Health Assessment Book Module and Lecture Notes Flashcards
The sitting position is used to assess what? and what are the cautions?
Head
Neck
Posterior and anterior thorax
Lungs
Breast
Axillae
Heart
Vital signs
UE
LE
Reflexes
Note: Older adults / weak pts may require support
The supine position is used to assess what? and what are the cautions?
Head
Neck
Axillae
Anterior thorax
Lungs
Breast
Heart
Vital signs
Abdomen
Extremities
Peripheral pulses
Note: This position is tolerated poorly by pts with cardiovascular and respiratory problems
The semi-fowler position is used to assess what? and what are the cautions?
JVD
Note: May be uncomfortable unless the feet and knees are elevated slightly
The sims position is used to assess what? and what are the cautions?
Rectum
Vagina
Note: This is difficult for older adults and people with limited joint movement
The dorsal recumbent position is used to assess what? and what are the cautions?
Female genitals
Rectum
Female reproductive tract
Note: May be contraindicated for pts with cardiopulmonary problems
What are the types of assessments?
Initial
Problem focused
Emergency
Time lapsed
The purpose of a physical exam is to?
Gather baseline date
Help establish nursing dx and plans of care
Confirm, supplement, or refute data from hx
Evaluate physiologic outcomes/ progress
Make clinical judgements
ID areas for health promotion and disease prevention
Disease prevention is which type of dx
Risk dx (problem and etiology only)
(Disease prevention r/t …)
Health promotion is which type of nursing dx?
Wellness dx
What is the sequence when performing an assessment?
Palpate LAST
Choose the answer with palpation LAST
What is direct auscultation?
Listening with the unaided ear
NO stethoscope
What is indirect ausculation?
Listening with stethoscope
