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Module 1 Exam > health history > Flashcards

health history Flashcards

1
Q

Purpose

A

Gather baseline data about the client’s health
Supplement, confirm, or refute previous data
Confirm and identify nursing diagnosis
Make clinical judgments r/t changes in data
Evaluate physiological outcomes of care

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2
Q

Interview *Types of data:

A

Subjective- Pain. Verbal descriptions
Objective- fact.

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3
Q

Primary data

A

Comes from patient. Adults with learning disabilities, communication barriers. Kids that cannot explain pain.
Primary-Neurological, Dementia barriers

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4
Q

Secondary

A

Other health care professionals, EMR, Family, Friends

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5
Q

Diagnostic Tests: LABORATORY

A

ABG’S, CBC, SPUTUM

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6
Q

RADIOLOGIC STUDIES

A

CHEST X-RAY, CT, V/Q SCAN, PET SCANS

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7
Q

Other diagnostic tests

A

SKIN TESTS
PULMONARY FUNCTION TESTS
ENDOSCOPY EXAMINATIONS

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8
Q

Methods of Data Collection

A

Interview
Orientation phase
Working phase
Termination phase

Nursing health history

Physical examination

Diagnostic and laboratory results

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9
Q

Types of Physical Assessment

A

Comprehensive-Full assessment with health history
Focused- on 1 problem
System specific-specific body system
Ongoing-Full blown exam

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10
Q

All Assessments are considered

A

HEAD to TOE

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11
Q

Elements of Assessment

A

HISTORY: Baseline and Problem-based
Exam-Vitals, inspect, auscultate, palpate

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12
Q

Process & the Physical

A

Assessment
Interview
Physical assessment

Nursing Diagnosis

Planning
Based on assessment data

Evaluation
Establishes nursing accountability

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13
Q

Techniques for Assessment

A

Inspection
Palpation
Percussion
Auscultation
Olfaction

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14
Q

Inspection (Visual). General rules

A

Good lighting

Expose all of part to be examined; drape or cover parts not being examined for privacy

Use additional lighting/devices for some areas of body; eyes, ears, throat

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15
Q

Inspection focuses on

A

Color
Shape/symmetry
Movement
Position

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16
Q

Palpation (Tactile)

A

Bimanual/manual technique

Dorsum of hand. Temp check

Palm or ulnar surface of hand.- check shape/texture

Palmar surface of finger/finger pads.- palpating pulses

17
Q

Light palpation

A

1 cm or ½ depth. Radial pulses

18
Q

Deep palpation

A

4 cm or 2 in depth. Abdominal assessment

19
Q

Palpate to assess:

A

Temperature
Thickness-wound bed
Shape-Breast exam for lump or nodule
Moisture-Skin clammy
Texture-Burn or scar
Resistance-ask to shrug while placing hand on
Resilience-How long can you hold knee up
Mobility-Go down stairs. knee is warm

20
Q

Percussion (Auditory & Tactile). Direct

A

Applied directly to body

21
Q

Indirect

A

Applied through another
surface

22
Q

Characteristics of sound

A

Frequency
# of oscillations per second generated by a vibrating object

Loudness
Amplitude of a sound wave

Quality
Descriptive

Duration:
Length of time that sounds lasts

23
Q

Use of the stethoscope:

A

Always directly place on skin**

24
Q

Bell best for

A

low pitched sounds (vascular & some heart sounds)

25
Q

Diaphragm

A

best for high pitched sounds (bowel and some abnormal lung sounds)

26
Q

Olfactory (Sense of Smell)

A

Used to detect ABNORMAL vs NORMAL

27
Q

Examples of what to look for in Olfactory assessment

A

USUALLY DESCRIPTIVE IN NATURE
Alcohol on breath
Foul smelling odor from wound
Sweet smelling odor from mouth

28
Q

Preparing for the Assessment

A

Gather all necessary equipment
Introduce yourself
Explain procedure
Use gloves if necessary
Wash hands before and after ANY contact with patient
Clean stethoscope head and blood pressure cuffs between patients
Make patient comfortable; allow for privacy and confidentiality

29
Q

Special Considerations for Aged

A

Recognize physical/sensory limitations
May need to adjust position
May need to allow more time (fatigue)
May need to allow more space
Recognize normal changes of aging vs abnormal

30
Q

Performing the Assessment

A

Health history typically taken prior to exam
Begin with general survey

31
Q

general survey

A

Race/Gender Movement/Gait
Age Hygiene/Grooming
Body type Dress
Posture Affect/Mood
Signs of distress Patient abuse
Substance abuse
Speech

32
Q

Signs of Abuse

A

Inconsistency between injury and statement
Bruises, lacerations, burns, bites
X-Ray show fractures in various stages of healing
Behavior issues; insomnia, anxiety, isolation

Module 1 Exam (6 decks)

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