, grooming and odors, (body, breath)
what are some questions to ask a client to gauge their level of orientation?
Person (tell me your name…can you tell me your doctors name)
place (where are you right now)
time ( what day of the week is it? what time of day is it?)
situation (why are you here)
