Health Assessment Lecture 2 Flashcards
Assessing a client’s health status is a major component of
nursing care and has three aspects:
(a) the nursing health history
(b) the physical assessment, and
(c) diagnostic testing
A ??? is conducted in a systematic and efficient manner starting at the head and proceeding downward
(head- to-toe assessment)
complete health assessment
cephalocaudal
head to toe
child development
proximal to distal, head to toe
Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface
dorsal recumbent
Back-lying position with legs extended; with or without pillow under the head
supine (horizontal recumbent)
A seated position, back unsupported and legs hanging freely
sitting
Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table
lithotomy
Side-lying position with lowermost arm behind the body, uppermost leg flexed a hip and knee, upper arm flexed at shoulder and elbow
sims
Lies on abdomen with head turned to the side, with or without a small pillow
prone
should be arranged so that the area to be assessed is exposed
and other body areas are covered.
Drapes
are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination.
The pads of the fingers
is the visual assessment; that is, assessing by using the sense
of sight or vision.
Inspection
is the examination of the body using the sense of touch.
Palpation
There are two types of palpation:
light and deep
should always precede deep palpation because heavy pressure on the fingertips can dull the sense of touch
Light palpation (superficial palpation)
type of palpation that is usually not done during a routine examination and requires significant practitioner skill
Deep
is done with one hand or with two. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations
Deep palpation
is the act of striking the body surface to elicit sounds that
can be heard or vibrations that can be felt
Percussion
There are two types of percussion:
direct and indirect
the nurse strikes the area to be percussed directly with the pads of the fingers.
direct percussion
is the striking of a finger (usually the middle finger) held against the body area to be assessed
Indirect percussion
Percussion elicits five types of sound
flatness
dullness
resonance
hyperresonance
tympany
is an extremely dull sound produced by very dense tissue such
a muscle or bone.
Flatness
is a thudlike sound produced by dense tissue such as the liver, spleen or heart.
Dullness
is a hollow sound such as that produced by lungs filled
with air
Resonance
is not produced in the normal body. It is described as
booming and can be heard over an emphysematous lung.
Hyperresonance
is a musical or drumlike sound produced from an air-filled
stomach.
Tympany
is the process of listening to sounds produced within the body
Auscultation
??? auscultation by listening to body sounds with the unaided ear
direct
??? auscultation by using a stethoscope
indirect
is the number of vibrations per second (frequency)
The pitch
refers to the loudness or softness of a sound
The intensity (amplitude)
? of a sound is its length (long or short).
The duration
is a subjective description of a sound, for example, whistling, gurgling, or snapping
The quality of sound
Sequence to conduct Physical Assessment
general survey
head
neck
general survey
appearance and mental status
vital signs
height and weight
are measured
(a) to establish baseline data against which measurements and
(b) to detect actual and potential health problems.
vital signs
Measuring the ??? and ??? provides important assessment data on the client’s general health status.
weight and height
If the client is a child under the age of 2 years, measure height in the ??? position with knees fully extended.
supine
The skull is made up of many bones, namely:
frontal, parietal, occipital, mastoid process, mandible, maxilla, and zygomatic.
(the degree of detail the eye can determine in an image)
visual acuity
(the area an individual can see when looking straight ahead
visual fields
The ear is divided into three parts:
external ear, middle ear, and inner ear
A nurse passages can inspect the nasal very simply with a
flashlight or a penlight
includes inspection and palpation of the external nose; patency of the nasal cavities; and inspection and palpation of the facial sinuses
Assessment of the nose
The ??? are composed of a number of structures:
lips, inner and buccal mucosa, the
tongue and floor of the mouth, teeth
and gums, hard and soft palate, uvula,
salivary glands, tonsillar pillars, and
tonsils.
mouth and oropharynx
The nurse inspects and palpates the client’s mouth and oropharynx using a ???. However, detailed assessment is usually performed by an expert such as the ???.
penlight;
dentist
includes the muscles,lymph
nodes, trachea, thyroid gland,
carotid arteries, and jugular
veins.
examination of the neck
areas of the neck are defined by the
sternocleidomastoid muscles
sternocleidomastoid muscles divide each side of the neck into 2 triangles:
anterior & posterior
The trachea, thyroid gland, anterior cervical nodes, and carotid artery lie within the ??? triangle.
anterior
The greatest number of lymph nodes are located in the ???
head and neck.
